The shifting burden of gastrointestinal and liver diseases across 11 Southeast Asian nations: a 1990–2021 systematic analysis from the global burden of disease study

Gastrointestinal (GI) and liver diseases impose a significant and escalating global health burden, contributing substantially to morbidity, mortality, and healthcare expenditure [1]. The Southeast Asian (SEA) region, a dynamic area comprising 11 nations with diverse socioeconomic, demographic, and healthcare landscapes, presents a particularly complex and heterogeneous picture of these conditions [2]. Historically, infectious GI ailments and high endemic rates of viral hepatitis have dominated the disease profile in many parts of Southeast Asia [3–5]. However, rapid urbanization, lifestyle modifications, and evolving dietary patterns are driving an epidemiological transition, leading to an increasing prominence of non-communicable GI and liver diseases [6, 7].

Understanding the contemporary trends and inter-country variations in the burden of specific GI and liver diseases across SEA nations is paramount for effective public health planning, resource allocation, and the development of targeted interventions [8, 9]. While regional progress has been made against certain conditions [10, 11], emerging threats such as non-alcoholic fatty liver disease (NAFLD), alcohol-related liver disease [12], and specific GI malignancies are gaining traction, posing new challenges to already strained health systems. Comprehensive, up-to-date analyses using standardized methodologies are crucial to delineate these shifts and identify priority areas for national and regional actions.

The Global Burden of Disease (GBD) study offers a valuable framework for such assessments, providing systematic estimates of disease burden over time [13]. The present study leverages GBD 2021 study data to provide a detailed analysis of the age-standardized disability-adjusted life year (DALY) rates for a comprehensive suite of GI and liver diseases across Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Republic of Singapore, Thailand, Timor-Leste, and the Socialist Republic of Vietnam from 1990 to 2021. Specifically, we aimed to: (1) quantify overall trends in GI and liver disease DALYs; (2) identify the leading GI and liver disease causes within each nation in 2021; (3) determine the top 3 causes exhibiting the highest relative percentage DALY rate increase (or smallest decrease) within each country between 1990 and 2021; and (4) identify the top 3 countries with the highest DALY rates for each GI and liver disease in 2021, thereby mapping the current burden and key evolving challenges in the region.

The present study, utilizing comprehensive GBD 2021 study data from 1990 to 2021, reveals the substantial and dynamic burden of GI and liver diseases across 11 SEA nations. The principal findings of the present study underscore 3 key themes: (1) the sheer scale and persistent nature of the digestive disease burden in the region, (2) the profound heterogeneity in disease patterns and trends among these countries, and (3) the clear evidence of an ongoing, yet incomplete, epidemiological transition, with varying balances between infectious and non-communicable causes.

The overarching decline in total GI and liver DALYs observed in most SEA nations likely reflects broad public health improvements, including enhanced sanitation, access to cleaner water, and improved primary healthcare, which have notably curtailed the impact of historically dominant infectious conditions such as diarrheal diseases [15]. However, the considerable variation in current DALY rates and the magnitude of decline between countries—with nations such as the Lao People’s Democratic Republic and Myanmar still facing a much higher overall burden compared with Singapore or Brunei—highlights persistent disparities in health system capacity and socioeconomic development [16, 17]. The progress is therefore uneven, reflecting deep-seated differences in health system capacity and infrastructure across the region.

We found that while infectious diseases declined, NCDs became increasingly prominent. This epidemiological shift, however, must be interpreted within the context of the region’s rapid socioeconomic and healthcare evolution. For instance, the concerning relative DALY rate increases for pancreatic cancer across 7 SEA nations, including Indonesia (+61.7%) and Vietnam (+51.6%), may reflect not only a true rise in incidence due to risk factors such as smoking, obesity, and diabetes but also improved diagnostic capabilities. Over the past 3 decades, the wider availability of advanced imaging technologies (e.g., CT, MRI) in urban centers would naturally lead to increased detection of previously occult malignancies, thereby inflating DALY rates. Similarly, the surge in NAFLD-related DALYs, particularly in economically transitioning nations such as Malaysia (+65.3%) and Thailand (+59.7%), points to a growing metabolic health crisis driven by changing diets and sedentary lifestyles [18, 19]. However, this trend is also amplified by greater clinical awareness and screening practices. Specific disease hotspots in 2021 reveal persistent challenges. High diarrheal disease rates continue in Indonesia, Lao People’s Democratic Republic, and Timor-Leste, likely reflecting ongoing deficiencies in water, sanitation, and hygiene (WASH) infrastructure that require sustained public health investment [20]. Cambodia, Myanmar, and Indonesia show concentrated burdens of chronic hepatitis B and C, emphasizing the need for robust viral hepatitis elimination programs that may face hurdles related to public health funding, screening coverage, and linkage to care [21]. In stark contrast, the prominence of NCDs such as colorectal cancer (Brunei, Malaysia, and Thailand) and pancreatic cancer (Brunei, Thailand, and Singapore) in higher-income nations underscores the dual influence of lifestyle-related risk factors and more established healthcare systems capable of diagnosing these conditions more effectively [22]. These divergent patterns, visualized in supplementary country plots, underscore the complex epidemiological transition across SEA.

These findings underscore profound public health implications for SEA nations. The region’s heterogeneity demands tailored national strategies, moving beyond a “one-size-fits-all” approach, informed by country-specific DALY profiles, socioeconomic context, and health system readiness, akin to a form of public health precision medicine [23]. While continued efforts against infectious diseases are vital in high-burden areas, a strategic regional pivot toward preventing and managing NCDs—particularly GI cancers, NAFLD, and alcohol-related liver disease—is crucial. This necessitates integrated primary (lifestyle, alcohol control, and HBV vaccination) [24, 25], secondary (cancer/hepatitis screening) [26], and tertiary (treatment access) prevention [27]. The alarming rise in pancreatic cancer and the burgeoning NAFLD epidemic require dedicated research into drivers and proactive public health responses, including awareness and primary care integration. Future research should prioritize subnational burden analyses to guide targeted interventions in larger nations and investigate determinants of increasing NCDs such as pancreatic cancer and NAFLD. Cost-effectiveness studies for screening and treatment programs within diverse SEA settings are also essential.

The strengths of the present study lie in its comprehensive use of GBD 2021 study data, providing standardized, comparable estimates across 11 countries for more than 32 years. This allows for a robust analysis of long-term trends and regional patterns. However, the findings must be interpreted in light of several important limitations. First, the study is subject to the inherent limitations of the GBD methodology itself. GBD estimates are the output of complex statistical models, and their precision is contingent on the quantity and quality of the primary input data, which varies substantially by country, disease, and year. For some nations and causes in this analysis, estimates may be based on sparse data, leading to wider UIs and less robust conclusions. Second, as an ecological study, our findings demonstrate associations at the population level and cannot be used to infer individual-level risk—the ecological fallacy. Third, this analysis of national-level data may mask significant subnational disparities in disease burden, particularly within large and diverse archipelagic nations such as Indonesia and the Philippines. Finally, changes in GBD modeling methodology or disease classification systems (based on ICD updates) over time could potentially influence some of the observed trends, independent of true epidemiological shifts.

In conclusion, SEA nations confront a complex and evolving burden of GI and liver diseases, characterized by a dual challenge. While successes against infectious diseases are evident, a formidable and growing threat from NCDs—including specific GI cancers and metabolic liver disease—now requires an urgent strategic pivot. The profound heterogeneity observed means that a “one-size-fits-all” approach is inadequate. Instead, national health policies must be precisely tailored, informed by country-specific DALY profiles and their underlying drivers, including socioeconomic status and healthcare capacity. This requires a dual-pronged public health response: continuing to strengthen WASH infrastructure and viral hepatitis programs in high-burden areas, while simultaneously implementing robust strategies for NCDs focused on primary prevention (e.g., metabolic risk factor control), targeted secondary prevention (e.g., cancer screening), and equitable access to advanced diagnostics and treatment.