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jha 2025, 28(3): 49-59 |
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Lotfi H, Ahmadi P, janmohamadi M, Ghorbani A. Estimating the economic burden of non-communicable diseases: insights from a cohort study in northeastern of Iran. jha 2025; 28 (3) :49-59
URL: http://jha.iums.ac.ir/article-1-4732-en.html
URL: http://jha.iums.ac.ir/article-1-4732-en.html
1- School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
2- Student Research Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran.
3- Department of Public Health, School of Health, Sabzevar University of Medical Sciences, Sabzevar, Iran. ,ghorbania1474@yahoo.com
2- Student Research Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran.
3- Department of Public Health, School of Health, Sabzevar University of Medical Sciences, Sabzevar, Iran. ,
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Discussion
The findings from the Sabzevar Cohort Study highlight the substantial health and economic impact of non-communicable diseases, particularly neurological disorders and diabetes, in northeastern Iran. Four major insights emerged as follows.
High burden of chronic headaches: Chronic headaches represented the largest share of DALYs, consistent with global GBD 2021 data ranking tension-type headache and migraine among the top ten causes of disability worldwide [7, 24]. This result underscores the under-recognized but significant contribution of headaches to productivity loss and reduced quality of life, especially among women.
Gender disparity in disease burden: Women exhibited higher prevalence and DALYs across most conditions. This aligns with global studies showing that women, particularly in middle age, experience greater disability due to neurological and metabolic conditions [8]. Both biological factors (e.g., hormonal fluctuations) and social determinants (e.g., limited access to healthcare and employment) likely contribute to this disparity.
Socioeconomic determinants of health: Illiteracy and unemployment were strongly associated with higher disease prevalence. This finding corresponds with global evidence that lower socioeconomic status is linked to elevated risks for NCDs [4,7,8,14]. Effective public health interventions in Iran must therefore integrate social and economic dimensions, such as education and job creation, to reduce health inequities.
Economic implications for working-age adults: The concentration of disease burden among adults aged 45–64 years, representing the main segment of the national workforce, leads to substantial productivity losses. This mirrors findings by Prince et al. [13], emphasizing the economic consequences of NCDs among middle-aged populations. The sensitivity analyses further revealed that economic estimates are influenced by discount rates, similar to observations from diabetes cost studies in India [14].
Overall, the study demonstrates a high cumulative disease burden, both in health and economic terms, among an urban Iranian population. Chronic headaches, epilepsy, and diabetes are the key contributors to DALYs, warranting priority in preventive and management strategies.
Limitations
Some limitations should be considered. There were some missing data for personal variables. Researchers were successful to call patients for completing some records but excluded some cases. In addition, spot disability weights were applied and sensitivity analysis for upper and lower bounds could not be performed due to unavailable required data in the database. Moreover, HCA in economic burden estimation ignores informal economic activities such as housekeeping and domestic cares.
Conclusion
The findings underscore the urgent need for comprehensive public health strategies addressing non-communicable diseases at both preventive and management levels. Targeted interventions should focus on modifiable lifestyle factors, early screening, and equitable access to care, especially for women and lower socioeconomic groups. Policymakers should also incorporate social determinants of health
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Introduction
Non-communicable diseases (NCDs) have emerged as one of the most pressing global public health challenges of the 21st century. Responsible for nearly 71% of all deaths worldwide, they have surpassed infectious diseases as the leading cause of mortality and disability across most regions of the world [1]. NCDs include a wide range of chronic disorders, such as cardiovascular diseases, diabetes, cancers, chronic respiratory conditions, and neurological and mental disorders [2]. The increasing prevalence of NCDs is particularly alarming in low- and middle-income countries, where rapid urbanization, demographic transitions, and lifestyle changes have contributed to unhealthy behaviors such as physical inactivity, poor dietary habit, and tobacco and alcohol use [3-5].
According to the World Health Organization, seven of the ten leading causes of global mortality in 2021 were due to non-communicable diseases [6]. Neurological disorders and diabetes rank among the leading contributors to years of life lost (YLL) and years lived with disability (YLD) worldwide [7,8]. Alzheimer’s disease and other dementias alone accounted for approximately 1.8 million deaths in 2021, nearly two-thirds of which were among women [9]. Diabetes, on the other hand, was responsible for a 95% increase in mortality since 2000 [10]. The growing burden of these diseases poses a serious challenge to healthcare systems, particularly in developing countries, by imposing both direct and indirect economic costs through healthcare utilization, productivity losses, and reduced quality of life [11–13].
To comprehensively quantify disease impact, the Disability-Adjusted Life Year (DALY) is widely used [15–17]. DALY combines YLL due to premature mortality and YLD due to disability, providing a standardized measure to compare disease burdens across populations and time. Each DALY represents one lost year of “healthy” life. Estimating DALYs allows policymakers to prioritize health interventions and allocate resources more efficiently.
In Iran, similar to global trends, NCDs have become a dominant health concern. This regional study collects extensive data on lifestyle, socioeconomic status, and health outcomes of adult participants and serves as a valuable dataset for estimating disease burden and its economic implications at the subnational level. This study aimed to estimate both the health and economic burden of selected non-communicable diseases, specifically neurological disorders (epilepsy, stroke, and chronic headaches) and diabetes, among participants in the Sabzevar Cohort Study.
Methods
Study setting and population: The Sabzevar Cohort Study, as part of the national Persian Cohort Consortium, provides an important opportunity to investigate the epidemiology and economic impact of NCDs among a northeastern Iranian population [18,19]. The Sabzevar Cohort Study is a population-based longitudinal study located in the western part of Khorasan Razavi Province, northeastern Iran. The cohort covers over 370,000 inhabitants. Data collection began in 2016 and captures detailed data on participants’ demographics, lifestyle, medical history, and health outcomes. This analysis included data from 4,241 adult participants aged 35–72 years. Information on the presence of neurological disorders (epilepsy, stroke, and chronic headaches) and diabetes as well as age, sex, date of diagnosis, and mortality status were extracted from the cohort database.
DALY calculation: DALYs were calculated using the standard Global Burden of Disease (GBD) framework [20]. The formula applied was: DALY=YLL+YLD, where YLL (Years of Life Lost) is the Number of deaths × Standard life expectancy at age of death, and YLD (Years Lived with Disability) is the Number of prevalent cases × Disability weight × Duration (years). Disability weights were obtained from the GBD study [21]: Epilepsy = 0.263, Stroke = 0.552, Chronic headache = 0.223 and Diabetes = 0.187. No age weighting was applied, consistent with the GBD 2019 methodology, ensuring equal value for all years of healthy life regardless of age. Standard life expectancy tables stratified by sex and age were used for YLL estimation [20].
Economic burden estimation: The human capital approach (HCA) was employed to estimate economic losses attributable to disease burden [22]. Economic burden was calculated by multiplying total DALYs by Iran’s GDP per capita (PPP) for 2023, valued at USD 17,921.7 [23]. A 7% discount rate was applied to account for the present value of future income losses, with sensitivity analyses conducted at 3% and 10% discount rates.
Data analysis: Descriptive statistics were used to summarize demographic characteristics and disease prevalence. DALY and economic burden estimates were calculated separately for each disease and then aggregated. Results were stratified by sex and age group to identify patterns and disparities.
Results
Among the 4,241 participants, 1,894 (44.7%) were male and 2,347 (55.3%) were female. The mean age was 49.22 years (range 35–72), with males averaging 50.4 years and females 48.2 years. Approximately 23.7% of participants were illiterate, and 46.8% had education levels below a bachelor’s degree. A majority (56.7%) were unemployed, while 42.3% were employed.
A total of 2,034 participants were diagnosed with neurological disorders, while 589 had diabetes. Neurological disorders, excluding learning disabilities, were more prevalent among women, particularly in the 45–54 age group. The highest diabetes prevalence was observed in the 55–64 age group, with 54.7% of cases being female.
Chronic headaches imposed the highest total disease burden, followed by epilepsy and diabetes. The total burden of neurological disorders was estimated at 10,795 DALYs, including one stroke-related death contributing 31 YLL. Diabetes contributed an additional 3,932 YLDs, with no recorded diabetes-related deaths. These figures for the different diseases were as follows: chronic headaches: 7,172 total DALYs (5,281 YLL + 1,891 YLD), epilepsy: 2,467 DALYs (1,711 YLL + 756 YLD), stroke: 1,125 DALYs (933 YLL + 192 YLD), and diabetes: 3,932 DALYs (811 YLL + 3,121 YLD). On average, each diabetic patient lost 7 ± 1.7 years of healthy life.
Table 1 shows the total economic burden based on HCA and a 7% discount rate in USD purchasing power parity (PPP). Sensitivity analyses revealed that reducing the discount rate to 3% increased the estimated economic burden by approximately 9–12%, while raising it to 10% reduced it by 6–8%. The total economic burden at different rates ranged between USD 191.4 million and 222.7 million PPP, demonstrating moderate sensitivity to the chosen discount rate.
Table 1. Estimate of economic burden of disease (PPP USD)
Non-communicable diseases (NCDs) have emerged as one of the most pressing global public health challenges of the 21st century. Responsible for nearly 71% of all deaths worldwide, they have surpassed infectious diseases as the leading cause of mortality and disability across most regions of the world [1]. NCDs include a wide range of chronic disorders, such as cardiovascular diseases, diabetes, cancers, chronic respiratory conditions, and neurological and mental disorders [2]. The increasing prevalence of NCDs is particularly alarming in low- and middle-income countries, where rapid urbanization, demographic transitions, and lifestyle changes have contributed to unhealthy behaviors such as physical inactivity, poor dietary habit, and tobacco and alcohol use [3-5].
According to the World Health Organization, seven of the ten leading causes of global mortality in 2021 were due to non-communicable diseases [6]. Neurological disorders and diabetes rank among the leading contributors to years of life lost (YLL) and years lived with disability (YLD) worldwide [7,8]. Alzheimer’s disease and other dementias alone accounted for approximately 1.8 million deaths in 2021, nearly two-thirds of which were among women [9]. Diabetes, on the other hand, was responsible for a 95% increase in mortality since 2000 [10]. The growing burden of these diseases poses a serious challenge to healthcare systems, particularly in developing countries, by imposing both direct and indirect economic costs through healthcare utilization, productivity losses, and reduced quality of life [11–13].
To comprehensively quantify disease impact, the Disability-Adjusted Life Year (DALY) is widely used [15–17]. DALY combines YLL due to premature mortality and YLD due to disability, providing a standardized measure to compare disease burdens across populations and time. Each DALY represents one lost year of “healthy” life. Estimating DALYs allows policymakers to prioritize health interventions and allocate resources more efficiently.
In Iran, similar to global trends, NCDs have become a dominant health concern. This regional study collects extensive data on lifestyle, socioeconomic status, and health outcomes of adult participants and serves as a valuable dataset for estimating disease burden and its economic implications at the subnational level. This study aimed to estimate both the health and economic burden of selected non-communicable diseases, specifically neurological disorders (epilepsy, stroke, and chronic headaches) and diabetes, among participants in the Sabzevar Cohort Study.
Methods
Study setting and population: The Sabzevar Cohort Study, as part of the national Persian Cohort Consortium, provides an important opportunity to investigate the epidemiology and economic impact of NCDs among a northeastern Iranian population [18,19]. The Sabzevar Cohort Study is a population-based longitudinal study located in the western part of Khorasan Razavi Province, northeastern Iran. The cohort covers over 370,000 inhabitants. Data collection began in 2016 and captures detailed data on participants’ demographics, lifestyle, medical history, and health outcomes. This analysis included data from 4,241 adult participants aged 35–72 years. Information on the presence of neurological disorders (epilepsy, stroke, and chronic headaches) and diabetes as well as age, sex, date of diagnosis, and mortality status were extracted from the cohort database.
DALY calculation: DALYs were calculated using the standard Global Burden of Disease (GBD) framework [20]. The formula applied was: DALY=YLL+YLD, where YLL (Years of Life Lost) is the Number of deaths × Standard life expectancy at age of death, and YLD (Years Lived with Disability) is the Number of prevalent cases × Disability weight × Duration (years). Disability weights were obtained from the GBD study [21]: Epilepsy = 0.263, Stroke = 0.552, Chronic headache = 0.223 and Diabetes = 0.187. No age weighting was applied, consistent with the GBD 2019 methodology, ensuring equal value for all years of healthy life regardless of age. Standard life expectancy tables stratified by sex and age were used for YLL estimation [20].
Economic burden estimation: The human capital approach (HCA) was employed to estimate economic losses attributable to disease burden [22]. Economic burden was calculated by multiplying total DALYs by Iran’s GDP per capita (PPP) for 2023, valued at USD 17,921.7 [23]. A 7% discount rate was applied to account for the present value of future income losses, with sensitivity analyses conducted at 3% and 10% discount rates.
Data analysis: Descriptive statistics were used to summarize demographic characteristics and disease prevalence. DALY and economic burden estimates were calculated separately for each disease and then aggregated. Results were stratified by sex and age group to identify patterns and disparities.
Results
Among the 4,241 participants, 1,894 (44.7%) were male and 2,347 (55.3%) were female. The mean age was 49.22 years (range 35–72), with males averaging 50.4 years and females 48.2 years. Approximately 23.7% of participants were illiterate, and 46.8% had education levels below a bachelor’s degree. A majority (56.7%) were unemployed, while 42.3% were employed.
A total of 2,034 participants were diagnosed with neurological disorders, while 589 had diabetes. Neurological disorders, excluding learning disabilities, were more prevalent among women, particularly in the 45–54 age group. The highest diabetes prevalence was observed in the 55–64 age group, with 54.7% of cases being female.
Chronic headaches imposed the highest total disease burden, followed by epilepsy and diabetes. The total burden of neurological disorders was estimated at 10,795 DALYs, including one stroke-related death contributing 31 YLL. Diabetes contributed an additional 3,932 YLDs, with no recorded diabetes-related deaths. These figures for the different diseases were as follows: chronic headaches: 7,172 total DALYs (5,281 YLL + 1,891 YLD), epilepsy: 2,467 DALYs (1,711 YLL + 756 YLD), stroke: 1,125 DALYs (933 YLL + 192 YLD), and diabetes: 3,932 DALYs (811 YLL + 3,121 YLD). On average, each diabetic patient lost 7 ± 1.7 years of healthy life.
Table 1 shows the total economic burden based on HCA and a 7% discount rate in USD purchasing power parity (PPP). Sensitivity analyses revealed that reducing the discount rate to 3% increased the estimated economic burden by approximately 9–12%, while raising it to 10% reduced it by 6–8%. The total economic burden at different rates ranged between USD 191.4 million and 222.7 million PPP, demonstrating moderate sensitivity to the chosen discount rate.
Table 1. Estimate of economic burden of disease (PPP USD)
| Disease | Total economic burden | Average per person |
| Epilepsy | 44,225,899 | 387,946 |
| Stroke | 20,169,397 | 380,554 |
| Chronic headache | 128,548,280 | 271,772 |
| Diabetes | 11,405,319 | 194,067 |
Discussion
The findings from the Sabzevar Cohort Study highlight the substantial health and economic impact of non-communicable diseases, particularly neurological disorders and diabetes, in northeastern Iran. Four major insights emerged as follows.
High burden of chronic headaches: Chronic headaches represented the largest share of DALYs, consistent with global GBD 2021 data ranking tension-type headache and migraine among the top ten causes of disability worldwide [7, 24]. This result underscores the under-recognized but significant contribution of headaches to productivity loss and reduced quality of life, especially among women.
Gender disparity in disease burden: Women exhibited higher prevalence and DALYs across most conditions. This aligns with global studies showing that women, particularly in middle age, experience greater disability due to neurological and metabolic conditions [8]. Both biological factors (e.g., hormonal fluctuations) and social determinants (e.g., limited access to healthcare and employment) likely contribute to this disparity.
Socioeconomic determinants of health: Illiteracy and unemployment were strongly associated with higher disease prevalence. This finding corresponds with global evidence that lower socioeconomic status is linked to elevated risks for NCDs [4,7,8,14]. Effective public health interventions in Iran must therefore integrate social and economic dimensions, such as education and job creation, to reduce health inequities.
Economic implications for working-age adults: The concentration of disease burden among adults aged 45–64 years, representing the main segment of the national workforce, leads to substantial productivity losses. This mirrors findings by Prince et al. [13], emphasizing the economic consequences of NCDs among middle-aged populations. The sensitivity analyses further revealed that economic estimates are influenced by discount rates, similar to observations from diabetes cost studies in India [14].
Overall, the study demonstrates a high cumulative disease burden, both in health and economic terms, among an urban Iranian population. Chronic headaches, epilepsy, and diabetes are the key contributors to DALYs, warranting priority in preventive and management strategies.
Limitations
Some limitations should be considered. There were some missing data for personal variables. Researchers were successful to call patients for completing some records but excluded some cases. In addition, spot disability weights were applied and sensitivity analysis for upper and lower bounds could not be performed due to unavailable required data in the database. Moreover, HCA in economic burden estimation ignores informal economic activities such as housekeeping and domestic cares.
Conclusion
The findings underscore the urgent need for comprehensive public health strategies addressing non-communicable diseases at both preventive and management levels. Targeted interventions should focus on modifiable lifestyle factors, early screening, and equitable access to care, especially for women and lower socioeconomic groups. Policymakers should also incorporate social determinants of health
into national NCD control strategies and strengthen first-level preventive services to mitigate the growing health and economic burden.
Declarations
Ethical considerations: Ethical approval for this study was obtained from the Ethics Committee of Sabzevar University of Medical Sciences. (MEDSAB.REC.1402.060. and MEDSAB.REC.1402.001).
Funding: This study was financially supported by Sabzevar University of Medical Sciences. The sponsor had no role in the design, implementation, data collection, analysis, and publication.
Conflict of interests: The authors declare that there is no conflict of interest.
Author contributions: H. L: Conceptualization, study design, data management, writing-review and editing, supervision and final approval; P. A: Data collection, data management, writing-drafting, final approval; M.JM: Data collection, data management, writing-drafting and final approval; A. Gh: Conceptualization, and study design, methodology, software, validation, data analysis, data management, writing-review and editing and final approval. All authors have read and approved the final version of the article.
Consent for publication: None.
Data availability: Data is accessible through the corresponding author.
AI deceleration: None.
Acknowledgements: Authors would like to express their special thanks and gratitude to the all participants of the Sabzevar Cohort Study for their invaluable contributions and commitment to advancing our understanding of non-communicable diseases (NCDs). We extend our appreciation to the research team and the healthcare professionals involved in data collection and analysis, whose dedication ensured the integrity and reliability of this study.
Declarations
Ethical considerations: Ethical approval for this study was obtained from the Ethics Committee of Sabzevar University of Medical Sciences. (MEDSAB.REC.1402.060. and MEDSAB.REC.1402.001).
Funding: This study was financially supported by Sabzevar University of Medical Sciences. The sponsor had no role in the design, implementation, data collection, analysis, and publication.
Conflict of interests: The authors declare that there is no conflict of interest.
Author contributions: H. L: Conceptualization, study design, data management, writing-review and editing, supervision and final approval; P. A: Data collection, data management, writing-drafting, final approval; M.JM: Data collection, data management, writing-drafting and final approval; A. Gh: Conceptualization, and study design, methodology, software, validation, data analysis, data management, writing-review and editing and final approval. All authors have read and approved the final version of the article.
Consent for publication: None.
Data availability: Data is accessible through the corresponding author.
AI deceleration: None.
Acknowledgements: Authors would like to express their special thanks and gratitude to the all participants of the Sabzevar Cohort Study for their invaluable contributions and commitment to advancing our understanding of non-communicable diseases (NCDs). We extend our appreciation to the research team and the healthcare professionals involved in data collection and analysis, whose dedication ensured the integrity and reliability of this study.
Type of Study: Short Communication |
Subject:
Health Economics
Received: 2025/08/29 | Accepted: 2025/12/7 | Published: 2025/12/19
Received: 2025/08/29 | Accepted: 2025/12/7 | Published: 2025/12/19
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