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Maria Beatriz Nascimento Sociology



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Consultado em 10 de janeiro de Igepri News. The supplementary results show these results for the leading six impairments estimated in GBD: anaemia, heart failure, vision loss, hearing loss, epilepsy, and infertility appendix 2. The immense burden of anaemia is shown, particularly for females in low-SDI regions. The differences in the burden of impairments by sex are also provided appendix 2. Mean estimates are shown. Anxiety disorders are a top cause of non-fatal burden for females and other musculoskeletal disorders are a top cause of non-fatal burden for males. Figure 4 shows the all-age and age-standardised YLD rates by SDI and GBD region between and for males and females combined for all causes and then separately for Level 1 causes.

However, there were important exceptions to this finding. First, some regions did not follow this trend consistently. Southern sub-Saharan Africa showed an increase in YLD rates for more than a decade before beginning a more precipitous decline coinciding with the apex of the HIV epidemic, whereas regions with a higher baseline SDI have generally experienced minimal changes or increases in age-standardised YLD rates over the past decade despite advances in SDI. We found that trends also varied over time depending on cause.

The NCD pattern also differed markedly between all-age and age-standardised rates for NCDs, with all-age rates increasing as SDI improved with relatively little change over time observed in age-standardised rates. For injuries, some regions initially experienced a declining burden as SDI increased, followed by an increasing burden as SDI continued to increase over time, as seen in Central Europe, for example. Coloured lines are global and region values for YLDs. Each point in a line represents 1 year, starting from and ending in In all regions, SDI has increased over time so progress in SDI is associated with points further to the right and later years for a given region, with a downwards gradient indicating a reduction in YLD rate. The black lines indicate the trajectories for each geography expected on the basis of SDI alone.

Table 2 shows global age-standardised prevalence for females and males for all Level 2 GBD causes as well as the relative difference between the sexes in and In , million — YLDs were in females and million — were in males. Global age-standardised prevalence rates per for males and females for Level 2 GBD causes with the relative difference between the sexes for and The relative difference for each of the 22 Level 2 causes between sexes were calculated using the values for females as the denominator. The causes are ranked by the value of the sex difference in All changes are significant. Figure 5A illustrates the differences in global prevalence for females and males for by age group for the 22 Level 2 GBD causes of non-fatal health loss, calculated as the female-specific estimate subtracted from the male-specific estimate such that causes on the left side of the chart are more prevalent in females while causes on the right side of the chart are more prevalent in males in a given age group.

Females experience overall higher prevalence in every age group and the highest age-specific global prevalence differences for female-predominant causes occur between the ages of 20 years and 49 years. From birth to 4 years of age, females have higher prevalence of other NCDs, which continues through all age groups, and of neoplasms than males, whereas neurological disorders are female predominant in all ages, becoming notably evident from age 5—9 years and continuing throughout all subsequent age groups. Although nutritional deficiencies are more prevalent in males in the earliest age groups up to age 9 years, they are more prevalent in females in subsequent age groups up to age 74 years, at which point they once again become more prevalent in males up to the oldest age group.

Females also have higher prevalence of self-harm and interpersonal violence starting from age 1—4 years and continuing until age 84 years, after which they become more prevalent in males. Digestive diseases are more prevalent in males in all age groups, whereas unintentional injuries emerge as a male-predominant cause from 5 years of age and remain as such until age 89 years, after which they become female predominant. Transport injuries are male predominant in all age groups starting from age 1—4 years. Respiratory infections and tuberculosis are male predominant in all ages. Cardiovascular diseases are male predominant starting from age 50—54 years, whereas chronic respiratory diseases emerge as a male-predominant cause from age 65—69 years.

The figure represents the difference in prevalence A and YLD rates B between males and females as well as the cause composition of those differences for each GBD age group for the Level 2 causes of non-fatal burden. Before age 10—14 years, males have greater YLD rates than females, driven largely by higher rates of nutritional deficiencies. From age 10—14 years and older, females have greater overall YLD rates in every age group.

Under the age of 1 year, females experience higher YLD rates due to neoplasms and maternal and neonatal disorders, whereas male infants experience higher YLD rates due to nutritional deficiencies and other NCDs. Starting at age 10 years, females experience a higher YLD rate due to other NCDs until age 50—54 years , musculoskeletal disorders, mental disorders, neurological disorders, and chronic respiratory diseases. Males experience higher YLD rates due to unintentional injuries, transport injuries, and substance use disorders for most of life, although females older than 80 years of age experience a higher rate of unintentional injuries than do males.

For self-harm and interpersonal violence, females experience higher rates than males until age 30—34 years, at which point males experience higher YLD rates. Figure 6 shows the extent to which males and females in region—cause combinations have diverged in terms of achieving equal change over time between and Each region—cause combination shows which sex has performed better over time either by decreasing more or by increasing less in terms of age-standardised YLD rates. Absolute difference in non-fatal trend equality for males and females in terms of age-standardised YLD rates, — This figure shows whether females or males experienced more favourable trends between and in terms of age-standardised YLDs by GBD region and Level 2 cause.

Circles indicate females experienced more favourable trends and triangles indicate males experienced more favourable trends, where more favourable refers to either decreasing more or increasing less. Green indicates that the overall trend is improving ie, decreasing age-standardised YLDs and red indicates that the overall trend is worsening ie, increasing age-standardised YLDs.

Yellow indicates cause-regions where one sex is increasing and the other sex is decreasing. For example, in Andean Latin America for substance use, the large yellow triangle means that males have experienced decreasing age-standardised YLDs whereas the trend for females is the opposite ie, increasing age-standardised YLDs. Different sizes refer to greater deviations from equal trends between and For example, for chronic respiratory conditions, males have experienced more favourable trends in both Andean Latin America and the Caribbean, with both regions having decreasing trends over time for both sexes, but the Caribbean is closer to having equal trends for males and females between and Figure 7 shows the leading 20 causes of prevalence and YLDs for females and males separately for , , and , with percentage change.

In , the most common causes for females were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias, whereas for males, the most common causes were oral disorders, headache disorders, and tuberculosis including latent tuberculosis. In , oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias remained the top three leading Level 3 causes of global age-standardised prevalence for females. In , oral disorders, headache disorders, and tuberculosis including latent tuberculosis remained the three Level 3 causes with greatest global age-standardised prevalence for males.

Leading 20 Level 3 causes of global prevalence for , , and , with percentage change in number of cases and all-age and age-standardised rates for each sex. Causes are connected by lines between time periods; solid lines are increases and dashed lines are decreases. For the time periods — and —17, three measures of change are shown: percentage change in the number of cases, percentage change in the all-age prevalence rate, and percentage change in the age-standardised prevalence rate.

Communicable, maternal, neonatal, and nutritional diseases are shown in red; non-communicable causes in blue; and injuries in green. Statistically significant changes are shown in bold. In terms of numbers of YLDs, in , the leading causes for both females and males were low back pain, headache disorders, and dietary iron deficiency figure 8. For both males and females, the top two leading causes of global YLDs remained consistent between both time periods, during which the total number of YLDs for each of these causes increased. The third top cause in was depressive disorders for females and diabetes for males.

Leading 20 Level 3 causes of global YLDs for , , and , with percentage change in number of YLDs and all age and age-standardised rates for each sex. For the time periods — and —17, three measures of change are shown: percentage change in the number of YLDs, percentage change in the all-age YLD rate, and percentage change in the age-standardised YLD rate. This pattern is concerning given the lack of substantial improvement in age-standardised rates over time as well as the increased magnitude of total health loss. These patterns are probably related to population growth and ageing as well as increasing numbers of YLDs from conditions such as type 2 diabetes and opioid use disorders, which were less common in YLD increases, even when age-standardised rates are slightly improving, might pose a burden to economies and health-care systems that have not expanded proportionally to population growth or in populations where economic improvements have not been equitably distributed.

This substantial portion of global YLDs might be amenable to treatment and care access, because headache disorders and depressive disorders can be treated with low-cost therapeutics. The persistence of depressive disorders and low back pain is also concerning given the former's relation with self-harm and the latter's relation with potential loss of functional status in the work force. For the first time in the GBD study, we estimated the burdens of type 1 and type 2 diabetes separately. Our estimates illustrate the emergence of diabetes as a leading cause of disability globally, ranking as the fourth leading cause of age-standardised YLDs in This increased burden was observed across all levels of development.

Diabetes poses complicated care challenges even in areas with reliable access to medical services. Preventive measures such as prediabetes screening, lifestyle modification, and treatment with low-cost medications such as metformin could avert worsening incidence rates, but as prevalence increases, health-care systems will also need to provide access to services such as wound care, surgical resources, medications including insulin, care for diabetic retinopathy, and increased focus on heightened cardiovascular disease risk.

We observed that these cases were distributed across all GBD regions, although more commonly in North Africa and the Middle East and in Oceania in terms of age-standardised rates. Given the complexity of chronic liver disease and the difficulty of effectively treating obesity, efforts to prevent obesity and to develop therapeutics for NAFLD will be increasingly important. After initial steep reductions in HIV incidence between and , the global rate of decline in new HIV infections continues, although it has slowed in recent years and global prevalence has increased slightly since , a trend which is probably driven by rapid expansion of antiretroviral therapy in high-prevalence countries and extended life expectancy of people living with HIV.

These longer lifespans call for increased resources for treatment and continued prevention and treatment interventions to maintain declines in incidence. The burden of malaria has also declined since the mids in terms of age-standardised incidence rates. High age-standardised incidence rates of acute viral hepatitis have persisted, however, with age-standardised incidence rates of hepatitis A and B combined exceeding malaria incidence in despite availability of vaccines.

The age-standardised incidence rate of acute hepatitis did not significantly change from to , from to , or from to , suggesting that more proactive global initiatives are important, particularly with respect to vaccine coverage 28 and cost-effective access to hepatitis C curative treatments. Among all ages, pneumococcal pneumonia has prevailed as the leading aetiological subtype of LRI, accounting for more than five times more YLDs than the second leading cause influenza.

The age-standardised incidence of diarrhoea varied nine-fold across GBD regions, with the lowest rates in Australasia and the highest rates in Oceania appendix 2. The burdens of pneumococcal pneumonia and rotavirus diarrhoea are notable given the availability of vaccines for these pathogens, highlighting the need for continued expansion of vaccine coverage and delivery systems. While the burden of musculoskeletal disorders, vision loss, and hearing loss in older ages has been a consistent theme in past GBD studies due to their substantial contribution to non-fatal health loss, the burden of medically complex, high-resource conditions has also become increasingly concerning.

GBD risk factor estimates show that the drivers for atherosclerotic cardiovascular diseases—high systolic blood pressure, 32 , 33 , 34 high cholesterol, poor diet, 35 high fasting plasma glucose, 35 and low physical activity 36 —prevail in many geographies, indicating that this burden can be expected to persist and possibly expand as populations age. While the efforts of primary prevention approaches such as statin therapy and smoking cessation are evident in the gradual declines in age-standardised prevalence in high-income countries over the past 28 years, the prevalence of cardiovascular disease in these populations still remains high, which might also reflect improved survival from acute events due to improved response systems and interventions such as percutaneous coronary intervention, coronary artery bypass grafting, and rapid stroke treatment guidelines, 37 , 38 , 39 , 40 as well as secondary prevention with statins, antihypertensives, and smoking cessation.

We anticipate that this burden will also expand as populations age, creating challenges for health-care systems given the lack of modifiable risk factors for some neurological conditions and effective treatments for conditions such as Alzheimer's disease. Given the extensive care requirements these conditions—in isolation or as comorbidities—demand from both health systems and social and familial supports, their morbidity can reflect not only diminished health for an individual and population but also lost capital in an economy and among caretakers. Opioid use disorders including opioid dependence have become an era-defining epidemic in the USA with more than 4 million prevalent cases in Cumulatively, these results show pervasive health loss from substance use, which might also cause lost human capital given the concentration of the burden in working ages.

The burden of mental disorders is present in both sexes and across all age groups after emerging in childhood with idiopathic intellectual disability and autism spectrum disorders and continuing into older ages with depressive disorders, anxiety disorders, and schizophrenia. These findings substantiate a global need for increased mental health and substance abuse treatment resources, improved judiciousness of opioid prescribing patterns particularly for chronic pain, and expanded harm-reduction strategies such as opioid substitution therapy and needle programmes. Figure 6 illustrates how divergent trends were nearly evenly distributed between males and females, despite the overall higher numbers of YLDs experienced by females.

As indicated by the higher Z score in female-favourable causes, the cause-regions where females did better over time tended to have greater improvements in age-standardised YLD rates than did the cause-regions where males did better over time. These observations imply that health systems might have achieved improvements in non-fatal burden that have not been shared across sexes. The underlying reasons for these imbalances are likely to be complex. For causes that are inherently more common in males or females, improvements in one sex over the other might reflect these causes differing in susceptibility to prevention, intervention, and treatment.

For example, autoimmune conditions such as rheumatoid arthritis can affect both males and females but are ordinarily more common in females. Similarly, females of childbearing age experience risk of pregnancy-related and maternal conditions, risks that could be pronounced in lower-resource settings without sufficient access to modern obstetric facilities and follow-up care. Additionally, some causes may be susceptible to systematic misdiagnosis due to conventional clinical heuristics based on flawed or non-existent evidence. For example, in some areas, females presenting with acute coronary syndrome are more commonly misdiagnosed, 68 whereas other causes, such as autism spectrum disorders, might be systematically underdiagnosed in females compared with males.

This finding is notable for two main reasons. First, these age groups have a considerable number of years to live that would otherwise be in full health, emphasising how conditions at these ages, even if having lower disability weights, can still contribute substantially to the non-fatal burden. Second, a disabling condition that occurs during this period of life could represent lost human capital. This loss will be increasingly important to characterise with human capital emerging as an important area of focus at the World Bank. In GBD , anaemia is classified as an impairment, with aetiologies ranging from rare genetic haemoglobinopathies to iron deficiency.

Because these aetiologies alone could cause a relatively small proportion of all anaemia cases, the magnitude of anaemia's burden would be obscured by the granularity of these aetiologies if it was not also estimated in aggregate. Globally, in terms of YLD rates in , anaemia is the leading impairment for females, males, and both sexes combined. If anaemia were treated as a cause, it would rank as the fourth leading Level 2 cause and as the first leading Level 3 cause in terms of age-standardised YLD rates globally for females in Overall, the most important systemic change to this year's study is the estimation of population and fertility in the GBD framework. In addition, we made changes to the GBD cause hierarchy for example adding an aggregate Level 3 headache disorders cause , which limits certain cause-specific comparisons with past GBD cycles; this is discussed in more detail in the Limitations section below.

Other notable cause-specific considerations, comparisons, and limitations that are new as of GBD are as follows. More details for each cause can be found in the supplementary methods appendix 1 section 4. Our overall diarrhoea incidence estimates were not affected. We also used diarrhoea-specific and LRI-specific summary exposure values as covariates in our models, which include location-specific and year-specific estimates of risk factors associated with diarrhoea or LRI. We observed that these covariates had significant relationships with diarrhoea and LRI incidence rates and therefore strengthened our estimates, particularly in data-sparse areas. Further modelling details are described in the supplementary methods appendix 1 section 4.

Estimates in recent years are expected to be less stable due to improvements in HIV treatment coverage and prevention. The hepatitis estimation process has changed to improve internal consistency between mortality and non-fatal estimates for GBD First, we included case-fatality rates from clinical data in our mortality models to improve the distribution of hepatitis deaths by virus.

Second, we developed a time series of hepatitis B virus vaccine coverage in infants to use as a covariate. Third, the aggregate cause-specific mortality rate of acute hepatitis, cirrhosis, and liver cancer due to hepatitis B and hepatitis C was combined with virus-specific seroprevalence data to ensure internal consistency among incidence, prevalence, remission, and excess mortality rates. Fourth, the prevalence of chronic hepatitis B and C are now captured in the cirrhosis and other chronic liver diseases cause group rather than in the prevalence estimates for acute hepatitis B and acute hepatitis C.

Overall, this caused prevalent cases of hepatitis B and C to be shifted from the acute hepatitis B and C causes to the cirrhosis and other chronic liver diseases cause. Several changes were adopted for GBD Adding clinical and claims records from outside the USA to our models affected congenital birth defects, haemoglobinopathies, and maternal disorders. Updating our inpatient admission per-capita estimates to include in-facility deliveries as a newborn admission affected neonatal disorders and congenital birth defects.

Adopting in-facility delivery estimates for processing clinical data for maternal disorders led to lower estimates of pregnancy complications, especially in high-utilisation settings. We refined our method for estimating age-specific preterm birth and its complications to be consistent with GBD risk factor analysis, which resulted in preterm birth prevalence being higher than in previous GBD estimates. We enforced internal consistency among our estimates such that, for example, the sum of all specific types of congenital heart disease must equal the total number of cases of congenital heart disease. These methodological changes have lowered global estimates for many of the specific causes of birth defects, enforced the internal consistency of mortality and non-fatal estimates, narrowed the unexplained geographical variation in disease incidence, and strengthened the empirical relationship with known environmental, nutritional, and behavioural determinants of these conditions.

For nutritional deficiencies, we extended our analysis of protein-energy malnutrition past age 5 years, incorporated cause-specific mortality rates, and included the prevalent cases of moderate wasting without oedema. Although the net result might seem to be an increase in the number of protein-energy malnutrition cases, it instead reflects a more comprehensive assessment of acute malnutrition than was estimated previously. Diabetes has been estimated in previous GBD studies, but this is the first year that type 1 and type 2 diabetes were estimated and reported separately.

The estimation strategy for diabetes is provided in more detail in the supplementary methods appendix 1 section 4 , but in summary, we measured overall diabetes and type 1 diabetes. We subtracted estimates of type 1 from overall diabetes to produce estimates for type 2 diabetes. One of the main limitations to measuring type 2 diabetes is that surveys of diabetes in adults do not make a distinction between cases of type 1 and type 2 diabetes. This difference is due to how we adjust for alcohol use in the population, which helps to distinguish these conditions from alcohol-driven liver disease. Our study shows a similar geographical pattern to the Younossi study, with higher rates in North America and the Middle East, corresponding to higher rates of obesity.

We split haemorrhagic stroke into subarachnoid haemorrhage and intracerebral haemorrhage as subtypes of stroke and added non-rheumatic valve disease as an additional cause and aetiology of heart failure. The overarching limitation in cardiovascular estimation is that low-income and middle-income locations are less likely to have diagnostic tests such as treadmill tests, ankle-brachial index measurement, and other modern diagnostics. This also limits the identification of preclinical atherosclerotic disease for individuals who have not had clinical events but who might have ischaemic changes with provocative cardiac testing.

Future incorporation of more clinical record data might help to address these limitations by providing more diagnostic detail for cause subtypes. We added several data sources that had lower estimates than the International Study of Asthma and Allergies in Childhood studies, which were the main source of asthma prevalence previously. Additionally, the adjustment factor for studies reporting on physician-diagnosed asthma without an additional question on wheezing changed between GBD and GBD after new data sources were added. For dementia, we added covariates for whether studies had common features present in their diagnostic protocol, such as a review of clinical records or a diagnosis by a clinician to try to correct for some of the heterogeneity between studies, because only a very small fraction of studies used the same methods.

We do not have reliable covariates for prevalence or incidence of dementia and other neurological disorders, although in future studies, estimates of neurological disorders will benefit from the increased use of clinical and claims records. In addition, we added new causes for three categories of benign and in-situ neoplasms: intestinal, cervical and uterine, and other. We estimated burden for a combined group of autism spectrum disorders consistent with the Diagnostic and Statistical Manual of Mental Disorders 5 designations in GBD as opposed to separately estimating autism and Asperger's syndrome and other autism disorders. Enhancements in the fatal modelling of opioid use disorders also contributed to these improved estimates.

Improvements were also made in terms of data additions, particularly for cocaine and amphetamine dependence, where new data showed greater subnational variation in Mexico and Brazil. For GBD , improvements were made to the computational framework required for injuries non-fatal measurement. These updates included incorporating GBD age groups and updating the differential equation solver for converting incidence to prevalence.

Poisoning was divided into the two subcauses of poisoning by carbon monoxide and poisoning by other agents. As is evidenced in figure 1 and the supplementary methods, there is considerable heterogeneity in terms of data density for each Level 1 location-cause combination in the GBD study. Data availability does not consistently correlate with burden—that is, high-burden causes and locations can have relatively sparse data for non-fatal outcomes. This will also be increasingly problematic as more countries start to experience greater burden from NCDs.

This poses a limitation as the severities experienced in this population probably do not reflect global severity distributions or reflect that severity distributions are likely to vary over time, location, age, and by treatment access. Even for the limited diseases such as COPD, epilepsy, and stroke for which data from epidemiological studies allow us to differentiate severity by age, time, and location, the underlying data sources are still extremely limited in coverage by age, time, and location. Relying on published data on severity is unlikely to provide improved estimates in the near future. We also plan to access linked data between administrative records with diagnostic information and health surveys using health status measures to quantify severity of disease and how this changes over time and by age and sex.

Comorbidity adjustment in GBD assumes independent distributions of comorbid conditions. This is a limitation because comorbidity distributions are known to vary by cause, age, sex, location, and time. For example, diabetes and cardiovascular disease are more likely to be comorbid than asthma and gynaecological disorders but currently our comorbidity adjustment does not capture these correlations. Clinical data records have known selection bias for subsets of the population that have access to health care. Some GBD causes rely heavily on clinical data given the lack of other sources, with efforts made to correct for this bias by using representative studies as a reference group.

Relying on data from a privately insured cohort in a high-income country poses limitations to the generalisability of these adjustments. This year, we also used tabulated claims records from Taiwan province of China for the first time in the GBD study, and in future publications we plan to continue incorporating claims data from additional countries to address this limitation. Acquiring further health insurance claims data will not only inform estimates in terms of incidence and prevalence measures but will also help to develop more accurate parameters that affect GBD estimates in other modelling steps. With regard to age-time patterns, in DisMod-MR 2.

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