UK health performance: findings of the Global Burden of Disease Study 2010

www.thelancet.com Published online March 5, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60355-4 1

Articles

UK health performance: findings of the Global Burden of Disease Study 2010Christopher J L Murray†, Michael A Richards, John N Newton, Kevin A Fenton, H Ross Anderson*, Charles Atkinson*, Derrick Bennett*, Eduardo Bernabé*, Hannah Blencowe*, Rupert Bourne*, Tasanee Braithwaite*, Carol Brayne*, Nigel G Bruce*, Traolach S Brugha*, Peter Burney*, Mukesh Dherani*, Helen Dolk*, Karen Edmond*, Majid Ezzati*, Abraham D Flaxman*, Tom D Fleming*, Greg Freedman*, David Gunnell*, Roderick J Hay*, Sally J Hutchings*, Summer Lockett Ohno*, Rafael Lozano*, Ronan A Lyons*, Wagner Marcenes*, Mohsen Naghavi*, Charles R Newton*, Neil Pearce*, Dan Pope*, Lesley Rushton*, Joshua A Salomon*, Kenji Shibuya*, Theo Vos*, Haidong Wang*, Hywel C Williams*, Anthony D Woolf*, Alan D Lopez, Adrian Davis

SummaryBackground The UK has had universal free health care and public health programmes for more than six decades. Several policy initiatives and structural reforms of the health system have been undertaken. Health expenditure has increased substantially since 1990, albeit from relatively low levels compared with other countries. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to examine the patterns of health loss in the UK, the leading preventable risks that explain some of these patterns, and how UK outcomes compare with a set of comparable countries in the European Union and elsewhere in 1990 and 2010.

Methods We used results of GBD 2010 for 1990 and 2010 for the UK and 18 other comparator nations (the original 15 members of the European Union, Australia, Canada, Norway, and the USA; henceforth EU15+). We present analyses of trends and relative performance for mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 259 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to the UK. We assessed the UK’s rank for age-standardised YLLs and DALYs for their leading causes compared with EU15+ in 1990 and 2010. We estimated 95% uncertainty intervals (UIs) for all measures.

Findings For both mortality and disability, overall health has improved substantially in absolute terms in the UK from 1990 to 2010. Life expectancy in the UK increased by 4·2 years (95% UI 4·2–4·3) from 1990 to 2010. However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates, and life expectancy in 1990, and its relative position had worsened by 2010. Although in most age groups, there have been reductions in age-specific mortality, for men aged 30–34 years, mortality rates have hardly changed (reduction of 3·7%, 95% UI 2·7–4·9). In terms of premature mortality, worsening ranks are most notable for men and women aged 20–54 years. For all age groups, the contributions of Alzheimer’s disease (increase of 137%, 16–277), cirrhosis (65%, –15 to 107), and drug use disorders (577%, 71–942) to premature mortality rose from 1990 to 2010. In 2010, compared with EU15+, the UK had significantly lower rates of age-standardised YLLs for road injury, diabetes, liver cancer, and chronic kidney disease, but significantly greater rates for ischaemic heart disease, chronic obstructive pulmonary disease, lower respiratory infections, breast cancer, other cardiovascular and circulatory disorders, oesophageal cancer, preterm birth complications, congenital anomalies, and aortic aneurysm. Because YLDs per person by age and sex have not changed substantially from 1990 to 2010 but age-specific mortality has been falling, the importance of chronic disability is rising. The major causes of YLDs in 2010 were mental and behavioural disorders (including substance abuse; 21·5% [95 UI 17·2–26·3] of YLDs), and musculoskeletal disorders (30·5% [25·5–35·7]). The leading risk factor in the UK was tobacco (11·8% [10·5–13·3] of DALYs), followed by increased blood pressure (9·0 % [7·5–10·5]), and high body-mass index (8·6% [7·4–9·8]). Diet and physical inactivity accounted for 14·3% (95% UI 12·8–15·9) of UK DALYs in 2010.

Interpretation The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action. Further progress in premature mortality from several major causes, such as cardiovascular diseases and cancers, will probably require improved public health, prevention, early intervention, and treatment activities. The growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response.

Funding Bill & Melinda Gates Foundation.

Introduction There are several reasons to expect the UK to set a standard for health that other countries might struggle to match. For six decades, the UK has provided universal free health

care, comprehensive primary care, an organised network of secondary and tertiary hospital services, and broad public health programmes. Since 1990, the UK Government has introduced public health measures for tobacco

Published Online March 5, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60355-4

See Online/Comment http://dx.doi.org/10.1016/S0140-6736(13)60188-9

*Authors listed alphabetically

†Corresponding author

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA (Prof C J L Murray MD, C Atkinson BS, A D Flaxman PhD, T D Fleming BS, G Freedman BA, S Lockett Ohno BA, Prof R Lozano MD, M Naghavi PhD, Prof T Vos PhD, H Wang PhD); National Cancer Action Team, National Cancer Programme, London, UK (Prof M A Richards MD); University of Manchester, Manchester, UK (Prof J N Newton FRCP); Public Health England, London, UK (Prof K A Fenton MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Clinical Trial Service Unit and Epidemiological Studies Unit (D Bennett PhD), University of Oxford, Oxford, UK (Prof C R Newton MD); Dental Institute (E Bernabé PhD), Kings College Hospital NHS Trust, King’s College London, London, UK (Prof R J Hay DM); London School of Hygiene and Tropical Medicine, London, UK (H Blencowe MBChB, Prof K Edmond PhD, Prof N Pearce PhD); Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK (Prof R Bourne FRCOphth); Moorfields Eye Hospital, London, UK (T Braithwaite MPH); University of Cambridge, Cambridge, UK (Prof C Brayne MD); University of Liverpool, Liverpool, UK (Prof N G Bruce PhD, M Dherani PhD, D Pope PhD);

Articles

2 www.thelancet.com Published online March 5, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60355-4

University of Leicester, Leicester, UK

(Prof T S Brugha MD); Department of Epidemiology

and Biostatistics, School of Public Health

(Prof M Ezzati PhD), Imperial College London, London, UK

(Prof P Burney MD, S J Hutchings BSc,

L Rushton PhD); University of Ulster, Jordanstown, UK

(Prof H Dolk DrPH); University of Bristol, Bristol, UK

(Prof D Gunnell DSc); Swansea University, Swansea, UK

(Prof R A Lyons MD); Queen Mary University

London, London, UK (Prof W Marcenes PhD); School

of Public Health, Harvard University, Boston, MA, USA

(Prof J A Salomon PhD); Department of Global Health

Policy, University of Tokyo, Tokyo, Japan

(Prof K Shibuya MD); University of Nottingham, Nottingham,

UK (Prof H C Williams PhD); Royal Cornwall Hospital, Truro,

UK (Prof A D Woolf FRCP); School of Population Health,

University of Queensland, Brisbane, QLD, Australia

(Prof A D Lopez PhD); and Chief Scientific Officer’s Office,

Department of Health, London, UK (Prof A Davis PhD)

Correspondence to: Prof Christopher J L Murray,

Institute for Health Metrics and Evaluation,

University of Washington, 2301 5th Avenue, Suite 600,

Seattle, WA 98121, USA [email protected]

control,1 immunisation,2,3 cancer and noncancer screening,4 and reduction of salt in foods;5 has undertaken substantial reform of all aspects of the health system, including management of cancer; and has increased health expenditure as a percentage of gross domestic product from 6·8% in 1995, to 9·6% in 2010.6 A major focus on a reduction in waiting times for diagnosis and elective procedures substantially decreased the backlog of elective procedures.7,8 In 1999, the National Institute for Health and Clinical Excellence (NICE) was established to provide evidencebased guidelines for prevention, diagnosis, and treatment of major causes of disease and ill health and to disseminate standards for quality of care.9 Various types of incentive schemes have been tried to expand coverage of some key preventive interventions in primary care.10 Finally, major structural changes in hospital organisation and management and in resource allocation have been progressively adopted, implemented, and revised.11–13

Although the underlying social, economic, and physical environments remain important factors influencing health outcomes, it is nevertheless impor tant and timely to investigate whether these UK investments in health care and public health have been followed by the expected improvements in health. If not, the data might suggest what more can and should be done to improve population health. Health policy has been devolved to the four nations of the UK. In April 2013, a new system for public health and health care in England will be implemented; Scotland, Wales, and Northern Ireland have different arrangements. For example, Public Health Wales was created in 2009 to protect and improve the health and wellbeing of the population of Wales. In England, various new organi sations are being launched, such as the National Health Service (NHS) Commissioning Board, Public Health England, Health Education England, and local clinical commissioning groups.13 In addition to the healthservice changes, substantial public health responsibilities and funding are being transferred from the health service to local governments in England, with the stated aim of addressing underlying problems more effectively, including the social determinants of health.

These new arrangements could provide new opportunities for information and intelligence—eg, results of research into patterns of disease, injury, and leading risk factors—to influence policy and strategy much more directly. Research is also now embodied as a core function of the NHS,14 and knowledge and intelligence is a core function of Public Health England. Some commentators, nevertheless, have raised concern that these changes in England could have adverse effects on universal access to care and ultimately health.15–17

There have been several enquiries into the patterns of health loss and trends in the UK. The 2011 English Chief Medical Officer’s report2 provided an authoritative assessment of many dimensions of health in England. Nolte and colleagues18 examined avoidable mortality in

the UK, and others investigated the contribution of different risk factors to mortality trends.19–24 Lyons and colleagues25 reported the UK burden of injuries. The newly released Global Burden of Diseases, Injuries, and Risk Factors Study 201026 (GBD 2010) provides an opportunity to go beyond these studies and compre hen sively examine the leading causes of disease burden and how they are changing. Consistent definitions, data sources, and methods were used in GBD 2010 to examine health loss from 291 diseases and injuries and 67 risk factors or risk factor clusters for 187 countries.26–33 A key strength of GBD 2010 was that change in patterns of health could be studied not only for premature mortality, but also for leading causes of disability. Furthermore, because the study assessed the same set of causes for all countries, it provides a con venient and appropriate platform for benchmarking performance. Benchmarking has two dimensions: to examine levels of health across several countries, and investigate and compare changes over time within each country. Both can help to put the UK health achievements in context and suggest areas of opportunity for improvement.

This report draws on a specific interrogation of the GBD 2010 data to examine three crucial areas: the patterns of health loss in the UK; the leading preventable risks that explain some of these patterns; and how UK outcomes compare with a set of comparable countries in the European Union and elsewhere in 1990 and 2010.

MethodsOverviewDetailed information about data, approaches used to enhance data quality and comparability, statistical modelling, and metrics for GBD 2010 have been reported previously.26–33 The GBD 2010 cause list has 291 diseases and injuries, which are organised in a hierarchy with up to four levels of disaggregation. For each cause, there are from one to 24 sequelae. Sequelae are the clinical outcomes that can be related to specific diseases and injuries, such as neuropathy due to diabetes. In total, the study includes 1160 sequelae.

The GBD uses several metrics to report results for health loss related to specific causes of disease and injury: deaths and death rates, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs), and disabilityadjusted lifeyears (DALYs). YLLs are computed by multiplying the number of deaths in each age group by a reference life expectancy at that age. The life expectancy at birth in the GBD 2010 reference life table is 86·0 years on the basis of the lowest observed death rates for each age group across countries in 2010, and is intended to represent an achievable pattern of mortality.26 YLDs are calculated by multiplying the prevalence of a sequela by its disability weight. Disability weights are largely based on surveys of the general population.30 DALYs are the arithmetic sum of YLLs and YLDs. Healthy life expectancy (HALE) is used to summarise overall population health,

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accounting for both length of life and levels of health experienced at different ages.31

MortalityWang and colleagues33 provided a detailed description of how agespecific mortality rates have been esti mated for each sex, country, and year. In highincome countries such as the UK, information about deaths is predominantly driven by data from official vital regis tration systems. Denominators have been based on census returns and intercensal estimates. For coun tries of low and middle income, various sources have been used to triangulate plausible levels of allcause mortality.34–36

Causes of deathNumbers of deaths and YLLs have been computed on the basis of underlying cause of death estimates for 235 causes of mortality from the list of 291 diseases and injuries, and for 20 age groups, both sexes, and 187 countries.28 Cause of death estimates have been developed with a comprehensive database of vital registration, verbal autopsy, mortality surveillance, and other sources covering 187 countries from 1980 to 2010. The quality of each data source has been assessed, and the codes for various revisions of the International Classification of Diseases and Injuries (ICD) have been mapped to the GBD 2010 cause list. Deaths assigned to illdefined diagnoses or to conditions that are not likely to be underlying causes of death (termed garbage codes) have been reassigned with standard algorithms.37,38 In 2010, 17·9% of deaths in the UK were assigned to causes that are unlikely to be the underlying cause of death or are illdefined, compared with 5·5% in Finland (the lowest) and 34·9% in Portugal (the highest). In the UK, many of these deaths are assigned to illdefined injuries. For cancers, populationbased cancer registries have also been used.

GBD 2010 is the most comprehensive effort yet to enhance the comparability of data for cause of death between countries, because of both the mapping between revisions of the ICD and the redistribution of garbage codes. Despite these attempts to enhance comparability over time, unrecognised changes in national certification practices and their interaction with ICD revisions might limit comparability of these data across countries and over time.39 In the UK, even after redistribution of illdefined causes and factors that are unlikely to be the underlying cause of death, the number of deaths assigned to pyelonephritis changed substantially between ICD9 and ICD10, which is probably an artifact. Trends in congenital anomaly deaths after the age of 50 years still seem to be affected by changes from ICD9 to ICD10, but this is present in all countries. Uncertainty in cause of death estimates has been captured using standard simulation methods by taking 1000 draws40 for each age, sex, country, year, and cause.28 Final uncertainty for deaths and YLLs reflect uncertainty in the levels of allcause mortality and

Age-

stan

dard

ised

dea

th ra

te

(per

100

000

)Ag

e-st

anda

rdis

ed Y

LLs (

per 1

00 0

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Age-

stan

dard

ised

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s (pe

r 100

000

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fe e

xpec

tanc

y at

birt

h (y

ears

)H

ALE

at b

irth

(yea

rs)

1990

2010

1990

2010

1990

2010

1990

2010

1990

2010

Rate

Rank

Rate

Rank

Rate

Rank

Rate

Rank

Rate

Rank

Rate

Rank

Life

ex

pect

ancy

Rank

Life

ex

pect

ancy

Rank

HAL

ERa

nkH

ALE

Rank

(Con

tinue

d fro

m p

revi

ous p

age)

Net

herla

nds

572

(5

67–

575)

7

(7–8

)42

6

(422

–43

0)

9

(8–1

0)11

847

(1

1 666

–11

974

)

2

(2–2

)79

88

(789

8–81

27)

6

(5–6

)11

355

(9

498–

13 38

7)

15

(5–1

7)11

492

(9

624–

13 4

45)

16

(7–1

7)77

·0

(76·

9–77

·1)

4

(3–5

)80

·6

(80·

5–80

·7)

9

(7–9

)66

·5

(64·

6–68

·3)

5

(2–8

)69

·1

(67·

0–70

·9)

8

(5–1

3)

Nor

way

580

(5

72–

584)

9

(9–9

)42

2

(418

–42

9)

8

(7–9

)12

291

(1

2 041

–12

495

)

6

(5–7

)79

04

(779

3–80

95)

5

(5–6

)12

365

(1

0 17

7–14

638

)

18

(17–

19)

12 32

9

(10

248–

14 6

34)

18

(17–

19)

76·8

(7

6·7–

76·9

)

9

(8–9

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·8

(80·

7–81

·0)

6

(5–7

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·2

(62·

8–67

·2)

17

(10–

18)

68·0

(6

5·6–

70·2

)

16

(12–

19)

Port

ugal

679

(6

72–

683)

18

(18–

18)

468

(4

64–

474)

17

(16–

17)

16 15

2

(15 8

00–

16 4

15)

19

(19–

19)

9407

(9

310–

9602

)

17

(16–

17)

11 4

09

(925

0–13

971

)

11

(2–1

7)11

123

(9

002–

13 6

00)

6

(2–1

7)74

·3

(74·

2–74

·4)

19

(19–

19)

79·4

(7

9·2–

79·5

)

17

(16–

17)

64·4

(6

2·3–

66·2

)

18

(15–

19)

68·6

(6

6·3–

70·5

)

13

(6–1

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Spai

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7

(553

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0)

3

(3–4

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3

(389

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3

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630

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786)

8

(8–9

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94

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3

(3–4

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136

(8

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(1–2

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(5–8

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1

(1–1

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Swed

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1

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196

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329)

1

(1–1

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96

(720

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1

(1–1

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378

(9

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17

(6–1

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(9

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(6–1

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3

(2–8

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4

(2–9

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USA

639

(6

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13

(12–

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516

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19

(19–

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15 13

0

(14

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3)

18

(18–

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47

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(19–

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10 50

3

(875

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2

(2–8

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509

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5)

2

(1–8

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(75·

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15

(14–

16)

78·2

(7

8·2–

78·3

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19

(19–

19)

65·6

(6

3·8–

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11

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17

(13–

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Data

in p

aren

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re 9

5% u

ncer

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ty in

terv

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Coun

trie

s hav

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best

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for e

ach

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f life

lost

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Tabl

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deat

h ra

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YLL

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and

life

exp

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HAL

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ned

Articles


uncertainty in the estimation of each cause of death in each age group, sex, country, and year.

YLDs and HALEYLDs have been estimated for 1160 sequelae of the diseases and injuries in the hierarchical cause list.32 Prevalence estimation for each sequela began with a systematic analysis of published and available unpublished data sources for prevalence, incidence, remission, and excess mortality. For most sequelae, estimates have been made on the basis of the database for all agesexcountryyear groups, with a Bayesian metaregression developed for GBD 2010 (DisModMR). When appropriate, DisModMR uses data for incidence, preva lence, remission, excess mortality, and causespecific mortality to generate prevalence estimates, assuming these rates are stable over time.

For GBD 2010, disability weights were measured for 220 unique health states that cover the 1160 disease and injury sequelae.30 For parsimony, disparate outcomes across some diseases have been grouped into a few more homogeneous outcomes. For example, disability from all acute infectious disease episodes is captured by a mild, moderate, or severe health state. Disability weights have been generated with data from more than 30 000 respondents obtained by populationbased surveys in five countries (the USA, Peru, Tanzania, Bangladesh, and Indonesia) and an open internet survey.30 936 respondents of the internet survey were from the UK. The primary elicitation method used was pairwise comparisons of two randomly selected health states, in which the respondent selected which health state they regarded as healthier. Results for health state severities were consistent across levels of educational attainment and cultural groups.30 Uncertainty in the disability weight for each sequela has been propagated into the estimates of YLDs for each disease and injury. Infor mation about agespecific mortality rates, and on overall agespecific YLDs per person, have been combined into the overall measure of health expectancy using a standard approach to extend the life table to capture adjustments for nonfatal health outcomes.31

Risk factorsDeaths, YLLs, YLDs, and DALYs attributable to 67 risk factors or clusters of risk factors were assessed in GBD 2010.27 Attributable deaths or DALYs were assessed with three key inputs. First, for each risk–outcome pair, relative risks of mortality or morbidity, or both, were estimated on the basis of metaanalyses of the published literature. Second, each risk factor exposure distribution in each country, age, sex group was estimated on the basis of published and unpublished data with mostly Bayesian estimation methods.27 Third, attributable deaths or DALYs were estimated by comparing the present distribution of exposure to a theoretical minimum risk counterfactual distribution of exposure selected for each risk factor. Each

risk factor or cluster of risk factors is analysed separately, such that the sum of attributable fractions for a disease or injury can be greater than 100%. Uncertainty in the relative

Figure 1: Age-specific mortality in the UK from 1990 to 2010(A) Percent change in age-specific mortality by sex. UK rank in (B) male and (C) female age-specific mortality when compared with the 15 original members of the European Union, Australia, Canada, the USA, and Norway. Shaded areas indicate 95% uncertainty intervals. In some cases, the 95% uncertainty interval has an upper and lower bound equal to the rank of the mean death rate. Countries have been ranked such that the best performer is ranked 1 for each indicator.

<1

0

10

20

30

40

50A

Decr

ease

(%)

0

5

10

15

20

5

10

15

20

B

Rank

0 1–4 5–910–14

15–1920–24

25–2930–34

35–3940–4

445–4

950–54

55–5960–6

465–6

970–74

75–79≥80

0

C

Rank

Age group (years)

Male Female

19902010

17

15

12

1313

87

7

7

10

1010

14

1414

14

1412 12

11

9 9

88 8

9

9

9 9

11 11

33

33

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5

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17

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0

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17 1718 18

17 17

17 17

15 15 15

1212

8

11 11

6 6

1314

16

1616

4

For more on denominators see http://www.mortality.org/

Articles


Figure 2: UK ranks for top 25 causes of YLLs for both

sexes combined with 95% UIs in 1990 and in 2010

for (A) all ages and (B) individuals aged

20–54 yearsYLLs=years of life lost.

UI=uncertainty interval. COPD=chronic obstructive

pulmonary disease.Communicable, maternal, neonatal, and nutritional disorders Non-communicable diseases Injuries

Mean rank (95% UI)

Disorder Disorder Mean rank (95% UI)

% change (95% UI)

1990 2010

Ascending order in rankDescending order in rank

A

B

23·3 (11 to 31) 24 Alzheimer’s disease

18·9 (13 to 24) 19 Aortic aneurysm

24·3 (20 to 28) 25 Bladder cancer

28 Bladder cancer

22·0 (14 to 27) 23 Brain cancer

6·5 (6 to 7) 6 Breast cancer5·0 (4 to 5) 5 COPD

15·7 (11 to 19) 14 Cirrhosis

6·5 (6 to 7) 7 Colorectal cancer

11·6 (10 to 15) 11 Congenital anomalies

16·0 (13 to 21) 16 Diabetes

26 Diabetes

16·7 (12 to 21) 17 Oesophageal cancer

1·0 (1 to 1) 1 Ischaemic heart disease

21·3 (16 to 26) 21 Leukaemia

4·1 (4 to 5) 4 Lower respiratory infections3·0 (2 to 3) 3 Lung cancer

20·7 (18 to 24) 20 Non-Hodgkin lymphoma

12·6 (10 to 15) 12 Other cardiovascular and circulatory13 Preterm birth complications

21·5 (15 to 27) 22 Ovarian cancer

15·8 (11 to 21) 15 Pancreatic cancer

12·7 (10 to 22)

18·4 (11 to 28) 18 Prostate cancer

8·6 (8 to 10) 9 Road injury8·5 (8 to 10) 8 Self-harm

11·3 (9 to 15) 10 Stomach cancer

2·0 (2 to 3) 2 Stroke

9·3 (6 to 12)10 Alzheimer’s disease 137 (16 to 277)

19·7 (14 to 26)18 Aortic aneurysm –11 (–28 to 7)

20·6 (14 to 29)20 Brain cancer –3 (–30 to 15)

7·1 (7 to 8)7 Breast cancer –24 (–30 to –17)

4·4 (4 to 6)4 COPD –11 (–19 to –2)

9·3 (8 to 14)9 Cirrhosis 65 (–15 to 107)

6·0 (5 to 7)6 Colorectal cancer –11 (–20 to 9)

17·2 (14 to 21)16 Congenital anomalies –36 (–45 to –20)

20·8 (14 to 39)21 Drug use disorders 577 (71 to 942)

64 Drug use disorders

15·2 (12 to 23)14 Oesophageal cancer 1 (–30 to 20)

22·6 (18 to 27)23 Falls 6 (–16 to 26)

26 Falls

1·0 (1 to 1)1 Ischaemic heart disease –51 (–54 to –37)

21·6 (16 to 26)22 Leukaemia –8 (–20 to 3)

4·6 (4 to 6)5 Lower respiratory infections –23 (–33 to –12)

2·3 (2 to 3)2 Lung cancer –24 (–35 to –14)

19·8 (15 to 26)19 Non-Hodgkin lymphoma –3 (–23 to 20)

10·4 (9 to 11)11 Other cardiovascular and circulatory 19 (–1 to 40)

23·2 (15 to 29)25 Ovarian cancer –12 (–32 to 25)

13·8 (11 to 18)13 Pancreatic cancer 5 (–16 to 18)

17·4 (12 to 24)17 Preterm birth complications –28 (–55 to 37)

16·0 (10 to 28)15 Prostate cancer 7 (–28 to 38)

12·6 (10 to 15)12 Road injury –40 (–48 to –23)

9·3 (7 to 11)8 Self-harm –16 (–25 to 8)

23·0 (14 to 27)24 Stomach cancer –49 (–55 to –32)

2·7 (2 to 3)3 Stroke –41 (–47 to –31)

9·6 (8 to 14) 9 Brain cancer

3·9 (3 to 4) 4 Breast cancer

17·7 (13 to 22) 18 COPD

13·5 (10 to 27) 11 Cervical cancer

7·7 (7 to 9) 8 Cirrhosis7·5 (7 to 9) 7 Colorectal cancer

24·6 (21 to 28) 25 Diabetes26 Diabetes

17·1 (11 to 23) 17 Epilepsy

22·9 (14 to 28) 22 Oesophageal cancer

14·8 (11 to 22) 14 Falls

21·6 (18 to 26) 21 HIV/AIDS

34 HIV/AIDS

19·8 (13 to 28) 20 Interpersonal violence

29 Interpersonal violence


14·1 (11 to 21) 12 Leukaemia

9·7 (8 to 11) 10 Lower respiratory infections

5·1 (4 to 6) 5 Lung cancer

23·5 (12 to 29) 24 Melanoma

14·1 (11 to 20) 13 Non-Hodgkin lymphoma

15·7 (12 to 20) 16 Other cardiovascular and circulatory15·1 (11 to 26) 15 Ovarian cancer

23·0 (14 to 29) 23 Pancreatic cancer

3·2 (3 to 4) 3 Road injury2·0 (2 to 2) 2 Self-harm

18·5 (11 to 25) 19 Stomach cancer

28 Stomach cancer

5·9 (5 to 6) 6 Stroke

19·1 (13 to 34)18 Alcohol use disorders 230 (26 to 429)

43 Alcohol use disorders

11·5 (9 to 18)12 Brain cancer –12 (–30 to 7)

4·5 (3 to 6)4 Breast cancer –24 (–31 to –16)

23·6 (19 to 27)25 COPD –25 (–38 to –10)

20·3 (16 to 24)21 Cardiomyopathy 22 (–6 to 54)

27 Cardiomyopathy

23·5 (13 to 29)24 Cervical cancer –35 (–53 to 5)

3·7 (3 to 7)3 Cirrhosis 109 (–4 to 175)

8·9 (7 to 10)9 Colorectal cancer –9 (–22 to 23)

5·6 (3 to 12)6 Drug use disorders 812 (74 to 1361)

32 Drug use disorders

16·3 (12 to 23)14 Epilepsy –4 (–21 to 23)

19·6 (13 to 27)19 Oesophageal cancer 8 (–28 to 41)

15·7 (13 to 21)13 Falls –9 (–26 to 20)

1·2 (1 to 2)1 Ischaemic heart disease –43 (–49 to –28)

18·2 (13 to 24)16 Leukaemia –19 (–32 to 2)

10·8 (10 to 13)10 Lower respiratory infections –6 (–23 to 12)

6·4 (3 to 7)7 Lung cancer –22 (–35 to 7)

20·6 (13 to 30)23 Melanoma 7 (–27 to 29)

16·8 (12 to 22)15 Non-Hodgkin lymphoma –12 (–33 to 27)

11·3 (10 to 13)11 Other cardiovascular and circulatory 34 (9 to 63)

18·2 (11 to 25)17 Ovarian cancer –12 (–40 to 45)

19·6 (13 to 26)20 Pancreatic cancer 8 (–15 to 39)

20·4 (13 to 32)22 Poisonings 18 (–43 to 72)

26 Poisonings

5·3 (3 to 7)5 Road injury –34 (–44 to –17)

1·8 (1 to 2)2 Self-harm –16 (–26 to 8)

8·0 (7 to 9)8 Stroke –34 (–44 to –24)

Articles


Figure 3: Age-standardised YLLs relative to comparator countries and ranking by cause in (A) 1990 and (B) 2010 Numbers in cells indicate the ranks of each country for each cause, with 1 representing the best performing country. Countries have been sorted on the basis of age-standardised all-cause YLLs for that year. Causes are ordered by the 30 leading causes of YLLs in the UK. Colours indicate whether the age-standardised YLL rate for the country is significantly lower (green), higher (red), or indistinguishable (yellow) from the mean age-standardised YLL rate across comparator countries, with 95% confidence. YLLs=years of life lost. COPD=chronic obstructive pulmonary disease.

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48

10312

1712166

1475

11189

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1668

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19187

1012

42

1016

137

19163

1798

145

15181112

1159

1432

10115

12137

194617168

18

13812

121116191567954

18103

1714

1713

16181484769

152

11101213195

42893

16611127

18171

195

15141310

2147

1118173

13166

1215185

1049

19

3111095

121416172

191516784

1318

1572

10161436485

1213181791

1911

4115

187

10263

198

141

171512139

16

127

103

14132

1945

159

16611817181

965

11192

1015783

1213141741

1618

2197

181

1165

1014174

1383

12169

15

5621

144

181693

1513128

191711107

4181525

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171592

117

13185

168

121

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10147

126

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987

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195

124

109

158

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210131146

167

15145

1217318

189

19

A

B

Lower than mean Ranking legend Indistinguishable from mean Higher than mean

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risks, exposure estimates, and theoretical minimum risk distributions and uncertainty in the background outcome rates have been propagated into the final estimates.

BenchmarkingThe primary analysis of GBD 2010 included 187 countries. For outcomes measured for specific age groups (deaths, YLLs, YLDs, and DALYs), we computed agestandardised rates. We used the WHO age standard; this age standard has a younger population structure than most countries in Europe in 2010. 41 For each outcome of each disease, injury, or risk factor, we ranked countries in 1990 and 2010 by the agestandardised rates. We also included summary outcomes of overall mortality (life expectancy) and overall population health (HALE). We compared UK outcomes with a set of highincome countries with similar or higher levels of health expenditure: the original 15 members of the EU, Australia, Canada, the USA, and Norway (henceforth EU15+). We included Australia, Canada, the USA, and Norway because they are highincome countries with some similarities of health systems and underlying disease patterns, and they have been previously included in benchmarking exercises for the UK.42 We report ranks from one to 19 across this set of countries. Comparison of agestandardised rates provides an opportunity to benchmark health outcomes across countries in a specific period, controlling for variation in numbers and crude rates due to differences in population age structure. By using the 1000 draws in GBD 2010 for each quantity of interest, we could compute 95% uncertainty intervals (UIs) for ranks and changes in ranks. For a specific country and cause, we tested whether a country is significantly above the EU15+ mean, indistinguishable from the mean, or below the mean.

Role of the funding sourceThe sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility to submit for publication.

ResultsIn absolute terms, life expectancy in the UK increased by 4·2 years (95% UI 4·2–4·3) from 1990 to 2010. Despite this progress, the UK was significantly below the mean of EU15+ for agestandardised death rate (p<0·001), agestandardised YLLs (p=0·028), and life expectancy at birth in 1990 (p<0·001), and for agestandardised death rate (p<0·001), agestandardised YLLs (p<0·001), and life expectancy at birth (p<0·001) in 2010. For YLDs, the UK rank has improved, but this change is not significant (table 1). The combined measure of HALE has improved, but the UK remains in the bottom half of the rankings (table 1).

In male individuals younger than 20 years, agespecific mortality rates fell by nearly 40% or more between 1990

and 2010, but the decrease was slightly lower for female individuals (figure 1). In most age groups older than 55 years, male mortality also fell by nearly 40% or more and female mortality by 35% or more (figure 1). However, for some adult age groups, reductions in mortality were much more modest—eg, for men aged 30–34 years, mortality rates have hardly changed, falling by a mere 3·7% (95% UI 2·7–4·9; figure 1). In all age groups younger than 55 years, the UK rank in male agespecific mortality has worsened substantially (figure 1). In men older than 55 years, reductions in death rates in the UK have been larger than for some other countries, improving the UK’s comparative ranking (figure 1). The UK female agespecific mortality has either worsened or stayed relatively stable at the bottom of the rankings in individuals younger than 55 years when compared with other EU15+ countries (figure 1). The UK’s highest ranking was for girls aged 5–9 years in 2010 (figure 1).

The top eight causes of YLLs in the UK remained the same from 1990 to 2010, although the order did change slightly (figure 2). Despite a large decrease in the number of YLLs it caused, ischaemic heart disease remained the leading cause of YLLs in 2010 (figure 2), as in many highincome countries.28,43 Lung cancer is the second (95% UI second to third) leading cause, stroke is the third (second to third), and COPD the fourth (fourth to sixth). Colorectal cancer is the sixth (fifth to seventh) and breast cancer is the seventh (seventh to eighth) cause. In women alone, breast cancer is the third (second to fourth) leading cause of YLLs in the UK. The rank of Alzheimer’s disease increased from 24th (11th–31st) to tenth (sixth to 12th) between 1990 and 2010, representing a 137% (16–277) absolute increase. Pre mature death from cirrhosis also increased substantially (figure 2). The percentage of YLLs attributable to drug use disorders increased by nearly six times, leaping from a rank of 64th (38th–74th) to 21st (14th–39th; figure 2); however, residual changes in coding practice between ICD9 and ICD10 might have exaggerated this shift. The largest percentage declines in mean ranks were recorded for stomach cancer and diabetes, followed by road injuries and congenital anomalies. Changes in congenital anomalies might have been due to decreases in casefatality rates and increased rates of pregnancy termination.

The leading causes of YLLs in individuals aged 20–54 years—an age group for which the UK seems to have done poorly in terms of allcause mortality compared with other highincome countries (figure 1)—are a mix of cancers and cardiovascular diseases, but also selfharm, road injury, and falls (figure 2). Cirrhosis, drug use disorders, and alcohol use disorders have increased substantially in absolute numbers of YLLs caused and ranking (figure 2). Some of the rapid increases might now be additionally adversely affected by the economic downturn, as possibly shown by data for suicides.44,45 Breast cancer was the fourth (third to sixth) leading cause of YLLs for both sexes in 1990 and 2010 (figure 2), but the

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leading cause for women. Despite concerted public health and sun protection campaigns, YLLs caused by melanoma continue to increase (figure 2). In this adult age group, the numbers of YLLs caused by cancers (especially cervical cancer and leukaemia), chronic obstructive pulmonary disease (COPD), and road injuries have decreased substantially (figure 2).

In 2010, the UK had significantly lower than the mean rate of agestandardised YLLs for road injury, diabetes, liver cancer, and chronic kidney disease (figure 3). However, the UK had higher than the mean rate for ischaemic heart disease, COPD, lower respiratory infections, breast cancer, other cardiovascular and circulatory disorders, oesophageal cancer, preterm birth complications, congenital anomalies, and aortic aneurysm. The fact that mean YLLs caused by breast cancer in the UK is higher than the overall mean (figure 3) is despite an absolute reduction in YLLs (figure 2). The substantial increase in YLLs caused by cirrhosis (figure 2) meant that the UK went from having significantly fewer YLLs than the mean in 1990 to being indistinguishable from the mean in 2010 (figure 3). We recorded a significant change in rank of the UK for three causes: ischaemic heart disease has improved (p<0·001); and other circulatory (p<0·001) and congenital anomalies

(p=0·004) have worsened. Despite sizable absolute reductions in the burden of breast cancer (figure 2), it is worth noting that the UK rank has not changed significantly (figure 3).

YLDs per person by age and sex have not changed substantially in the UK, but agespecific mortality has been improving (appendix). More individuals are living into the period of life when prevalence of chronic disabling conditions is high; the increase in life expectancy at birth is greater than the increase in HALE (table 1), meaning more years are lived with disability. This finding is true for all EU15+ countries, although the difference between the increase in life expectancy at birth and HALE varies from 0·5 years in Greece to 1·7 years in Luxembourg; the UK has the 11th largest difference (1·0 years; table 1).

Cardiovascular diseases, chronic respiratory con ditions, and neurological disorders all contributed sub stantially to the burden of disability in the UK in 2010; YLDs for all three were more pronounced in individuals aged at least 80 years than in others (figure 4). However, the largest contributors to the burden of YLDs were mental and behavioural disorders (including substance abuse; 21·5%, 95% UI 17·2–26·3) and musculoskeletal disorders (30·5%, 25·5–35·7; figure 4). Together, these two groups accounted for more than half of all UK YLDs in 2010.

Figure 4: YLDs in the UK by cause and age in 2010YLDs=years lived with disability.

Intentional injuriesUnintentional injuriesTransport injuriesOther non-communicable diseasesMusculoskeletal disordersDiabetes, urogenital, blood, and endocrineMental and behavioural disordersNeurological disordersDigestive diseasesCirrhosisChronic respiratory diseasesCardiovascular and circulatory diseasesCancerOther communicable diseasesNutritional deficienciesNeonatal disordersMaternal disordersNeglected tropical diseases and malariaDiarrhoea, lower respiratory infections, and other common infectious diseasesHIV/AIDS and tuberculosis

0–6 days

7–27 days

28–364 days

1–4 years

5–9 years

10–14 years

15–19 years

20–24 years

25–29 years

30–34 years

35–39 years

40–44 years

45–49 years

50–54 years

55–59 years

60–64 years

65–69 years

70–74 years

75–79 years

≥80 years0

200 000

400 000

600 000

800 000

YLDs

Age group

See Online for appendix

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Diabetes, urogenital, blood, and endocrine disorders have important contri bu tions to disability, as do other noncommunicable disorders (including vision loss, hearing loss, and skin diseases) and unintentional injuries (includ ing falls; figure 4). Although agespecific numbers of YLDs overall steadily rise with age, the effect of population age structure is that 77·8% (95% UI 77·1–78·5) of YLDs occurred before age 70 years in the UK.

In 2010, the leading musculoskeletal causes were low back pain (first, 95% UI first to first), neck pain, (fourth, second to seventh), other musculoskeletal disorders (fifth, second to ninth), and osteoarthritis (11th, seventh to 15th). In absolute terms, the burden of musculoskeletal dis orders is rising largely because more individuals are living into the age groups at highest risk. Falls were the second leading cause of YLDs and have increased in absolute terms by 32% (95% UI 14–50) from 1990 to 2010 (figure 5). Six mental and behavioural disorders were in the 20 leading causes of YLDs: major depressive disorder, anxiety, drug use, alcohol use, schizophrenia, and bipolar disorder (figure 5). Of the 20 leading causes of YLDs in 1990, only three fell in absolute terms: other hearing loss, ischaemic heart disease, and edentulism (figure 5). YLDs for diabetes increased, but the change was not significant (figure 5).

Putting premature mortality and disability together in terms of DALYs provides an overall picture of the

leading health problems in the UK. YLDs accounted for 49·9% (95% UI 45·2–54·2) of DALYs in 2010, up from 41·1% (36·6–45·3) in 1990. The top ten causes represent a mixture of conditions that largely cause disability, such as low back pain, major depressive disorder, and neck pain (table 2). The dominant causes of premature mortality, including ischaemic heart disease, stroke, and lung cancer, were all still among the top five causes in 2010 despite sub stantial decreases since 1990. Because of their substantial contribution to YLDs, falls were among the top ten causes of DALYs. Of the 20 most important causes, Alzheimer’s disease showed the largest increase between 1990 and 2010.

In 2010, the DALY rates for major depressive disorder, diabetes, and chronic kidney disease were significantly lower than the mean (figure 6). However, the DALY rates for COPD, drug use disorders, lower respiratory infections, breast cancer, and preterm birth complications in the UK were significantly higher than the mean of EU15+ (figure 6). Compared with 1990, five causes switched from being significantly better than the mean to indistinguishable from the mean in 2010: road injury, selfharm, con genital anomalies, other cardiovascular diseases, and cirrhosis (figure 6).

The harmful effects of tobacco, including secondhand smoke, accounted for 11·8% (95% UI 10·5–13·3) of all DALYs in the UK in 2010. Taken together, all

Figure 5: UK ranks for top 25 causes of YLDs for both sexes and all ages combined with 95% UIs in 1990 and 2010 YLDs=years lived with disability. UI=uncertainty interval. COPD=chronic obstructive pulmonary disease.

Communicable, maternal, neonatal, and nutritional disorders Non-communicable diseases Injuries

Mean rank (95% UI)

Disorder Disorder Mean rank (95% UI)

% change (95% UI)

1990 2010

Ascending order in rankDescending order in rank

15·4 (11 to 23) 14 Alcohol use disorders

16·7 (13 to 22) 16 Alzheimer’s disease

5·4 (2 to 9) 5 Anxiety disorders

8·5 (3 to 13) 10 Asthma

19·7 (13 to 26) 21 Benign prostatic hyperplasia19·5 (12 to 27) 20 Bipolar disorder

7·3 (3 to 11) 7 COPD

25·5 (21 to 30) 25 Chronic kidney disease

18·2 (13 to 23) 19 Diabetes

8·1 (4 to 11) 8 Drug use disorders

20·6 (14 to 27) 22 Dysthymia

16·6 (11 to 23) 15 Edentulism

5·4 (2 to 10) 6 Falls


1·0 (1 to 1) 1 Low back pain3·4 (2 to 8) 2 Major depressive disorder

8·3 (4 to 12) 9 Migraine

3·8 (2 to 7) 3 Neck pain

11·1 (7 to 16) 11 Osteoarthritis

15·2 (10 to 22) 13 Other hearing loss

4·7 (2 to 9) 4 Other musculoskeletal disorders

25·5 (14 to 37) 24 Other vision loss

26 Other vision loss

24·2 (20 to 29) 23 Rheumatoid arthritis

14·0 (11 to 20) 12 Road injury

17·2 (11 to 23) 17 Schizophrenia

12·2 (9 to 16)12 Alcohol use disorders 48 (6 to 104)13·5 (11 to 17)13 Alzheimer’s disease 41 (19 to 64)

6·1 (2 to 9)6 Anxiety disorders 6 (–14 to 31)

8·7 (4 to 14)9 Asthma 10 (–2 to 22)

17·4 (12 to 24)16 Benign prostatic hyperplasia 26 (–6 to 65)

20·2 (13 to 27)20 Bipolar disorder 5 (–20 to 37)

7·1 (3 to 12)7 COPD 14 (–0 to 31)

23·8 (18 to 28)24 Chronic kidney disease 25 (10 to 45)

18·4 (15 to 24)18 Diabetes 8 (–9 to 29)

8·5 (5 to 11)8 Drug use disorders 7 (–9 to 25)

20·4 (15 to 28)21 Dysthymia 10 (–3 to 25)

24·3 (18 to 31)25 Edentulism –32 (–42 to –21)

3·7 (2 to 7)2 Falls 32 (14 to 50)

19·4 (13 to 26)19 Ischaemic heart disease –1 (–19 to 20)

1·0 (1 to 1)1 Low back pain 12 (2 to 23)

3·8 (2 to 8)3 Major depressive disorder 9 (–11 to 33)

8·9 (5 to 13)10 Migraine 7 (–11 to 27)

3·9 (2 to 7)4 Neck pain 13 (2 to 26)

11·0 (7 to 15)11 Osteoarthritis 16 (–4 to 41)

18·4 (11 to 26)17 Other hearing loss –10 (–22 to 2)

4·7 (2 to 9)5 Other musculoskeletal disorders 15 (–25 to 70)

23·0 (18 to 28)22 Rheumatoid arthritis 19 (2 to 38)

14·5 (11 to 19)14 Road injury 12 (–10 to 36)16·9 (11 to 23)15 Schizophrenia 15 (2 to 30)

23·4 (16 to 32)23 Stroke 50 (–24 to 178)

28 Stroke

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components of diet and physical inactivity accounted for 14·3% (12·8–15·9) of DALYs. Increased blood pressure alone accounted for 9·0% (7·5–10·5) and high bodymass index for 8·6% (7·4–9·8). These risk factors

largely increase rates of cardiovascular diseases and cancers. However, the DALYs attributable to each of these risks cannot be simply added together, because some are mediated through each other— eg, fruit

All ages DALYs (thousands) DALYs (per 100 000)

1990 2010 %Δ 1990 2010 %Δ

All causes 18 220 (16 925–19 633) 16 820 (15 388–18 362) –7·7 31 842 (29 579–34 312) 27 163 (24 850–29 653) –14·7

Communicable, maternal, neonatal, and nutritional disorders

1196 (1101–1328) 919 (825–1050) –23·2 2091 (1924–2320) 1484 (1332–1695) –29·0

HIV/AIDS and tuberculosis 55 (48–62) 39 (33–46) –28·1 95 (85–108) 63 (53–75) –33·5

Tuberculosis 23 (19–28) 17 (13–22) –25·3 40 (33–49) 28 (21–36) –30·9

HIV/AIDS 32 (28–36) 22 (19–26) –30·1 56 (50–62) 36 (30–42) –35·4

HIV disease resulting in mycobacterial infection 1 (1–2) 1 (0–1) –50·3 2 (2–3) 1 (1–1) –54·1

HIV disease resulting in other specified or unspecified diseases

31 (28–34) 22 (18–25) –29·3 53 (48–59) 35 (30–40) –34·6

Diarrhoea, lower respiratory infections, meningitis, and other common infectious diseases

672 (599–792) 541 (470–655) –19·5 1175 (1047–1384) 874 (760–1057) –25·6

Diarrhoeal diseases 65 (46–90) 77 (57–102) 18·3 114 (80–157) 124 (92–165) 9·3

Typhoid and paratyphoid fevers <0·5 (0–0·5) <0·5 (0–0·5) –2·7 <0·5 (0–1) <0·5 (0–1) –10·1

Lower respiratory infections 497 (445–596) 384 (332–479) –22·8 868 (778–1041) 619 (537–774) –28·6

Upper respiratory infections 18 (6–41) 17 (6–45) –1·7 31 (11–72) 28 (9–72) –9·1

Otitis media 31 (18–50) 30 (18–49) –3·5 54 (32–88) 48 (29–79) –10·8

Meningitis 45 (38–51) 23 (19–27) –49·2 78 (66–89) 37 (31–44) –53·1

Pneumococcal meningitis 7 (6–9) 4 (3–5) –48·7 13 (10–15) 6 (5–7) –52·6

H influenzae type B meningitis 8 (6–10) 3 (2–4) –62·8 14 (10–17) 5 (4–6) –65·6

Meningococcal infection 14 (11–16) 8 (6–9) –45·8 24 (20–29) 12 (10–15) –49·9

Other meningitis 16 (13–19) 8 (7–10) –46·0 27 (22–32) 14 (11–17) –50·1

Encephalitis 4 (4–5) 3 (2–3) –41·7 8 (6–9) 4 (3–5) –46·1

Diphtheria <0·5 (0–1) <0·5 (0–1) –51·0 <0·5 (0–2) <0·5 (0–1) –54·7

Whooping cough 8 (0–37) 4 (0–18) –50·4 14 (1–65) 7 (0–29) –54·2

Tetanus <0·5 (0–2) <0·5 (0–0·5) –75·9 1 (0–3) <0·5 (0–1) –77·7

Measles 1 (0–1) <0·5 (0–1) –51·0 1 (1–2) <0·5 (0–1) –54·7

Varicella 4 (1–10) 4 (2–10) 6·5 6 (2–18) 6 (3–16) –1·6

Neglected tropical diseases and malaria 15 (9–25) 14 (9–25) –3·7 26 (16–44) 23 (14–41) –11·0

Malaria <0·5 (0–0·5) <0·5 (0–0·5) –69·0 <0·5 (0–1) <0·5 (0–0·5) –71·4

Echinococcosis 1 (0–3) 1 (0–3) 3·2 2 (0–5) 2 (0–6) –4·6

Dengue 8 (3–18) 8 (3–18) –2·0 14 (5–31) 12 (5–28) –9·4

Rabies 1 (0–1) <0·5 (0–1) –34·1 1 (1–2) 1 (0–1) –39·1

Food-borne trematodiases <0·5 (0–0·5) <0·5 (0–0·5) –38·8 <0·5 (0–0·5) <0·5 (0–0·5) –43·5

Other neglected tropical diseases 5 (4–7) 5 (4–7) –2·6 9 (7–13) 8 (6–12) –10·0

Maternal disorders 7 (5–9) 5 (4–6) –24·6 12 (9–15) 8 (6–10) –30·3

Maternal haemorrhage 1 (1–2) 1 (1–1) –22·6 2 (1–3) 1 (1–2) –28·5

Maternal sepsis <0·5 (0–0·5) <0·5 (0–0·5) –29·9 <0·5 (0–1) <0·5 (0–0·5) –35·2

Hypertensive disorders of pregnancy 1 (1–1) 1 (1–1) –21·6 2 (1–2) 1 (1–2) –27·6

Obstructed labour <0·5 (0–1) <0·5 (0–0·5) –13·0 <0·5 (0–1) <0·5 (0–1) –19·6

Abortion 1 (1–1) <0·5 (0–1) –34·5 1 (1–2) 1 (1–1) –39·4

Other maternal disorders 3 (3–4) 3 (2–3) –24·1 6 (5–8) 4 (3–5) –29·8

Neonatal disorders 305 (262–346) 200 (177–224) –34·4 534 (457–604) 323 (285–362) –39·4

Preterm birth complications 189 (120–256) 135 (104–170) –28·8 330 (210–447) 217 (167–274) –34·2

Neonatal encephalopathy (birth asphyxia/trauma) 86 (62–114) 48 (38–60) –44·6 151 (108–199) 77 (61–97) –48·8

Sepsis and other infectious disorders of the newborn baby

15 (8–27) 9 (5–16) –39·3 26 (13–48) 15 (8–26) –44·0

Other neonatal disorders 15 (8–25) 9 (6–13) –41·7 27 (13–44) 14 (9–22) –46·1

(Continues on next page)

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1990 2010 %Δ 1990 2010 %Δ

(Continued from previous page)

Nutritional deficiencies 107 (81–140) 82 (58–118) –23·4 188 (142–245) 133 (94–190) –29·2

Protein–energy malnutrition 16 (10–18) 6 (5–9) –61·8 27 (17–32) 10 (7–15) –64·7

Iodine deficiency 20 (9–38) 21 (9–42) 4·4 35 (16–66) 34 (15–67) –3·5

Iron-deficiency anaemia 69 (51–95) 55 (36–81) –20·8 121 (89–166) 89 (59–131) –26·8

Other nutritional deficiencies 2 (1–3) <0·5 (0–1) –82·3 4 (3–5) 1 (1–1) –83·6

Other communicable, maternal, neonatal, and nutritional disorders

35 (29–46) 37 (28–47) 3·7 62 (50–81) 59 (45–75) –4·2

Sexually transmitted diseases excluding HIV 11 (6–20) 9 (5–16) –18·7 20 (11–34) 15 (8–26) –24·9

Syphilis 2 (1–3) 1 (1–1) –43·2 3 (2–5) 2 (1–2) –47·5

Sexually transmitted chlamydial diseases 4 (2–8) 3 (1–7) –9·2 6 (3–13) 5 (2–12) –16·1

Gonococcal infection 2 (1–4) 2 (1–4) –2·2 4 (2–8) 3 (1–7) –9·7

Trichomoniasis 2 (0–6) 1 (0–4) –32·6 3 (0–11) 2 (0–6) –37·7

Other sexually transmitted diseases 2 (1–4) 1 (1–3) –20·7 3 (2–6) 2 (1–4) –26·7

Hepatitis 6 (5–8) 7 (6–9) 15·8 10 (9–13) 11 (9–14) 7·0

Acute hepatitis A 2 (1–3) 2 (1–2) –21·8 3 (2–5) 2 (1–4) –27·8

Acute hepatitis B 3 (2–4) 2 (1–4) –11·6 4 (3–6) 4 (2–6) –18·3

Acute hepatitis C 2 (1–3) 3 (2–4) 108·3 3 (2–4) 5 (3–7) 92·4

Leprosy <0·5 (0–0·5) <0·5 (0–0·5) –87·5 <0·5 (0–0·5) <0·5 (0–0·5) –88·5

Other infectious diseases 18 (15–24) 21 (13–25) 13·5 32 (27–42) 33 (22–41) 4·9

Non-communicable diseases 15 644 (14 455–16 909) 14 549 (13 267–15 908) –7·0 27 340 (25 262–29 551) 23 495 (21 426–26 691) –14·1

Neoplasms 3174 (3003–3364) 2841 (2694–3001) –10·5 5547 (5248–5879) 4589 (4351–4846) –17·3

Oesophageal cancer 129 (108–166) 130 (92–156) 0·4 225 (189–291) 209 (149–252) –7·2

Stomach cancer 185 (139–242) 94 (76–145) –49·0 323 (243–423) 152 (124–235) –52·9

Liver cancer 30 (27–41) 61 (38–71) 104·9 52 (47–72) 99 (61–114) 89·4

Liver cancer secondary to hepatitis B 7 (5–9) 14 (8–17) 108·8 12 (10–16) 22 (13–28) 92·9

Liver cancer secondary to hepatitis C 11 (9–16) 23 (14–29) 113·5 19 (16–27) 38 (23–46) 97·3

Liver cancer secondary to alcohol use 8 (7–12) 17 (11–21) 108·3 15 (12–20) 28 (18–33) 92·5

Other liver cancer 4 (3–5) 7 (4–8) 68·0 7 (6–9) 11 (7–13) 55·2

Larynx cancer 24 (14–41) 17 (10–27) –31·5 43 (25–72) 27 (16–43) –36·7

Trachea, bronchus, and lung cancers 808 (661–987) 612 (498–767) –24·2 1412 (1155–1726) 989 (805–1238) –30·0

Breast cancer 374 (351–404) 295 (271–320) –21·1 654 (614–706) 477 (438–517) –27·1

Cervical cancer 62 (36–79) 36 (27–64) –41·8 108 (63–138) 58 (44–103) –46·3

Uterine cancer 24 (15–46) 29 (13–37) 21·3 41 (26–81) 46 (20–59) 12·0

Prostate cancer 129 (79–200) 147 (86–226) 13·8 225 (138–349) 237 (139–365) 5·1

Colon and rectum cancers 362 (306–411) 325 (291–394) –10·2 632 (534–718) 525 (470–637) –17·0

Mouth cancer 30 (27–36) 36 (30–41) 18·4 53 (46–63) 57 (48–66) 9·4

Nasopharynx cancer 6 (5–9) 6 (4–9) –0·6 11 (8–16) 10 (7–15) –8·2

Cancer of other part of pharynx and oropharynx 14 (11–22) 20 (12–25) 41·6 25 (19–38) 33 (19–41) 30·8

Gallbladder and biliary tract cancer 20 (14–29) 18 (13–27) –7·6 35 (24–51) 29 (21–43) –14·6

Pancreatic cancer 135 (104–180) 141 (106–181) 4·4 235 (181–315) 227 (171–293) –3·5

Malignant melanoma of skin 41 (29–71) 53 (28–68) 29·7 71 (51–125) 85 (46–110) 19·9

Non-melanoma skin cancer 11 (7–15) 11 (8–16) 7·9 19 (12–26) 19 (13–25) –0·3

Ovarian cancer 105 (77–139) 92 (66–128) –12·3 184 (135–243) 149 (107–207) –19·0

Testicular cancer 8 (5–10) 6 (4–10) –21·5 13 (8–18) 10 (7–16) –27·4

Kidney and other urinary organ cancers 66 (49–92) 77 (57–103) 17·6 115 (85–161) 125 (91–166) 8·6

Bladder cancer 96 (78–115) 68 (56–87) –29·0 167 (137–201) 110 (91–141) –34·4

Brain and nervous system cancers 104 (74–150) 101 (63–135) –2·8 182 (129–263) 164 (102–218) –10·1

Thyroid cancer 7 (5–9) 7 (5–9) –0·0 12 (9–17) 11 (8–14) –7·6


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1990 2010 %Δ 1990 2010 %Δ


Hodgkin's disease 17 (11–26) 13 (9–19) –27·1 30 (20–45) 20 (14–31) –32·7

Non-Hodgkin lymphoma 108 (93–125) 105 (85–125) –2·8 189 (162–218) 170 (137–202) –10·2

Multiple myeloma 50 (34–77) 51 (32–72) 2·8 87 (59–135) 83 (52–117) –5·0

Leukaemia 106 (87–132) 98 (81–120) –7·7 185 (152–231) 158 (131–193) –14·7

Other neoplasms 125 (98–183) 192 (115–254) 54·0 218 (171–320) 310 (185–410) 42·3

Cardiovascular and circulatory diseases 4450 (4172–4600) 2710 (2566–2938) –39·1 7777 (7292–8039) 4376 (4144–4745) –43·7

Rheumatic heart disease 63 (57–69) 35 (30–41) –43·5 110 (100–120) 57 (49–65) –47·8

Ischaemic heart disease 2840 (2594–2941) 1454 (1361–1708) –48·8 4963 (4533–5140) 2348 (2198–2758) –52·7

Cerebrovascular disease 1044 (930–1132) 664 (589–764) –36·4 1825 (1626–1978) 1073 (952–1233) –41·2

Ischaemic stroke 602 (536–652) 392 (346–458) –34·9 1053 (937–1140) 633 (558–740) –39·9

Haemorrhagic and other non-ischaemic stroke 442 (400–491) 272 (235–303) –38·3 772 (699–859) 440 (380–489) –43·0

Hypertensive heart disease 61 (50–77) 55 (45–66) –9·5 106 (87–135) 89 (73–106) –16·3

Cardiomyopathy and myocarditis 52 (43–62) 56 (50–60) 7·9 90 (75–108) 90 (81–97) –0·3

Atrial fibrillation and flutter 50 (36–68) 71 (54–92) 42·0 87 (63–119) 114 (87–148) 31·2

Aortic aneurysm 116 (89–152) 103 (82–131) –11·3 203 (156–266) 167 (132–212) –18·1

Peripheral vascular disease 29 (19–44) 40 (27–60) 36·1 51 (33–77) 64 (44–96) 25·8

Endocarditis 12 (10–16) 10 (9–12) –13·8 21 (17–27) 17 (14–19) –20·3

Other cardiovascular and circulatory diseases 184 (160–213) 221 (202–243) 20·2 322 (280–373) 358 (327–393) 11·0

Chronic respiratory diseases 1175 (958–1453) 1191 (958–1499) 1·4 2053 (1675–2540) 1924 (1547–2420) –6·3

Chronic obstructive pulmonary disease 714 (594–866) 707 (573–875) –1·0 1249 (1038–1513) 1142 (925–1413) –8·5

Pneumoconiosis 18 (12–29) 13 (9–19) –26·1 31 (20–51) 21 (15–31) –31·7

Asthma 276 (160–429) 304 (180–470) 10·0 482 (279–749) 490 (290–759) 1·6

Interstitial lung disease and pulmonary sarcoidosis 46 (30–76) 56 (35–78) 23·2 80 (52–133) 91 (57–125) 13·8

Other chronic respiratory diseases 121 (94–155) 111 (87–139) –8·1 211 (165–271) 179 (140–224) –15·1

Cirrhosis of the liver 137 (120–188) 219 (139–257) 60·0 239 (210–329) 354 (224–415) 47·9

Cirrhosis of the liver secondary to hepatitis B 12 (10–17) 19 (11–24) 56·6 21 (17–30) 31 (18–39) 44·7

Cirrhosis of the liver secondary to hepatitis C 56 (47–75) 84 (54–103) 50·5 98 (82–130) 136 (88–167) 39·1

Cirrhosis of the liver secondary to alcohol use 51 (42–74) 87 (51–109) 68·6 90 (74–130) 140 (82–176) 55·8

Other cirrhosis of the liver 18 (15–24) 30 (18–37) 67·6 31 (26–43) 48 (30–59) 54·9

Digestive diseases (except cirrhosis) 283 (251–324) 302 (254–370) 6·8 494 (438–566) 487 (410–598) –1·3

Peptic ulcer disease 82 (69–89) 42 (36–51) –48·4 143 (121–156) 68 (58–83) –52·3

Gastritis and duodenitis 7 (5–9) 7 (5–10) 2·3 12 (9–16) 11 (9–15) –5·5

Appendicitis 5 (3–7) 5 (3–7) 5·2 9 (6–13) 9 (5–12) –2·8

Paralytic ileus and intestinal obstruction without hernia 23 (16–30) 23 (17–32) 1·0 40 (29–53) 38 (27–51) –6·6

Inguinal or femoral hernia 8 (5–17) 7 (4–15) –13·2 14 (8–30) 12 (7–24) –19·8

Non-infective inflammatory bowel disease 42 (27–65) 51 (28–95) 21·9 73 (48–114) 82 (46–153) 12·7

Vascular disorders of intestine 29 (15–62) 31 (17–59) 7·0 51 (26–108) 51 (27–96) –1·1

Gallbladder and bile duct disease 19 (15–24) 24 (17–31) 28·5 33 (26–43) 39 (27–50) 18·7

Pancreatitis 19 (15–27) 27 (20–36) 39·1 34 (25–46) 43 (32–58) 28·5

Other digestive diseases 49 (37–66) 83 (64–105) 71·9 85 (64–116) 135 (104–170) 58·9

Neurological disorders 766 (643–905) 1015 (867–1162) 32·6 1338 (1124–1582) 1639 (1399–1876) 22·5

Alzheimer's disease and other dementias 220 (163–313) 387 (304–488) 75·8 385 (284–546) 625 (491–788) 62·5

Parkinson's disease 53 (37–66) 71 (55–97) 35·2 92 (65–115) 115 (89–157) 24·9

Epilepsy 93 (79–111) 97 (80–115) 4·3 163 (138–193) 157 (130–185) –3·7

Multiple sclerosis 43 (36–52) 49 (40–60) 13·5 76 (62–91) 80 (64–96) 4·9

Migraine 264 (172–366) 283 (179–390) 6·8 462 (301–639) 456 (288–630) –1·3

Tension-type headache 17 (10–27) 19 (11–30) 10·5 30 (17–48) 30 (18–49) 2·1

Other neurological disorders 75 (58–101) 109 (84–144) 45·7 131 (101–177) 177 (135–233) 34·6


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1990 2010 %Δ 1990 2010 %Δ


Mental and behavioural disorders 1657 (1342–1989) 1940 (1579–2326) 17·1 2895 (2345–3476) 3133 (2550–3756) 8·2

Schizophrenia 129 (81–179) 147 (93–200) 14·0 225 (142–312) 237 (150–323) 5·3

Alcohol use disorders 146 (97–214) 227 (155–320) 56·1 255 (169–375) 367 (250–516) 44·2

Drug use disorders 285 (204–379) 384 (279–490) 34·8 497 (357–662) 620 (451–791) 24·6

Opioid use disorders 118 (81–157) 184 (131–235) 56·3 206 (142–275) 297 (211–379) 44·5

Cocaine use disorders 20 (12–32) 21 (12–33) 3·5 36 (21–55) 34 (20–53) –4·4

Amphetamine use disorders 47 (26–75) 47 (26–75) –0·6 83 (45–132) 76 (42–122) –8·2

Cannabis use disorders 29 (14–54) 28 (14–51) –3·6 51 (25–94) 46 (22–83) –10·9

Other drug use disorders 70 (44–102) 103 (69–136) 47·8 122 (78–179) 167 (111–220) 36·6

Unipolar depressive disorders 497 (369–644) 541 (403–687) 9·0 868 (646–1,125) 874 (650–1,110) 0·7

Major depressive disorder 401 (296–528) 436 (324–566) 8·7 701 (518–923) 704 (524–913) 0·4

Dysthymia 95 (63–133) 105 (68–148) 10·3 167 (111–233) 170 (110–239) 1·9

Bipolar affective disorder 104 (64–158) 108 (67–160) 4·0 181 (111–276) 174 (108–259) –3·9

Anxiety disorders 335 (226–474) 354 (240–500) 5·5 586 (394–829) 571 (388–807) –2·5

Eating disorders 34 (22–49) 52 (31–81) 53·9 59 (38–86) 83 (50–131) 42·2

Pervasive development disorders 58 (40–81) 63 (44–88) 9·1 101 (70–142) 102 (71–142) 0·8

Autism 28 (19–39) 31 (20–43) 10·1 49 (33–68) 49 (33–69) 1·7

Asperger's syndrome 30 (20–43) 33 (22–47) 8·2 53 (35–76) 53 (35–76) –0·1

Childhood behavioural disorders 37 (22–56) 37 (23–58) 0·2 65 (38–98) 60 (37–93) –7·4

Attention-deficit hyperactivity disorder 4 (2–6) 4 (2–6) 1·4 6 (3–10) 6 (3–10) –6·3

Conduct disorder 34 (19–52) 34 (20–54) 0·1 59 (33–91) 55 (32–86) –7·5

Idiopathic intellectual disability 8 (4–14) 7 (3–12) –18·3 15 (8–24) 11 (5–19) –24·5

Other mental and behavioural disorders 23 (13–34) 18 (10–31) –24·0 41 (22–59) 29 (16–50) –29·8

Diabetes, urogenital, blood, and endocrine diseases 706 (591–857) 807 (657–977) 14·4 1233 (1032–1498) 1304 (1061–1578) 5·7

Diabetes mellitus 242 (201–294) 208 (166–265) –13·8 422 (352–514) 337 (269–428) –20·3

Acute glomerulonephritis 1 (0–1) <0·5 (0–0·5) –48·0 1 (1–2) <0·5 (0–1) –52·0

Chronic kidney diseases 132 (112–157) 143 (118–175) 8·2 231 (195–274) 231 (191–282) –0·1

Chronic kidney disease due to diabetes mellitus 27 (20–34) 30 (22–39) 11·1 46 (36–59) 48 (36–62) 2·7

Chronic kidney disease due to hypertension 26 (22–32) 28 (22–35) 7·6 45 (38–55) 45 (36–57) –0·6

Chronic kidney disease unspecified 80 (67–96) 86 (69–105) 7·4 140 (116–168) 139 (112–169) –0·8

Urinary diseases and male infertility 131 (88–189) 207 (142–286) 58·3 229 (153–330) 335 (229–462) 46·3

Tubulointerstitial nephritis, pyelonephritis, and urinary tract infections

15 (10–25) 53 (19–87) 255·0 26 (18–44) 86 (31–141) 228·0

Urolithiasis 8 (5–12) 9 (6–14) 12·6 14 (9–21) 14 (9–22) 4·0

Benign prostatic hyperplasia 102 (63–155) 127 (78–197) 24·6 179 (110–271) 206 (126–318) 15·1

Male infertility 1 (0–1) 1 (0–2) 7·4 1 (0–3) 1 (0–3) –0·7

Other urinary diseases 5 (4–7) 17 (10–23) 233·3 9 (7–13) 27 (16–37) 208·0

Gynaecological diseases 73 (41–123) 79 (44–135) 7·7 128 (72–215) 128 (71–218) –0·5

Uterine fibroids 16 (8–30) 19 (9–37) 22·3 28 (13–53) 31 (14–60) 13·1

Polycystic ovarian syndrome 22 (10–41) 22 (10–41) –1·1 38 (18–71) 35 (17–65) –8·6

Female infertility 1 (0–1) 1 (0–1) 5·2 1 (0–2) 1 (0–2) –2·8

Endometriosis 4 (1–8) 4 (1–8) 0·5 7 (2–13) 7 (2–12) –7·2

Genital prolapse 20 (7–43) 22 (8–45) 7·9 35 (13–75) 35 (14–73) –0·3

Premenstrual syndrome 10 (0–28) 11 (1–28) 3·8 18 (1–48) 17 (1–46) –4·1

Other gynaecological diseases 1 (0–1) 1 (1–1) 51·2 1 (1–2) 1 (1–2) 39·7

Haemoglobinopathies and haemolytic anaemias 101 (73–138) 102 (73–138) 0·4 177 (127–241) 164 (117–223) –7·3

Thalassaemias 28 (19–40) 25 (17–37) –8·7 48 (32–69) 41 (27–60) –15·7

Sickle cell disorders 64 (44–90) 67 (46–95) 5·1 112 (76–157) 109 (74–153) –2·9


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1990 2010 %Δ 1990 2010 %Δ


G6PD deficiency 2 (1–3) 2 (1–2) –18·0 3 (3–5) 3 (2–3) –24·3

Other haemoglobinopathies and haemolytic anaemias

8 (6–10) 7 (6–10) –1·6 13 (10–17) 12 (9–16) –9·0

Other endocrine, nutritional, blood, and immune disorders

25 (16–38) 67 (29–94) 166·6 44 (29–66) 108 (47–152) 146·3

Musculoskeletal disorders 2302 (1721–2919) 2616 (1974–3306) 13·6 4023 (3007–5102) 4224 (3188–5338) 5·0

Rheumatoid arthritis 98 (76–125) 106 (77–138) 7·4 172 (133–218) 171 (125–223) –0·7

Osteoarthritis 189 (118–280) 217 (137–322) 15·1 330 (205–490) 351 (221–520) 6·4

Low back and neck pain 1655 (1158–2214) 1859 (1283–2481) 12·3 2893 (2023–3869) 3002 (2212–4260) 3·8

Low back pain 1276 (890–1725) 1432 (974–1927) 12·2 2231 (1555–3015) 2313 (1574–3113) 3·7

Neck pain 379 (263–520) 427 (294–591) 12·7 662 (460–908) 689 (476–954) 4·1

Gout 3 (2–5) 4 (2–6) 21·0 5 (3–8) 6 (4–9) 11·8

Other musculoskeletal disorders 356 (245–488) 429 (314–571) 20·8 621 (429–852) 694 (506–921) 11·6

Other non-communicable diseases 993 (744–1,363) 905 (665–1274) –8·8 1735 (1300–2381) 1462 (1074–2057) –15·7

Congenital anomalies 194 (162–219) 132 (115–157) –32·0 340 (284–383) 213 (185–253) –37·2

Neural tube defects 16 (10–25) 6 (4–9) –60·8 27 (17–44) 10 (7–14) –63·8

Congenital heart anomalies 126 (101–146) 55 (45–68) –56·7 221 (176–255) 88 (72–110) –60·0

Cleft lip and cleft palate 1 (1–2) 1 (1–2) –14·9 2 (1–3) 2 (1–3) –21·4

Down's syndrome 10 (7–13) 14 (10–19) 46·2 17 (12–23) 23 (16–30) 35·1

Other chromosomal abnormalities 14 (9–22) 14 (10–21) –3·2 25 (16–38) 22 (16–34) –10·5

Other congenital anomalies 27 (15–48) 42 (24–60) 55·7 47 (26–84) 68 (39–98) 43·8

Skin and subcutaneous diseases 309 (204–471) 330 (217–500) 6·8 539 (357–824) 532 (351–808) –1·3

Eczema 70 (35–113) 75 (36–122) 6·7 122 (61–197) 121 (59–197) –1·4

Psoriasis 14 (7–22) 15 (7–24) 9·0 24 (12–38) 24 (12–38) 0·7

Cellulitis 6 (4–11) 6 (4–10) –1·2 10 (7–20) 9 (6–17) –8·7

Abscess, impetigo, and other bacterial skin diseases 9 (7–14) 10 (7–14) 3·5 16 (12–25) 16 (11–23) –4·4

Scabies 3 (1–7) 3 (1–7) 0·9 6 (3–12) 6 (2–11) –6·7

Fungal skin diseases 14 (4–32) 15 (5–36) 10·7 24 (7–56) 24 (8–57) 2·3

Viral skin diseases 25 (10–49) 27 (11–52) 6·3 44 (18–86) 43 (18–83) –1·8

Acne vulgaris 47 (21–93) 44 (19–87) –6·3 81 (36–163) 71 (31–140) –13·4

Alopecia areata 12 (4–23) 13 (4–25) 8·3 20 (6–40) 20 (6–40) 0·1

Pruritus 27 (12–53) 32 (14–63) 15·8 48 (22–93) 51 (23–101) 7·0

Urticaria 21 (8–38) 23 (9–41) 8·4 37 (14–66) 37 (14–66) 0·2

Decubitus ulcer 13 (9–21) 15 (10–23) 10·2 23 (15–36) 24 (16–37) 1·8

Other skin and subcutaneous diseases 48 (22–91) 54 (25–101) 13·4 84 (38–158) 88 (41–164) 4·8

Sense organ diseases 285 (198–406) 287 (196–413) 0·7 498 (346–709) 463 (317–667) –7·0

Glaucoma 7 (5–9) 10 (7–15) 58·3 11 (8–16) 17 (11–23) 46·3

Cataracts 41 (28–57) 31 (21–44) –23·7 72 (49–100) 51 (34–71) –29·5

Macular degeneration 12 (8–17) 20 (13–28) 66·1 21 (15–29) 32 (22–45) 53·5

Refraction and accommodation disorders 16 (11–21) 17 (12–23) 11·3 27 (19–36) 28 (20–37) 2·9

Other hearing loss 136 (79–219) 122 (70–200) –10·4 237 (138–383) 196 (113–323) –17·2

Other vision loss 73 (32–142) 85 (38–168) 16·7 127 (56–248) 137 (62–271) 7·9

Other sense organ diseases 1 (0–3) 1 (1–3) 12·4 2 (1–5) 2 (1–6) 3·8

Oral disorders 170 (97–266) 138 (80–224) –19·3 298 (169–465) 222 (129–362) –25·4

Dental caries 15 (6–28) 16 (7–32) 9·9 26 (11–49) 27 (11–52) 1·6

Periodontal disease 33 (12–70) 38 (14–80) 14·6 57 (22–123) 61 (23–130) 5·9

Edentulism 123 (69–190) 84 (48–129) –31·9 215 (120–332) 135 (77–209) –37·0

Sudden infant death syndrome 34 (15–67) 19 (10–30) –44·8 60 (26–117) 31 (17–48) –49·0


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consumption has one of its primary effects through lowering blood pressure. Between 1990 and 2010, DALYs attributable to ambient air pollution decreased by 64% (57–68; table 3), which is a public health success story.

The leading risk factor in the UK in 2010 was tobacco smoking (figure 7), as it was in 1990. It remains the most important risk despite a 41% (95% UI 35–46) decrease in attributable DALYs. Two risks are roughly equal to each other in magnitude: high blood pressure and high bodymass index, each causing about 9% of the burden of disease. Alcohol burden is distributed across all age groups; but a substantial fraction (66%, 95% UI 58–77) of this burden is in individuals younger than 55 years. 28% (95% UI 19–37) of alcoholattributable DALYs are in women. High bodymass index and alcohol are the only leading risks evaluated in 1990 and 2010, for which attributable burden has not fallen. Increased total cholesterol was the fourth (fourth to sixth) leading cause in 1990, but has improved to the seventh (sixth to tenth), after attributable DALYs decreased by 60% (46–72). High

fasting plasma glucose accounted for 3·2% (2·2–4·2) of DALYs in 2010 (figure 7), and is ranked ninth (seventh to 12th) among the risk factors. The burden related to drug use has increased in absolute terms by 32% (8–55), rising from a rank of 15th (14th to 18th) to 11th (ninth to 15th). The rank of ambient air pollution fell from seventh (seventh to ninth) to 12th (tenth to 15th).

DiscussionIn 1990, overall health outcomes in the UK were significantly below average compared with EU15+. Mortality in nearly every age group in the UK has decreased in the past two decades, and disability prevalence has not increased. As a result, life expectancy at birth and HALE have improved. This progress, however, has not been large enough to match or surpass the average of EU15+. Our analysis of agespecific mortality has shown that the UK significantly improved relative to other nations between 1990 and 2010 only for men older than 55 years. The effect of tobacco on these patterns is


1990 2010 %Δ 1990 2010 %Δ


Injuries 1380 (1190–1642) 1352 (1123–1662) –2·0 2411 (2080–2869) 2183 (1813–2684) –9·4

Transport injuries 430 (362–517) 350 (282–443) –18·5 751 (633–903) 565 (455–716) –24·7

Road injury 396 (336–476) 311 (251–390) –21·4 692 (586–832) 502 (405–630) –27·4

Pedestrian injury by road vehicle 93 (74–119) 64 (51–82) –30·9 163 (130–208) 104 (82–132) –36·1

Pedal cycle vehicle 19 (14–24) 18 (14–22) –5·0 32 (25–42) 28 (22–36) –12·2

Motorised vehicle with two wheels 67 (52–85) 59 (47–75) –12·2 117 (91–149) 95 (76–120) –18·9

Motorised vehicle with three or more wheels 218 (180–263) 175 (142–220) –19·8 381 (314–460) 283 (229–355) –25·9

Road injury other 4 (3–5) 3 (2–4) –30·5 7 (5–9) 4 (3–6) –35·8

Other transport injury 34 (26–44) 39 (29–53) 14·7 59 (46–77) 63 (46–86) 6·0

Unintentional injuries other than transport injuries 643 (514–819) 750 (595–967) 16·6 1124 (897–1431) 1211 (961–1562) 7·8

Falls 422 (314–560) 532 (403–715) 26·0 738 (549–979) 860 (650–1,155) 16·5

Drowning 19 (16–25) 18 (12–22) –6·4 34 (29–43) 29 (20–35) –13·5

Fire, heat, and hot substances 39 (29–48) 27 (20–38) –31·2 68 (51–85) 43 (32–61) –36·5

Poisonings 27 (22–40) 27 (16–35) 1·3 47 (38–70) 44 (25–57) –6·4

Exposure to mechanical forces 41 (29–51) 21 (15–34) –48·3 72 (51–89) 35 (24–56) –52·2

Mechanical forces (firearm) 5 (4–7) 2 (1–3) –65·5 9 (6–13) 3 (2–4) –68·1

Mechanical forces (other) 38 (31–48) 23 (17–31) –40·4 67 (54–84) 37 (27–50) –44·9

Adverse effects of medical treatment 12 (10–16) 27 (21–35) 118·2 22 (17–28) 44 (34–57) 101·6

Animal contact 4 (3–6) 2 (2–3) –39·7 7 (5–10) 4 (3–5) –44·3

Animal contact (venomous) 2 (2–4) 1 (1–2) –51·1 4 (3–6) 2 (1–3) –54·9

Animal contact (non-venomous) 2 (1–2) 1 (1–2) –23·6 3 (2–4) 2 (1–3) –29·4

Unintentional injuries not classified elsewhere 77 (63–97) 94 (76–117) 21·9 135 (110–169) 153 (123–190) 12·6

Self-harm and interpersonal violence 306 (252–363) 251 (217–334) –18·1 535 (440–635) 405 (351–539) –24·3

Self-harm 257 (204–317) 216 (177–292) –15·9 448 (357–553) 348 (285–471) –22·3

Interpersonal violence 50 (38–60) 35 (27–50) –29·2 87 (67–106) 57 (44–81) –34·6

Assault by firearm 7 (5–10) 6 (5–8) –17·1 13 (10–17) 10 (8–13) –23·4

Assault by sharp object 13 (9–17) 12 (9–19) –1·4 22 (16–30) 20 (15–30) –8·9

Assault by other means 31 (23–38) 18 (14–25) –40·0 54 (41–66) 30 (23–40) –44·5

Data are DALYs (95% uncertainty interval) or % change. DALYs=disability-adjusted life-years. %Δ=percentage change. H influenzae=Haemophilus influenzae.

Table 2: DALYs for 259 causes in 1990 and 2010 for all ages and both sexes combined, and per 100 000 for the UK

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probably important. The legacy of extremely high tobacco consumption after World War 2 in men—which only began to fall in the 1970s23,46,47—has contributed to both the

poor UK outcomes in 1990 and the relative progress for men older than 55 years. Very poor relative per formance for some cancers and COPD are also related to the legacy

Figure 6: Age-standardised DALYs relative to comparator countries and ranking by cause in (A) 1990 and (B) 2010 Numbers in cells indicate the ranks by country for each cause, with 1 representing the best performing country. Countries have been sorted on the basis of age-standardised all-cause DALYs for that year. Causes are ordered by the 30 leading causes of DALYs in the UK. Colours indicate whether the age-standardised DALY rate for the country is significantly lower (green), higher (red), or indistinguishable (yellow) from the mean age-standardised DALY rate across the comparator countries, with 95% confidence. DALYs=disability-adjusted life-years. COPD=chronic obstructive pulmonary disease.

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Lower than mean Ranking legend Indistinguishable from mean Higher than mean

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Men Women Both sexes

1990 2010 1990 2010 1990 2010

Unimproved water and sanitation 0 (0–1) 0 (0–0) 0 (0–1) 0 (0–0) 1 (0–2) 0 (0–1)

Unimproved water source 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–1) 0 (0–0)

Unimproved sanitation 0 (0–1) 0 (0–0) 0 (0–1) 0 (0–0) 1 (0–1) 0 (0–0)

Air pollution ·· ·· ·· ·· ·· ··

Ambient particulate matter pollution 615 (540–691) 224 (189–265) 381 (322–432) 137 (112–168) 996 (875–1116) 361 (304–423)

Household air pollution from solid fuels ·· ·· ·· ·· ·· ··

Ambient ozone pollution 8 (2–15) 5 (1–10) 5 (1–9) 4 (1–9) 12 (4–24) 9 (2–18)

Other environmental risks 53 (37–75) 100 (65–153) 34 (22–48) 72 (45–110) 87 (65–114) 172 (119–257)

Residential radon ·· 23 (2–70) ·· 15 (2–49) ·· 38 (4–115)

Lead exposure 53 (37–75) 77 (53–110) 34 (22–48) 56 (36–80) 87 (65–114) 134 (99–173)

Child and maternal undernutrition 51 (38–68) 44 (30–61) 27 (19–38) 16 (8–29) 78 (59–105) 59 (40–86)

Suboptimal breastfeeding ·· ·· ·· ·· ·· ··

Non-exclusive breastfeeding ·· ·· ·· ·· ·· ··

Discontinued breastfeeding ·· ·· ·· ·· ·· ··

Childhood underweight 2 (2–3) 1 (1–1) 2 (1–3) 1 (0–1) 4 (3–6) 2 (1–2)

Iron deficiency 46 (34–63) 42 (29–59) 23 (15–34) 13 (6–27) 69 (51–95) 55 (36–81)

Vitamin A deficiency 1 (0–1) 0 (0–1) 1 (0–1) 0 (0–1) 1 (0–2) 1 (0–1)

Zinc deficiency 2 (1–3) 1 (0–2) 2 (1–3) 1 (0–2) 3 (1–6) 2 (1–4)

Tobacco smoking (including second-hand smoke) 2163 (1933–2372) 1173 (1048–1378) 1218 (1057–1401) 835 (632–968) 3381 (3100–3659) 2007 (1771–2280)

Tobacco smoking 2089 (1851–2304) 1145 (1020–1356) 1165 (996–1350) 819 (617–951) 3254 (2962–3544) 1965 (1728–2244)

Second-hand smoke 74 (52–97) 27 (19–37) 53 (37–71) 15 (10–21) 127 (93–161) 43 (30–55)

Alcohol and drug use 488 (278–677) 798 (616–983) 221 (98–324) 301 (221–380) 708 (469–953) 1099 (881–1337)

Alcohol use 276 (80–438) 508 (365–646) 128 (15–225) 192 (120–259) 404 (185–606) 700 (530–873)

Drug use 217 (158–286) 296 (211–375) 95 (67–128) 110 (81–143) 311 (230–407) 407 (304–511)

Physiological risk factors ·· ·· ·· ·· ·· ··

High fasting plasma glucose 503 (372–650) 319 (194–450) 361 (271–455) 216 (136–305) 865 (688–1051) 535 (377–715)

High total cholesterol 945 (786–1101) 382 (233–528) 613 (488–718) 235 (137–354) 1558 (1315–1788) 617 (428–830)

High blood pressure 1699 (1514–1866) 880 (697–1051) 1334 (1188–1455) 649 (510–793) 3033 (2765–3289) 1529 (1286–1755)

High body-mass index 817 (665–962) 807 (689–937) 638 (504–766) 645 (535–772) 1455 (1184–1715) 1451 (1240–1686)

Low bone mineral density 34 (24–47) 52 (35–73) 33 (20–48) 41 (22–61) 68 (47–93) 92 (65–126)

Dietary risk factors and physical inactivity 2180 (1988–2316) 1409 (1302–1576) 1409 (1249–1525) 1005 (913–1173) 3589 (3294–3812) 2414 (2237–2668)

Diet low in fruits 858 (612–1079) 498 (364–627) 520 (381–653) 295 (222–380) 1378 (1016–1718) 793 (594–991)

Diet low in vegetables 353 (237–472) 208 (143–274) 235 (157–308) 132 (88–179) 588 (398–776) 340 (235–446)

Diet low in whole grains 131 (5–284) 103 (21–184) 69 (1–170) 57 (7–105) 200 (38–382) 160 (63–257)

Diet low in nuts and seeds 759 (495–967) 369 (231–490) 411 (258–538) 186 (112–273) 1170 (759–1499) 555 (342–741)

Diet low in milk 20 (6–34) 20 (6–34) 16 (4–28) 13 (4–24) 36 (10–62) 33 (9–57)

Diet high in red meat 11 (4–18) 11 (4–17) 9 (4–14) 7 (3–12) 20 (8–31) 18 (8–28)

Diet high in processed meat 376 (90–722) 204 (59–352) 199 (56–356) 98 (36–176) 576 (147–1011) 302 (100–523)

Diet high in sugar-sweetened beverages 23 (18–30) 16 (11–21) 18 (13–24) 12 (9–16) 42 (32–53) 28 (20–36)

Diet low in fibre 343 (155–531) 181 (86–282) 180 (81–278) 90 (46–142) 523 (236–799) 271 (132–419)

Diet low in calcium 31 (18–43) 31 (18–47) 14 (9–19) 11 (8–16) 44 (28–62) 43 (26–60)

Diet low in seafood omega-3 fatty acids 392 (285–497) 193 (138–257) 200 (142–257) 90 (63–136) 592 (433–751) 282 (202–378)

Diet low in polyunsaturated fatty acids 208 (98–317) 102 (49–156) 107 (51–166) 49 (23–79) 316 (148–481) 151 (73–232)

Diet high in trans fatty acids 187 (132–246) 87 (61–117) 97 (66–129) 43 (29–65) 284 (202–366) 130 (92–176)

Diet high in sodium 436 (271–594) 267 (169–365) 270 (167–369) 170 (105–237) 706 (443–957) 437 (276–597)

Physical inactivity and low physical activity ·· 446 (374–535) ·· 389 (336–466) ·· 835 (716–975)

Occupational risk factors 259 (197–335) 250 (176–333) 103 (73–138) 118 (80–161) 361 (272–467) 368 (265–490)

Occupational carcinogens 80 (57–126) 90 (49–129) 21 (14–37) 28 (12–43) 101 (78–150) 118 (70–164)

Occupational exposure–asbestos 72 (50–117) 85 (44–123) 18 (12–34) 26 (10–41) 90 (67–137) 111 (63–155)

Occupational exposure–arsenic 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–1) 0 (0–0)

Occupational exposure–benzene 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 1 (0–2) 1 (0–2)


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of tobacco. Despite falling rates of tobaccoattributable burden for both men and women, the UK has a more advanced epidemic than most highincome nations;22,23 tobacco remains the leading risk factor in the UK in 2010.

The detailed analysis of premature mortality in our study suggests that the UK has significantly lower rates

of premature mortality than the mean for EU15+ for several important disorders, such as diabetes and chronic kidney diseases. This finding is supported by the fairly small burden attributable to increased fasting plasma glucose in the risk factor analysis. As part of the GBD methodology, detailed efforts have been made to make

Men Women Both sexes

1990 2010 1990 2010 1990 2010


Occupational exposure–beryllium 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0)

Occupational exposure–cadmium 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0)

Occupational exposure–chromium 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0)

Occupational exposure–diesel engine exhaust 2 (1–3) 1 (1–2) 0 (0–1) 0 (0–1) 3 (2–4) 2 (1–3)

Occupational exposure–second-hand smoke 2 (2–3) 1 (1–2) 1 (1–2) 1 (1–1) 4 (3–5) 2 (2–3)

Occupational exposure–formaldehyde 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0)

Occupational exposure–nickel 1 (0–2) 1 (0–1) 0 (0–0) 0 (0–0) 1 (0–3) 1 (0–2)

Occupational exposure–polycyclic aromatic hydrocarbons

0 (0–1) 0 (0–0) 0 (0–0) 0 (0–0) 1 (0–1) 0 (0–1)

Occupational exposure–silica 2 (1–2) 1 (1–1) 0 (0–0) 0 (0–0) 2 (1–2) 1 (1–2)

Occupational exposure–sulphuric acid 0 (0–1) 0 (0–1) 0 (0–0) 0 (0–0) 0 (0–1) 0 (0–1)

Occupational asthmagens 9 (5–14) 7 (4–12) 7 (4–11) 7 (4–11) 15 (9–24) 15 (8–23)

Occupational particulate matter, gases, and fumes 24 (9–42) 22 (8–39) 6 (2–11) 7 (2–14) 30 (11–53) 29 (11–53)

Occupational noise 10 (6–17) 7 (4–12) 2 (1–4) 3 (2–6) 13 (7–21) 10 (6–17)

Occupational risk factors for injuries 28 (22–37) 20 (14–27) 0 (0–0) 0 (0–0) 26 (20–35) 17 (12–25)

Occupational low back pain 107 (67–155) 103 (62–157) 68 (45–98) 74 (47–110) 176 (114–251) 178 (111–263)

Sexual abuse and violence ·· 36 (25–50) ·· 98 (68–136) ·· 134 (101–175)

Childhood sexual abuse ·· 36 (25–50) ·· 35 (24–47) ·· 71 (53–92)

Intimate partner violence ·· ·· ·· 68 (42–104) ·· 68 (42–104)

No data indicates that attributable disability-adjusted life-years were not quantified. 0 indicates zero deaths or DALYs attributable.

Table 3: Disability-adjusted life-years (in thousands) attributable–risk factors or risk factor clusters in the UK

Figure 7: Burden of disease attributable to 20 leading risk factors for both sexes in 2010, expressed as a percentage of UK disability-adjusted life-yearsThe negative percentage for alcohol is the protective effect of mild alcohol use on ischaemic heart disease and diabetes.

–1 0 2 4 6 8 10 12Disability-adjusted life-years (%)

Lead exposureDiet low in polyunsaturated fatty acids

Diet low in whole grainsOccupational low back pain

Diet low in fibreDiet low in seafood omega-3 fatty acids

Diet high in processed meatDiet low in vegetables

Ambient particulate matter pollutionDrug use

Diet high in sodiumHigh fasting plasma glucose

Diet low in nuts and seedsHigh total cholesterol

Diet low in fruitsAlcohol use

Physical inactivity and low physical activityHigh body-mass index

High blood pressureTobacco smoking (including second-hand smoke)

CancerCardiovascular and circulatory diseasesChronic respiratory diseasesCirrhosisDigestive diseasesNeurological disordersMental and behavioural disordersDiabetes, urogenital, blood, and endocrineMusculoskeletal disordersOther non-communicable diseases

HIV/AIDS and tuberculosisDiarrhoea, lower respiratory infections, and other common infectious diseasesNeglected tropical diseases and malariaMaternal disordersNeonatal disordersNutritional deficienciesOther communicable diseasesTransport injuriesUnintentional injuriesIntentional injuries

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cause of death results comparable by examining and redistributing garbage codes. Differential certification of causes of death across the EU15+ could still be affecting the results for diabetes,48 although such variation is less likely to affect the analysis of attributable burden because burden is based on the prevalence of increased fasting plasma glucose and the relative risks of mortality by cause as a function of fasting plasma glucose. Notably, the number of deaths estimated in this study as being attributable to increased fasting plasma glucose is close to the number of diabetes deaths estimated by the National Diabetes Audit.49,50 Further evidence supporting our finding that the UK has a relatively lower burden from diabetes than do other EU15+ countries comes from the analysis of all available survey data by Danaei and colleagues.51 They reported that, in 2008, diabetes prevalence within the EU15+ countries ranged from 6·0% to 13·0% for male individuals and 4·0% to 9·0% for female individuals; the UK had a prevalence of 8·0% and ranked fifth for male individuals, and a prevalence of 6·0% and ranked sixth for female individuals.

Another finding that could be related to medical certification and hospital discharge coding is the significantly higher premature mortality from lower respiratory infections in the UK than the mean for EU15+.52 Higher incidence rates could be related to factors such as housing and social inequalities; higher case fatality rates in the UK compared with other nations theoretically could be a factor, because lower respiratory outcomes are sensitive to the quality of care.53,54 Because little direct evidence is available, the significantly higher than mean agestandardised rates of both YLLs and DALYs across the 19 countries deserves further investigation.

Despite important progress in reduction of deaths from cancers, including lung, stomach, and breast cancers, cancers accounted for 32% of YLLs in the UK in 2010. The UK continues to have significantly higher premature mortality from breast cancer than the mean. Detailed comparative studies of breast cancer incidence and 5year survival42 have also drawn attention to the unusually poor breast cancer survival rates in the UK.55 The risk factor analysis points to several risks that have important effects on cancer, such as tobacco, but also several components of diet.

Our findings suggest that the UK is performing relatively poorly for the major causes of chronic lung disease; the UK performed significantly worse than the mean in EU15+ for COPD, and was indistinguishable from the average for lung cancer and asthma. Therefore, active tobacco control policies should be pursued in the UK, as elsewhere, and as smoking prevalence declines, other smaller contributors should receive due attention, such as occupational exposure to dust, gases, and environmental radon. Generally, higher priority should be given to the burden of respiratory diseases. The UK has one of the highest rates of asthma in the world and

many millions of work days are still lost to COPD.56 Respiratory diseases also account for a large proportion of current inequalities in health outcomes across the UK.57 A 2012 report has emphasised unexplained variations in levels of care,57 which partly explain poor outcomes in some areas.

The first ranked cause of YLLs in the UK in 2010 was ischaemic heart disease and the third ranked was stroke. Despite substantial reductions, the UK still has mortality rates from ischaemic heart disease that are significantly above the mean of EU15+ and stroke is statistically indistinguishable from the mean. In other words, there is probably a large scope to improve outcomes. Our analysis of risk factors identified the large burden related to hypertension, which exceeds that for alcohol and high bodymass index. Improved early detection and longterm management of high blood pressure could be one clear route to accelerate progress for the leading causes of avoidable cardiovascular mortality. Data from examination surveys in England and Scotland58–60 confirm that existing approaches have not adequately identified and treated hypertension. In Scotland in 2009, one in five men and one in seven women younger than 75 years had untreated hyper tension.60 Although there is evidence of some improvements in hypertension control in England,58,59 only a third of men with hypertension were controlled in 2006.58 This represents a pool of potentially preventable mortality and morbidity.

In the UK, nearly complete registration with the NHS provides a potential vehicle for systematic identification of patients with hypertension, applying best practice guidelines and ensuring regular review. The NHS Health Check programme,61 launched in 2009, is intended to progressively reduce the number of undiagnosed individuals with hypertension and other cardiovascular risk factors in the next 5 years. The options for enhanced hypertension control are cost effective and well described in NICE guidance.62 Our analysis of risk factors also emphasises that there could be important opportunities for primary prevention through reduced alcohol and salt intake, reduced bodymass index values, increased physical activity, and increased intake of specific dietary components, such as fruit.

As identified by the Chief Medical Officer for England,2 the prevalence of various forms of liver disease has increased substantially in the past 20 years. Additionally, deaths from drug use disorders and disability from drug dependence have risen greatly. In individuals aged 20–54 years—the age group for which the UK has worsened substantially in the rankings for allcause mortality—both drugs and alcohol seem to have played a prominent part in the health of both men and women. Increases in the numbers of deaths due to alcohol and drugs in this age group have overshadowed the substantial gains from cervical cancer screening and road injury reduction. These problems in younger populations draw attention to the importance of separate

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examination of the population health needs in these age groups. The UK Government is considering the results of a public consultation on minimum pricing for alcohol, which many doctors believe could help to address the harm done by progressive increases in affordability of alcohol.63 Responsibility for addressing the harm done by drugs in England will henceforth be assigned to a new organisation, Public Health England. Public Health England will build on the work of the National Treatment Agency, which is being assimilated into the new organisation. We believe that, in response to the burden of drug abuse, a renewed focus on promotion of recovery and reductions in harm from drug abuse is needed.

An important finding from our analysis of the UK results from GBD 2010 is the rising importance of chronic disability. The leading 17 causes of YLDs are all increasing in absolute terms. This shift is driven by some changes in age structure but largely through increased longevity. Because the prevalence of many conditions rises steadily with age, a longer lifespan leads to more years spent with chronic disability. Foremost among the causes are musculoskeletal disorders, mental disorders, substance use, falls, vision loss, hearing loss and oral disorders. Although healthcare cost and activity data confirm that these conditions consume massive UK health system resources,64 concerted public health and highquality integrated medical care strategies are not implemented systematically. Interventions are available for musculoskeletal disorders, but to what extent the health system is delivering is unclear. Musculoskeletal disorders will only increase in importance in view of present trends and require more urgent policy attention.65 Falls prevention is another area in which there are demonstrable intervention strategies,66 but they have yet to be widely implemented.67 Trends for vision loss vary; cataractrelated vision loss decreased between 1990 and 2010 because of increased surgical rates,68 but glaucoma and agerelated macular degeneration increased. Hearing loss continues to be an area in which there is low and highly variable takeup of available interventions and little systematic data for outcomes.2

The risk factor analysis confirms the importance of tobacco and alcohol and the rising burden of overweight and obesity.4 It also shows the potential of a more nuanced diet strategy. Almost twothirds of the burden of cardiovascular diseases can be attributed to the com bination of all dietary components and physical inactivity. Diet messages and diet policy have historically empha sised a focus on salt, sugar, and fat intake.69 GBD 2010 suggests the importance of a reduction in salt intake as a population measure. Convincing or probable evidence for sugar was only available for GBD 2010 for the effects of sugarsweetened beverages. Diets high in sugarsweetened beverages accounted for a very small pro portion of DALYs. The assessment of fat needs much more reflection; some fats are probably beneficial, such as polyunsaturated fatty acids or omega3 fatty acids.70 A metaanalysis of

substitution of carbohydrates for saturated fats71 showed no benefit. By contrast, our analysis suggested that some dietary components can have a substantial positive effect at the population level, such as fruit, nuts and seeds, vegetables, fibre, and whole grains. Modulation of national consumption of these food types will need careful examination of evidence for the effectiveness of various policy options, such as voluntary agreements, subsidies, taxes, marketing, and information campaigns.72 Recent reductions in salt intake in the UK are an example of successful diet modulation.5 Reassuringly, several efforts to increase fruit and vegetable consumption are already underway.73 A new diet policy that builds on these findings and evidence for which policies have worked in other settings could help the UK to improve performance for cardio vascular outcomes.

This study has several important limitations. The results suffer from all the limitations of GBD 2010.26–33 In GBD 2010, there were no data for some of the 1160 disabling sequelae for some or even many countries. As detailed elsewhere,32 Bayesian statistical models were used to estimate prevalence of conditions in each country, age, sex, and year. The nature of this estimation process means that, without data or powerful covariates, estimated variance might be smaller than the real variance across countries in a region, but UIs for a specific estimate might be exaggerated. Results for the UK have been informed by many available data sources for the UK or England, such as vital registration data, hospital discharge data, several rounds of the Health Survey for England, surveillance data, and a myriad of studies of specific diseases, injuries, or risk factors. Nevertheless, the data are weak or absent for some conditions (eg, sensory conditions2).

Comparisons of YLDs are affected by the disability weights derived from the general population, which are substantially different from disability weights elicited from healthcare professionals for some conditions, such as vision and hearing loss.30,32,74,75 The continuing assessment of the burden of disease in the UK would benefit from a systematic evaluation of where data are most limited; some important sources of data that were not available and have not been incorporated into GBD 2010 could be included in future revisions. For congenital anomalies, the EUROCAT registry data were used for YLDs but could be used more extensively to explore whether congenital anomalies are better recorded in UK death certificates than in other countries.

UIs provide some information about the extent of available information for the UK. Uncertainty could be underestimated for various reasons, such as unrecognised bias in published studies. However, the nature of the estimation process for causes of death and prevalence of sequelae more generally leads to exaggerated UIs in a highincome country such as the UK. These wide UIs limit the number of significant changes that we could detect from 1990 to 2010 and potentially

For interventions for musculoskeletal disorders see http://www.nice.org.uk

For EUROCAT registry data see http://www.eurocat-network.eu/

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the number of times we could detect a country as above or below the mean.

Country ranks for agestandardised YLLs could still be affected by variation in national certification practice, particularly causes such as congenital anomalies, diabetes,76 some cancers,77 and COPD,78 although, after careful and detailed examination of the cause of death data, we have not identified any reason to suspect this variation is a major issue. Because countries vary in size and potentially in the extent of geographic inequality within each country, country ranks should be interpreted in the context of potential sub populations in the UK that are significantly above the mean and among the best even if the country as a whole is below the mean for an outcome.

The analysis of risk factors focused on proximal and behavioural risks. The important role of social determinants79 was not quantified in GBD 2010, because of little available data and insufficient evidence. The absence of factors such as inequality or poverty in this assessment should not be taken as an implication that they are less important than the proximal factors in this study. Quantification of their comparative size in the UK—as elsewhere—should be a public health priority.

Continuing reform of the UK health system in recent years has created a further series of natural experiments. In England, the newly formed agency Public Health England has a broad responsibility to address popu lation health challenges and to support local govern ment. It has been tasked to advocate for change with the best available data and evidence (including that from GBD 2010). It is intended to work in close partnership with the NHS Commissioning Board, but also with leading institutions in the public, private, and nongovernmental sectors to secure the best possible advice and support for implementation. Data aggre gated to an appropriate level for statistical interpretation will be reported for various health outcomes, includ ing inequalities, to allow local councils and NHS Commissioners to assess their own com parative per formance, and so that the public can hold responsible authorities accountable. Public Health Wales and the English Public Health Observatories already produce local health and inequality profiles.80

Several causes of chronic disability, such as mental disorders, substance abuse, musculoskeletal disorders, vision impairment, and hearing impairment, garner relatively less policy attention. In view of shifts in the patterns of health loss, these disabling conditions should also be on the agenda for all UK public health agencies.81 Our findings might also have implications for the NHS and the Commissioning Board. In the future, the NHS will be charged with achieving measurable gains in health in a mandate from the UK Government. Leading causes of YLLs—especially those for which the UK is significantly below the average of the EU15+ countries and not improving—deserve special attention in planning for evidencebased, highquality care delivery and in setting priorities for education, training, and research.

The challenges identified here—eg, the large burden due to high blood pressure, falls, musculoskeletal disorders, and mental health; the continuing importance of tobacco; the increasing effect of alcohol and drugs; and the potential benefit of improvements in national diet and physical activity—will require strong national and local leadership to ensure an effective multisectoral integrated response is achieved and sustained. Many of the proximal causes of death and disability identified here also have their origins in social and economic deter minants; these causes will require specific and compre hensive multisectoral policy attention.79 Although many commendable gains have been made to reduce hazards to health in the UK in the past few decades—tobacco control being perhaps the most important—much remains to be done. The leading causes of death and disability that we have identified, some of which are increasing rapidly, suggest that policy attention and the responsibilities of new public health institutions need to be carefully and urgently focused and strengthened in some areas. Efforts to improve and protect health, prevent disease and injury, and deliver highquality health care to the population must be tailored to address the risks and causes associated with the greatest burden if overall performance is to improve. There is some evidence that policy is responding accordingly, but this response will need to be accelerated and monitored if the UK is to rapidly improve its position as a leader in population health among highincome countries. Overall, our data clearly show the need and opportunity for a renewed effort across the UK to strive to reduce the tragedy of premature mortality and the toll of disability for all.ContributorsCJLM prepared the first draft and finalised the report on the basis of comments from all other authors and reviewer feedback. CJLM, MAR, JNN, KAF, and AD played key parts in formulation of the analysis for the UK with GBD 2010 results. All other authors contributed to the GBD 2010 analysis.

Conflicts of interestMAR is the Director for Reducing Premature Mortality (Domain 1; NHS Commissioning Board). JNN is Chief Knowledge Officer for Public Health England. KAF is Director of Health and Wellbeing for Public Health England. LR has received honoraria for board membership of the European Centre for Ecotoxicology of Chemicals, and research grants to Imperial College London from the European Chemical Industry Council and Conservation of Clean Air and Water Europe. The other authors declare that they have no conflicts of interest.

AcknowledgmentsFunding for this study was provided by the Bill & Melinda Gates Foundation. This research was done as part of GBD 2010; we would like to thank all individuals who have contributed to this study. We thank Duncan Selbie (Public Health England) for comments on drafts of the report; Muir Gray for comment, debate, and encouragement; and Richard Gleave and Jonathan Marron (Public Health England) for helping to frame the research questions.

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UK health performance: findings of the Global Burden of Disease Study 2010

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