Global Burden of Disease: satisfaction for Italian results

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The burden of diseases (BoD), i.e. the impact of diseases in terms of mortality and disability, has gained unprecedented visibility as a health topic on such a prestigious scientific journal as Lancet. The entire December 2012 issue, a total of 7 articles and 8 editorials, was in fact dedicated to the Global Burden of Disease Study 2010 (GBD 2010). At the beginning of March 2013, other data were subsequently published, in particular the results by countries that sparked a lot of interest and even some surprise.

The study

Massive, collaborative and challenging: these are the three adjectives used by Lancet to describe the GBD 2010. Indeed, it is the most extensive survey ever carried out on a global scale to describe the distribution and causes of diseases and their risk factors . It took 5 years of work, involving 486 researchers from 303 institutions in 50 countries.

It was coordinated by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington in collaboration with the University of Queensland, the Harvard School of Public Health, the Johns Hopkins Bloomberg School of Public Health, the University of Tokyo, the Imperial College London and the World Health Organization.

IHME is headed by Chris Murray, who developed the QALY ( Quality Adjusted Life Year ) the metrics used to measure the life-years gained taking into account the quality of life, making it possible to combine mortality and morbidity estimates into a single "number".
It is not hard to imagine that this new Murray's creation, the GBD 2010, will become a milestone in health and health care matters, as Murray himself declared: "For policy makers, researchers and informed citizens, the Global burden approach provides an opportunity to see the big picture, compare diseases and risk factors and understand, in a given context (place, time, age, gender) what are the main contributors to health loss."

The GBD 2010 draws a world where infectious diseases, maternal and child illness and malnutrition are gradually decreasing. Fewer children are dying every year, but more young and middle-aged adults are dying and suffering from chronic degenerative diseases (non-communicable diseases) which have become the dominant cause of death and disability worldwide. The end result is that if since 1970 the world population has improved its life expectancy by about a decade, for most of these years people will not be in good health.

The method

The GBD 2010 is the "second installment" of the project commissioned in 1990 by the World Bank. Compared to the original study, the amount of analyzed variables and collected data vastly increased, by approximately 400 times: the number of examined diseases increased from 107 to 291, the risk factors from 10 to 67, the macro-regions on the globe from 8 to 21. It is also possible to analyze data by gender, for 20 age groups and, thanks to the availability of two series of information, to predict the trends of phenomena over the next twenty years.

Obviously the impact of diseases has been described in terms of mortality, years of life lost due to premature mortality (Years of Life Lost due to premature mortality, YLLs), years of life lived in non optimal health conditions or disability (Years Lived with Disability, YLDs) and life expectancy adjusted for disability (Disability-Adjusted Life-Years, DALYs).

The interpretation of complex statistical models is accessible also to those who lack specific knowledge through straight-forward interactive graphic presentations (here the data visualization address, and the instructions for visualizing data).
According to the GBD 2010 working group, these representations "offer the opportunity to explore data otherwise unusable, if presented in a traditional manner occupying millions of rows, and they represent a democratization of data."

Italy's come back and the British ...

If Italian cyclist Gino Bartali with his unpretentious style surprised the French as a climber, this time it's the British who have been taken aback by the Italian people traditionally suffering from chronic crisis.
In fact, even if recently the Italian economy has not been very healthy, that of its its citizens is improving significantly, according to data from the GBD 2010.

Italy ranks second in terms of life expectancy, the first among European nations and surpassed only by Japan. It is important to note that longevity (about 81.5 years) is characterized by good health or limited periods of disability.   
The major risk factors are those related to eating habits, blood hypertension and tobacco smoke. The latter, as passive smoking, also weighs significantly on children's health.
The main causes leading to premature mortality continue to be cardiovascular and cerebrovascular diseases and tumors of the respiratory tract. There are good news regarding cirrhosis which decreased by 38% as a factor of morbidity from 1990 to 2010.

The data for the UK, though showing better results compared to this country's figures in 1990, progressed more slowly compared to almost all other developed nations. In other words the British were overtaken and slipped down in the GBD 2010 rankings. If in the 1990 study they ranked above the average in 8 of the 30 disease groups, in the 2010 study their lead was maintained in only 3 groups. UK data are particularly unsatisfactory as regards premature mortality (between 20 and 54 years) probably burdened by alcohol abuse and drug use.

These figures were mentioned rather disapprovingly by both scientific magazines such as the British Medical Journal and the media, starting with the BBC.
Precisely the BBC focused on the comparison with Italian data, wondering on the possible causes of the 18 month gap in life expectancy in favour of Italy, reflecting on the fact that Italians smoke more than the British (but only from 2006), and for years the Italian NHS has spent more than the UK National Health Service (only recently has this relation been reversed).

The BBC has asked these questions to Stefania Salmaso, Director of the Italian National Centre of Epidemiology, Surveillance and Health Promotion (CNESPS) of the Istituto Superiore di Sanità, the Italian Health Institute, who has justified the current results on the basis of not so recent changes, the so-called epidemiological transition that has improved the overall living conditions in Italy. In particular, with regard to the Italian diet: "Since the '60s, there has been a big improvement in the Italian diet, with much more fresh fruits, vegetables and fish and a wider variety of foods. Moreover, olive oil is part of the traditional Mediterranean diet, while in the British diet animal fats are prevalent."

Even drinking habits are radically different as in Italy drinking wine with meals is the prevalent form of alcohol consumption, while in the UK, in addition to beer, spirits and binge drinking are a dramatic commonplace. On this issue, however, we should not delude ourselves: "These habits are rapidly changing especially among young people and are a threat to public health, with a potential impact in the future."

"An important contribution to Italians' health also stems from public initiatives for the promotion of healthy lifestyles such as Gaining Health and with monitoring goals, aimed at planning health interventions, such as the PASSI Surveillance System." explained, Stefania Salmaso. And to the question of how one can reconcile the Italian economic crisis with these positive health results, she answered "maybe this means money isn't everything?".

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