UK health performance: findings of the Global Burden of Disease Study 2010
Published March 4, 2013, in The Lancet (opens in a new window)
The United Kingdom has provided universal health care and public health programming for more than six decades. To guide future policymaking in the UK, it is important to analyze trends in population health over time. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), researchers examined three critical questions: what are the patterns of health loss in the UK, what are the leading preventable risks that explain some of those patterns, and how do UK outcomes compare to a set of comparable countries in the European Union (EU) and elsewhere in 1990 and 2010.
In addition to the UK, the analysis included 18 comparator countries with similar or higher levels of health expenditure: the 15 original EU countries, Australia, Canada, Norway, and the United States. The GBD 2010 cause list has 291 diseases and injuries, which are organized in a hierarchy with up to four levels of disaggregation. For each cause, there are as many as 24 sequelae, or clinical outcomes related to specific diseases and injuries, for a total of 1,160. Several metrics are used to estimate health loss: deaths and death rates, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Another indicator, healthy life expectancy, or HALE, is used to summarize overall population health, accounting for both length of life and levels of health experienced at different ages. This analysis ranks the UK relative to the 18 other countries in terms of these metrics, for both 1990 and 2010, and with 95% uncertainty intervals.
In absolute terms, for metrics of both mortality and disability, overall health has improved substantially in the UK from 1990 to 2010, and life expectancy increased by 4.2 years during that period. Of the 19 countries included in the analysis, however, the UK was significantly below the mean in 1990 in terms of every metric, and its relative position worsened by 2010. Only in men over the age of 55 did the UK experience significantly faster drops in death rates compared with other nations between 1990 and 2010; mortality for this group declined by nearly 40% compared to 35% for women of the same age.
For some younger adults, progress in reducing mortality was much more modest over the two decades and, for others the rates have worsened. In the 30 to 34 age group, for example, changes in mortality rates have been minimal, falling by less than 4%. They have worsened significantly, however, for males in all age groups below 55. For females under 55, the UK has either declined in relative rank or remained relatively stable near the bottom of the set of comparator countries. The leading causes in this age group are primarily cancers and cardiovascular diseases, but self-harm, road injuries, and falls also have high rankings.
Overall, the eight leading causes of death in the UK were largely unchanged over the 20-year period, with ischemic heart disease, chronic obstructive pulmonary disease (COPD), stroke, lung cancer, and lower respiratory infections remaining in the top five. Despite declining by 51% between 1990 and 2010, ischemic heart disease is the leading cause of premature mortality, as measured by YLLs, in the UK.
By comparison, there has been a significant increase in the contribution of Alzheimer’s disease (an increase of 137%, rising from a rank of 24th to 10th), cirrhosis (up 65%, from 14th to 9th), and drug use disorders (up 577%, from 64th to 21st). The largest declines were for stomach cancer and diabetes, followed by road injuries and congenital anomalies.
Disability is causing a much greater proportion of the burden of disease, as the increase in life expectancy at birth has become greater than the increase in healthy life expectancy. This means that people are living longer but spending their later years with more health problems compared to 20 years ago. In 2010, mental and behavioral disorders (predominantly depression, anxiety, drug and alcohol use, schizophrenia, and bipolar disorder) and musculoskeletal disorders (mainly lower back pain and falls) were responsible for more than half of all years lived with disability, or YLDs, in the UK.
The leading risk factor in the UK is tobacco followed by three risks of about equal magnitude: alcohol use, elevated blood pressure, and high body mass index (BMI), each causing approximately 9% of the burden of disease. Taken together, diet and physical inactivity account for 14.2% DALYs in the UK, with high BMI alone accounting for 8.6%. These risks largely cause increased rates of cardiovascular diseases and cancers.
The analysis of age-specific mortality demonstrates that, relative to other countries, the UK has only improved significantly for males over age 55. The impact of tobacco on these patterns is important, as the UK has a more advanced tobacco epidemic than most high-income countries. The legacy of tobacco consumption, which began post-World War II and started to fall in the 1970s, has contributed to both the poor UK outcomes in 1990 and also the relative progress for males over 55 more recently.
The comparison to other countries suggests that the UK is performing poorly for the major causes of chronic lung disease; it has one of the highest rates of asthma in the world and many millions of work days are still lost to COPD. This finding reinforces the need for more effective tobacco control policies, but also the importance of ensuring that, as smoking prevalence declines, other smaller contributors are considered, such as workplace exposure to dust, gases, and environmental radon.
The first and third causes of YLLs in the UK are ischemic heart disease and stroke, respectively. Despite considerable reductions, the UK still has levels of mortality from ischemic heart disease that are significantly above average relative to the 14 European comparator countries, and its mortality from stroke is near average. These findings suggest there is likely to be considerable scope for improving cardiovascular outcomes.
In the analysis of risk factors, the large burden related to hypertension exceeds those for alcohol and elevated BMI. Improved early detection and better long-term management of elevated blood pressure may be one key to accelerated progress on the leading causes of avoidable cardiovascular mortality. The analysis of risk factors also highlights the potential opportunities for prevention through increases in physical activity and reductions in alcohol use, salt intake, and BMI.
The risk factor analysis reveals another trend: the rising burden of overweight and obesity. Approximately two-thirds of the burden of cardiovascular diseases can be attributed to the combination of diet components and physical inactivity. Dietary messages and policy have historically emphasized the importance of reducing salt, sugar, and fat intake. This analysis suggests that some diet components can have a substantial positive effect at the population level, including fruit, nuts and seeds, vegetables, fiber, and whole grains. An updated, more nuanced diet policy that builds on these findings could aid in improving UK cardiovascular outcomes.
There has also been a substantial increase in various forms of liver disease in the last 20 years, and a marked rise in deaths from drug use disorders and disability from drug dependence. In the 20 to 54 age group, drugs and alcohol seem to have played a prominent role in death and disability for both men and women. The concentration of these problems in younger populations highlights the importance of examining the unique needs of distinct age groups and renewing the focus on promoting recovery and reducing the harm from drug abuse.
Finally, the analysis also suggests the rising importance of chronic disability. The leading 17 causes of YLDs are all increasing in absolute terms. Because the prevalence of many of these conditions rises steadily with age, longer lifespans lead to more years spent with chronic disability. Public health and medical interventions are available for many of these causes and, to increase their effectiveness, must be closely coordinated and systematically implemented.
Murray CJL, Richards MAR, Newton JN ,et al. UK health performance: findings of the Global Burden of Disease Study 2010. The Lancet.2013 March 5; http://dx.doi.org/10.1016/S0140-6736(13)60355-4.