Abstract
Background
Household air pollution is identified as one of the leading risk factors for mortalities from type 2 diabetes mellitus. However, there is limited epidemiological information to support decision-making in low-income countries. This study aimed to estimate the magnitude of years of life lost due to type 2 diabetes mellitus attributable to household air pollution from solid fuels among adults aged 55 years and above in Ethiopia from 1990 to 2023.
Methods
The study used methods, tools, and estimates from the Global Burden of Diseases 2023 study. A Comparative Risk Assessment framework was applied to estimate the years of life lost.
Results
There were an estimated 42,669 years of life lost (95% UI: 24,310-67,089) from type 2 diabetes mellitus attributable to household air pollution among adults aged 55 years and above in Ethiopia in 2023, with 26,183 years of life lost (95% UI: 13,213-44,070) among males and 16,486 years of life lost (95% UI: 8752-28,224) among females. The highest number of years of life lost was estimated in Oromia, Amhara, and Southern Nations, Nationalities, and Peoples, whereas the lowest was in Harari, Gambella, and Dire Dawa. The corresponding rate was 571 years of life lost per 100,000 adults (95% UI: 325-897), with 673 years of life lost per 100,000 males (95% UI: 340-1133) and 460 years of life lost per 100,000 females (95% UI: 244-787). The average estimated rate was higher among males, and increased with age. Between 1990 and 2023, the years of life lost rate remains stable across the country. However, the rate declined in Addis Ababa.
Conclusion
This study revealed that there was a high burden of years of life lost from type 2 diabetes mellitus attributable to household air pollution among older adults in Ethiopia, with marked regional and male-predominant disparities. Priorities include scaling clean cooking fuel access in high-burden regions and adopting gender-sensitive strategies for older men. Integrating household air pollution reduction into Ethiopia’s diabetes and aging-health frameworks is essential to reverse the stagnant trend and reduce preventable premature mortality.
Keywords: household air pollution, type 2 diabetes mellitus, years of life lost
Plain Language Summary
Household air pollution is identified as one of the leading risk factors for mortalities from type 2 diabetes mellitus. However, there is limited epidemiological information to describe the public health burden of this relationship in low-income countries. This study aimed to analyze the trends in years of life lost due to type 2 diabetes mellitus attributable to household air pollution from solid fuels among individuals aged 55 years and above in Ethiopia from 1990 to 2023.
Background
Diabetes mellitus is a condition marked by high blood sugar levels. 1 The most common types of diabetes mellitus are type 1 and type 2. Type 2 diabetes mellitus (T2DM) is common among old-age people, accounting for more than 90% of all instances. 2 There is a growing body of scientific evidence about the link between chronic exposure to household air pollution (HAP) from solid fuels and the burden of T2DM. 3 Older age people living in Sub-Saharan Africa, where about 80% of households use biomass fuels for cooking, are disproportionately affected. 4
To create focused and efficient health policies, it is imperative to evaluate the impacts of exposure to HAP on T2DM. This is especially crucial in nations like Ethiopia, where enforcement of environmental and health regulations is lax and varies greatly between states. 5 The majority of research has focused on the general impacts of particulate matter pollution, with a scarcity of studies examining the precise burden of T2DM attributable to HAP from biomass fuel use, such as charcoal, animal dung, and wood.
This study aimed to estimate the magnitude of years of life lost (YLLs) (i.e., a measure of premature mortality) from T2DM attributable to HAP from solid fuels among people aged 55 years and above in Ethiopia from 1990 to 2023, using methods, data, and tools from the Global Burden of Diseases (GBD) 2023 study. An age of 55 years and above is the lowest age category available in the GBD classification, which better represents the older adults, affected by T2DM.
Methods
Study setting
This analysis was conducted in Ethiopia, which was administratively divided into regional states, namely Afar, Tigray, Amhara, Somali, Oromia, Gambella, Benishangul-Gumuz, Southern Nations, Nationalities, and Peoples (SNNP), and Harari, and city administrations at Addis Ababa and Dire Dawa. In the country, HAP was a significant public health concern due to the widespread use of solid fuels, such as wood, dung, and charcoal for cooking. 6 Moreover, poor self-care activities, inadequate hypoglycemia prevention practices, and systemic healthcare barriers were the key challenges of diabetes prevention and control. 7
Data sources
The GBD 2023 estimates were extracted from the GBD Results Tool following the official release of the estimates on 12 October 2025. The input data underwent two rounds of independent quality review, including checks for extreme leverage points, outliers, and consistency with established epidemiological patterns. These data included health and demographic surveys, welfare monitoring surveys, socio-demographic surveys, and censuses. The complete list of these data is available at: https://sources.healthdata.org/collection/sources-2023?components=1&covariates=105&locations=179.
Data analyses
The GBD study estimates YLLs from T2DM attributable to HAP using a Comparative Risk Assessment (CRA) framework.8,9 First, exposure assessment via Spatiotemporal Gaussian Process Regression (ST-GPR) estimates the proportion of the population using solid fuels, converted to fine particulate matter (PM2.5) concentrations. Second, integrated exposure-response curves provide relative risk (RR) functions for T2DM per PM2.5 level. Third, the theoretical minimum risk exposure level (TMREL) is set at 2.4–5.9 µg/m3. Fourth, the population attributable fraction (PAF) is calculated using the formula: , where P(x) is the exposure distribution and RR(x) is the risk at level x. Fifth, attributable YLLs = total T2DM YLLs × PAF. The CRA framework compartmentalizes exposure by separating ambient and household pollution, integrates non-linear risks to avoid overestimation, and adjusts for mediation (e.g., low birth weight) to ensure accurate attribution. Standard GBD reference life table was used to calculate the YLLs in each age-sex group.
The 95% uncertainty intervals (95% UIs) were generated by 1,000 draws from posterior distributions. The percentage change in estimates was quantified by comparing the values at the start and end of the period, using the following formula: The net change was significant if the 95% UIs did not cross zero.
Systematic bias in exposure data was corrected by applying a MR-BRT (Meta-Regression—Bayesian, Regularized, Trimmed) modeling tool. It accounts for measurement errors, variations in study design, different case definitions, and inconsistent reference levels across studies. Sensitivity analyses that tested the stability of PAF estimates by changing important assumptions regarding counterfactual exposure distributions and effect sizes were used to validate the CRA framework. 10
Results
Years of life lost
In 2023, there were an estimated 42,669 YLLs (95% UI: 24,310-67,089) from T2DM attributable to HAP from solid fuels among individuals aged 55 years and above in Ethiopia, with 26,183 YLLs (95% UI: 13,213-44,070) among males and 16,486 YLLs (95% UI: 8752-28,224) among females. Oromia [14,120 YLLs (95% UI: 7972-22,265)], Amhara [11,705 YLLs (95% UI: 6614-18,855)], and SNNP [6300 YLLs (95% UI: 3686-9947)] had the highest number of YLLs, whereas Harari [128 YLLs (95% UI: 71-211)], Gambella [161 YLLs (95% UI: 83-266)], and Dire Dawa [215 YLLs (95% UI: 119-343)] experienced the lowest (Table 1).
Table 1.
YLLs from T2DM attributable to HAP from solid fuels among adults aged 55 years and above in Ethiopia, 1990 to 2023.
| Region | Sex | YLLs Count (95% UI) | YLLs per 100,000 (95% UI) | Annualized rate of change (95% UI)) |
|---|---|---|---|---|
| 2023 | 2023 | 1990 – 2023 | ||
| Ethiopia | Male | 26,183 (13213-44070) | 673 (340-1133) | -0.02 (-0.54, 0.77) |
| Female | 16,486 (8752-28224) | 460 (244-787) | -0.27 (-0.59, 0.33) | |
| Both | 42,669 (24310-67089) | 571 (325-897) | -0.14 (-0.47, 0.39) | |
| Addis Ababa | Male | 671 (291-1317) | 427 (185-839) | -0.37 (-0.72, 0.29) |
| Female | 513 (253-967) | 295 (145-556) | -0.48 (-0.69, -0.10) | |
| Both | 1184 (617-1905) | 358 (187-576) | -0.43 (-0.67, -0.07) | |
| Afar | Male | 318 (147-572) | 618 (286-1110) | 0.11 (-0.48, 1.36) |
| Female | 179 (93-296) | 632 (327-1049) | 0.10 (-0.50, 1.22) | |
| Both | 497 (271-849) | 623 (340-1064) | 0.11 (-0.37, 0.85) | |
| Amhara | Male | 7179 (3576-12194) | 666 (332-1132) | 0.04 (-0.53, 0.99) |
| Female | 4526 (2405-8043) | 449 (238-798) | -0.32 (-0.64, 0.27) | |
| Both | 11705 (6614-18855) | 561 (317-904) | -0.14 (-0.48, 0.42) | |
| Oromia | Male | 8272 (4119-13765) | 684 (341-1139) | -0.08 (-0.57, 0.65) |
| Female | 5847 (2987-10344) | 503 (257-891) | -0.23 (-0.57, 0.41) | |
| Both | 14120 (7972-22265) | 596 (336-939) | -0.15 (-0.49, 0.36) | |
| Somali | Male | 1445 (660-2660) | 569 (260-1048) | 0.08 (-0.54, 1.20) |
| Female | 589 (315-980) | 447 (239-744) | -0.32 (-0.64, 0.26) | |
| Both | 2034 (1099-3464) | 528 (285-898) | -0.12 (-0.49, 0.48) | |
| Benishangul-Gumuz | Male | 240 (110-425) | 570 (260-1009) | -0.08 (-0.58, 0.86) |
| Female | 184 (93-315) | 529 (268-908) | -0.05 (-0.53, 1.05) | |
| Both | 424 (238-700) | 551 (310-910) | -0.07 (-0.42, 0.64) | |
| SNNP | Male | 3872 (1846-6547) | 695 (331-1175) | 0.01 (-0.55, 0.98) |
| Female | 2428 (1217-4234) | 449 (225-783) | -0.23 (-0.60, 0.49) | |
| Both | 6300 (3686-9947) | 574 (336-906) | -0.11 (-0.48, 0.44) | |
| South West | Male | 781 (364-1411) | 986 (460-1783) | -0.08 (-0.61, 0.83) |
| Female | 320 (158-601) | 472 (233-888) | -0.31 (-0.66, 0.46) | |
| Both | 1101 (582-1873) | 749 (397-1275) | -0.16 (-0.53, 0.38) | |
| Tigray | Male | 1769 (866-3095) | 632 (310-1107) | 0.14 (-0.47, 1.27) |
| Female | 1155 (579-2055) | 420 (210-747) | -0.23 (-0.58, 0.48) | |
| Both | 2923 (1642-4723) | 527 (296-851) | -0.04 (-0.43, 0.53) | |
| Harari | Male | 73 (34-137) | 833 (387-1552) | 0.17 (-0.46, 1.26) |
| Female | 55 (29-96) | 544 (283-951) | -0.27 (-0.60, 0.38) | |
| Both | 128 (71-211) | 679 (377-1117) | -0.07 (-0.45, 0.48) | |
| Sidama | Male | 1316 (614-2436) | 923 (431-1708) | 0.26 (-0.46, 1.49) |
| Female | 560 (268-1019) | 473 (226-861) | -0.17 (-0.60, 0.63) | |
| Both | 1876 (1003-3241) | 719 (384-1242) | 0.09 (-0.39, 0.79) | |
| Gambella | Male | 113 (56-194) | 841 (416-1440) | 0.15 (-0.48, 1.21) |
| Female | 48 (24-84) | 311 (153-548) | -0.48 (-0.74, 0.04) | |
| Both | 161 (83-266) | 558 (289-921) | -0.14 (-0.51, 0.48) | |
| Dire Dawa | Male | 133 (61-236) | 725 (332-1292) | -0.09 (-0.58, 0.72) |
| Female | 82 (42-140) | 397 (202-674) | -0.37 (-0.64, 0.15) | |
| Both | 215 (119-343) | 551 (305-879) | -0.21 (-0.52, 0.24) |
There were an estimated 571 YLLs per 100,000 adults aged 55 years and above (95% UI: 325-897), with 673 YLLs per 100,000 males (95% UI: 340-1133) and 460 YLLs per 100,000 females (95% UI: 244-787). The average estimated rate of YLLs was higher among males compared to females nationally and sub-nationally (Figure 1). Moreover, the average estimates increased as age increased (Figure 2). Compared to the rate in 1990, the YLLs rate remains unchanged in 2023 throughout the country since the 95% UIs crossed the zero value. However, Addis Ababa had a 43% decline (95% UI: -67, -7) (Table 1).
Figure 1.
YLLs rate from T2DM attributable to HAP from solid fuels among adults age 55 years and above by sex and locations in Ethiopia, 2023.
Figure 2.
Age-sex specific YLLs rate from T2DM attributable to HAP from solid fuels among adults age 55 years and above in Ethiopia, 2023.
Discussion
This study aimed to estimate the distribution of YLLs from T2DM attributable to HAP from solid fuel among individual aged 55 years and above in Ethiopia from 1990 to 2023. There were an estimated 42,669 YLLs (95% UI: 24,310-67,089) in 2023, with 26,183 YLLs (95% UI: 13,213-44,070) among males and 16,486 YLLs (95% UI: 8752-28,224) among females. The highest number of YLLs was estimated in Oromia, Amhara, and SNNP, whereas the lowest was in Harari, Gambella, and Dire Dawa. The corresponding rate was 571 YLLs per 100,000 adults (95% UI: 325-897), with 673 YLLs per 100,000 males (95% UI: 340-1133) and 460 YLLs per 100,000 females (95% UI: 244-787). The average estimated rate was higher among males compared to females, and increased with age. The YLLs rate remains stable across the country between 1990 and 2023. However, the rate declined in Addis Ababa.
Subnationally, there was variation in the distribution of the absolute number of YLLs from T2DM attributable to HAP from solid fuel. The estimated disparity may due to differences in the population size, healthcare access and late diagnosis, and life style shifts.
In 2023, the study estimated 571 YLLs from T2DM attributable to HAP from solid fuel per 100,000 adults aged 55 years and above, which underscores a critical, often overlooked link between T2DM and HAP from solid fuels. Historically viewed as a cardiovascular and respiratory risk factor, high concentrations of fine particulate matter from HAP trigger oxidative stress, systemic inflammation, and insulin resistance, accelerating T2DM complications and premature mortality in older adults. 11 This result was in agreement with a previous study that indicated most of the air pollution-attributable burden of T2DM in Sub-Sahara stemmed from HAP. 3
Among adults aged 55 years and older, the YLLs rate from T2DM attributable to HAP from solid fuels did not significantly change between 1990 and 2023. The continued burden likely reflects underlying socioeconomic factors, as households with lower socioeconomic status disproportionately rely on solid fuels for cooking. Thus, accelerating the transition to clean cooking fuels, improving kitchen ventilation, and implementing targeted T2DM screening for the elderly can be recommended to reduce the burden. Moreover, interventions must shift from incremental, traditional stove improvements to universal access to clean energy sources. 12
The decline in YLLs from T2DM attributable to HAP in Addis Ababa between 1990 and 2023 was largely driven by a decrease in the use of solid fuels for cooking. Access to cleaner energy sources like electricity and liquefied petroleum gas has expanded, reducing cumulative exposure to fine particulate matter (PM2.5) that drives insulin resistance.11,12
Males experienced higher average estimates of YLLs from T2DM attributable to HAP from solid fuel compared to females. These align with previous studies. 13 Several factors may account for this gender disparity. Men often have prolonged exposure to outdoor environments and higher rates of inhaling particulate matter. 14 Furthermore, men are more likely to have additional T2DM risk factors such as smoking, alcohol consumption, and poorer dietary patterns, which may contribute to this gender-specific variation.13,15 These gendered disparities underscore the need for targeted interventions that address sex-specific risk behaviors.
The average rate of YLLs from T2DM attributable to HAP from solid fuel in Ethiopia rose with age due to biological decline, cumulative exposure, and comorbidity burden. Aging impairs pancreatic beta-cell function and insulin sensitivity, raising diabetes risk. Lifelong HAP exposure drives oxidative stress and chronic inflammation, accelerating insulin resistance and β-cell dysfunction. 16 As people age, longer exposure duration extends diabetes latency and worsens metabolic outcomes. Older adults also face comorbidities like hypertension and cardiovascular disease, which increase mortality once diabetes develops, leading to higher YLLs. These trends align with national and global analyses showing that T2DM burden attributable to HAP peaks in older populations.17,18
When evaluating the goals of universal health coverage, diabetes treatment was utilized as an indicator of the nations' healthcare systems. 15 The UN has set a goal to lower the number of early deaths from diabetes and other non-communicable diseases by 2030. 19 The Lancet Commission on Diabetes advocated for a greater reliance on high-quality data, with an emphasis on low- and middle-income nations, to help policymakers better identify risks and define needs to promote improvements in diabetes prevention and care. 20
This study’s findings highlight the need for multi-sectoral interventions targeting older adults while addressing persistent geographic and gender disparities in T2DM burden from HAP. The stable national YLLs rate over three decades signals policy failures beyond urban centers like Addis Ababa. High burdens in Oromia and Amhara, coupled with higher male premature mortality, indicate that current clean-cooking initiatives are not equitably reaching fuel-dependent, high-risk populations. National strategies must therefore prioritize scaling clean-cooking adoption in rural areas and integrate HAP reduction into diabetes care pathways for older men. Furthermore, strengthening age-disaggregated health surveillance is essential to direct resources where YLLs rates are highest. 21
The GBD approach’s general weaknesses have already been discussed elsewhere.3,10,17,18 The main limitation of this study is the heavy reliance on modeled GBD 2023 estimates, which in Ethiopia are constrained by the absence of a national air pollution health surveillance system and a general lack of granular, sub-national data. This dependence means that local exposure patterns, second-hand smoke, and other key confounding factors are not directly measured.
Conclusion
This study indicated that there was a high burden of YLLs from T2DM attributable to HAP among older adults in Ethiopia, with considerable regional and male-predominant disparities, underscoring the urgent need for targeted interventions. Priority should be given to scaling up clean cooking fuel access in high-burden regions while replicating Addis Ababa’s successful decline through urban-centric policies. Gender-sensitive strategies addressing older men’s higher exposure and mortality risks are essential. Integrating HAP reduction into Ethiopia’s diabetes and aging-health frameworks will help reverse the stagnant trend and reduce preventable YLLs.
Footnotes
Authors contributions: ST conceived and designed the study. ST, LA, YF, DDH, BKL, EM, HAA, YAW, GE, EAA, HL, MM, YA, and MTS were involved in the analysis and interpretation of the findings. All authors have approved the final version of the manuscript.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
ORCID iDs
Lechisa Asefa https://orcid.org/0000-0002-0750-651X
Degefa Dhengesu Hero https://orcid.org/0000-0002-3437-978X
Hailu Lemma https://orcid.org/0000-0002-2020-1024
Medhin Mehari https://orcid.org/0000-0001-7985-1841
Yonas Angaw https://orcid.org/0000-0002-5119-9414
Ethical considerations
The study used secondary data from the GBD 2023 study. Moreover, the estimates were aggregated at population-level so that individual information is adequately anonymized.
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