Burden of disease in Colombian Orinoquia, 2017

Introduction

Population health diagnoses are highly relevant since they allow the determination of health requirements and support strategies for policy orientation and health intervention programs. From this perspective, estimating the burden of disease of a population using the synthetic indicator of disability-adjusted life years (DALYs) allows the identification of health status as well as the definition of intervention priorities in this population. In this context, the World Health Organization (WHO) has been measuring the burden of disease for more than two decades and has been using it for population health diagnoses globally, regionally, and nationally in member countries through DALYs aiming to guide public policies and providing diagnostics for the planning of health systems, policies, and programs (Dessu, Girum, Geremew, and Zeleke, 2020; Fitzmaurice et al., 2019; Hay et al., 2017; Lai, Habicht, and Kiivet, 2009; Melaku et al., 2018; Mokdad et al., 2018; Murray et al., 2012; Nomura et al., 2017; Noordhout et al.,2018; Vos et al., 2020; Yoon and Yoon, 2016; Zhou et al., 2019).

DALYs, as a composite indicator, implement specific values to quantify morbidity (not as the frequency of occurrence of the disease but as the time lived in states of less-than-optimal health) and mortality (not as the number of deaths but as the time that an individual lost by dying before reaching life expectancy), unifying them under the same unit of measurement, time (specifically years of life), which allows the comparison between diseases regardless of their etiology, pathogenesis, or symptomatology. DALYs balance the assessment of health events of low lethality and low prevalence with prolonged periods of health impairment versus those of high prevalence and/or lethality, solving antagonisms generated by simple indicators of morbidity and mortality in decision-making.

DALYs measure the absence of health through healthy life-years lost in the population of a territory. This time is composed of the sum of years of life lost (YLL) due to premature death and years of life with disability (YLD). YLL are the years that an individual stops living having died before reaching a standard theoretical life expectancy. In this study, 92 years was used as the maximum standard theoretical age for men and women—a value recommended by WHO and corresponding to a projection for 2050 made by the United Nations Population Division (World Health Organization, 2017). YLD are the years that a person lives in a suboptimal health condition or with health impairments in any of the domains of mobility, self-care, activities of daily living, pain, discomfort, anxiety, depression, social participation, or cognition (Salomon et al., 2015).

The use of the synthetic indicator DALYs in Colombia has been limited. In terms of the number of studies, global burden studies have been carried out with national coverage (Peñaloza et al., 2014; Rodríguez-García, Peñaloza-Quintero, and Amaya-Lara, 2017) or subnational (Grisales, et al., 2016), and studies of specific health conditions (Castañeda-Porras and Segura, 2018; Nieto-López, Grisales-Romero et al., 2022). In Colombian Orinoquia, which comprises the four departments of Arauca, Casanare, Meta, and Vichada, and is inhabited by about 1.7 million people, who are the object of study of this research, there have been no burden of disease studies performed nor measurements of the non-fatal effects of diseases that can be used as a diagnosis of health status to guide health policies and programs taken.

Not having studies that measure the non-fatal effects of the disease causes an underestimation of the impact that these diseases have on the population, affecting decision-making processes. This study allowed for the measurement of the burden of disease of Orinoquia inhabitants for the first time, establishing evidence to prioritize health decision-making.

Methods

Results

Fatal and non-fatal effects of the disease (DALYs)

The burden of disease in Orinoquia was estimated at 288,740.2 DALYs (95% UI, 210, 714.6-382,948.8), and a rate of 16,141.9 DALYs per 100,000 inhabitants (95% UI, 11,779.9-21,408.6); 59.1% of DALYS occurred in men, and 60% of them belonged to the age group 25 to 74 years (Underlying data, Table 4 (Gutierrez (2022f)). The high rate present in children under five years of age is remarkable when compared with age groups of five to 49 years, and it was noticeable that in the age group of 20 to 29 years, the DALYs rate of men doubled that of women (Figure 1).

Figure 1. Distribution of disability-adjusted life years (DALYs) by sex and age.

Results based on the three large groups showed that NCD produced the greatest burden of disease in Orinoquia, causing 179,993.6 DALYs, (95% UI, 115,030.2-268,405), 62.3% of the health gap in the region, followed by the group of ECI, to which 24.6% of DALYs were attributed. It was highlighted that, for each DALY per CMNND, approximately 4.7 DALYs per NCD were indicated. Estimates by sex revealed the excess of DALYs in men as the main difference when considering ECI, as they accounted for 81.9% of DALYs (Underlying data, Table 4 (Gutierrez (2022f)).

Concerning age, a positive gradient was observed between age and DALYs due to NCD (from the age of 10 years); for CMNND, the greatest burden occurred in individuals under 10 years of age, causing 40.8% of DALYs in that age group. DALYs due to ECI predominantly affected people aged between 10 and 49 years, causing 60.5% of DALYs in the group (Figure 2).

Figure 2. Distribution of large disease groups by age groups.

Notes: NCD: Noncommunicable diseases; ECI: External cause injuries; CMNND: Communicable, maternal, neonatal, and nutritional diseases. DALYs: Disability-adjusted life years.

Regarding subgroups (level two), respiratory infections (including TB), sexually transmitted infections (including HIV/AIDS), and nutritional deficiencies caused 57.1% of DALYs in CMNND. In these subgroups, men accounted for most DALYs. Concerning age, the greatest accumulation of DALYs was due to respiratory infections in the 50-to-74-year-old group, followed by sexually transmitted infections, in the 45 to 49 years group, and nutritional deficiencies in individuals under 10 years of age. On the other hand, neoplasms, cardiovascular diseases, digestive diseases, and diabetes produced 64.5% of DALYs in NCD. With regard to sex, women were the largest contributors to DALYs due to neoplasms, while among men, cardiovascular diseases and digestive diseases were predominant. In terms of age, neoplasms mostly affected people aged 25 to 74 years, whereas heart diseases and digestive diseases had the greatest effect on people between 50 and 74 years. Finally, the self-injuries, interpersonal violence, and road traffic injuries subgroups caused 83% of DALYs, mainly in men aged 25 to 49 years (Underlying data, Table 4 (Gutierrez (2022f)).

In the analysis of subgroups by sex, the five highest rates of DALYS showed that men and women shared neoplasms and cardiovascular disease as first causes. However, the difference by sex is remarkable. While personal violence and self-injury predominated in men (in that order), road traffic and unintentional injuries did so in women. The first cause of DALYS was neoplasms, and in their first five causes, digestive diseases, work-related musculoskeletal disorders and respiratory infections were found (Underlying data, Table 4 (Gutierrez (2022f)).

Respecting diseases and injuries (level three), the ten leading causes accounted for 49% of DALYS in the region (Underlying data, Table 4 (Gutierrez (2022f)). According to their rates, the first three diseases or injuries that contributed to burden were the following: interpersonal violence 1,581.5 DALYs per 100,000 inhabitants (95% UI, 411.7-3,589.5), ischemic heart disease 1,430.4 DALYs per 100,000 inhabitants (95% UI, 528.9-2,471.3), and road traffic injuries 1,235.8 DALYs per 100,000 inhabitants (95% UI, 459-2,323.9), as can be seen in Figure 3.

Figure 3. Disability-adjusted life years (DALYs) rates of the first 10 diseases or injuries, Orinoquia 2017.

However, when analyzing the first five causes of DALYs by sex, important differences between men and women were found (Figure 4). In women, the following group (all belonging to the NCD) predominated (in descending order): ischemic heart disease, stroke, genital cancer, type 2 diabetes mellitus, and dorsopathies. Conversely for men, the first five causes were the following: interpersonal violence, road traffic injuries, ischemic heart disease, unintentional injuries, and self-injuries. Four of these belong to the ECI group, and a prominent contribution of interpersonal violence was found. The only disease present in both sexes in its first five causes was ischemic heart disease.

Figure 4. Disability-adjusted life years (DALY) rates of the first five diseases or injuries by sex, Orinoquia 2017.

Concerning the most affected age groups in each of the ten global causes, interpersonal violence and road traffic injuries mainly affected people aged between 15 and 34 years; unintentional injuries were common in all ages with a slight increase in individuals over 75 years of age; HIV/AIDS affected people aged between 20 and 44 years; and dorsopathies impact individuals from 14 years. Type 2 diabetes mellitus, ischemic heart disease, and stroke were present after 60 years of age, and pneumonia involved people aged between zero and four years and over 69 years of age (Underlying data, Table 4 (Gutierrez (2022f)).

Discussion

This study showed the experience of the first measurement of the burden of disease in Colombian Orinoquia. It required the use of secondary data sources, whose custody is the responsibility of the national health authority. Morbidity and death data were validated according to the known strategies for this purpose and based on validation and data cleaning protocols. Although this study did not aim to explain determining factors of health in Orinoquia, analyzed diseases and injuries have already been related to lifestyle, biological, environmental, and sociocultural factors as well as inequalities (Roth et al., 2018; Sánchez-Ledesma et al., 2018; Vos et al., 2020).

It is important to note that the center of the discussion is the burden of disease, which unifies the time lost by premature death and the time in states of less-than-optimal health (disability) in an indicator without separating the relationship of the natural history of each disease, which means not observing disability or premature death caused by disease or injury as separate events. According to this approach, groups and subgroups of disease and/or injury and diseases or injuries that produce the greatest burden of disease in Orinoquia and its departments are presented.

When compared to ECI and CMNND, NCD provided the highest burden of disease -the major cause of loss of health, in terms of DALYs (YLL, YLD)- affecting both men and women substantially from 50 years of age. A similar finding was made in reports from Colombia, Latin America, and other parts of the world (Dantés-Gómez et al., 2011; Grisales et al., 2016; Peñaloza et al., 2014) and estimates in Uruguay (Ministerio de Salud, 2010), Argentina (Borruel, Mas, and Borruel, 2010), Chile (Universidad Católica de Chile, 2008), Mexico, Brazil, Costa Rica and Peru (Dantés-Gómez et al., 2011). Worldwide studies have reported similar results (Hay et al., 2017; Kyu et al., 2018; Nomura et al., 2017; Noordhout et al., 2018; Vos et al., 2020).

When disaggregating the burden from NCD, based on YLL and YLD in Orinoquia, it was defined that premature mortality (YLL) played a fundamental role, accounting for 77.9% of DALYs by NCD in the region, similar to what was found in Colombia (Grisales et al., 2016; Peñaloza et al., 2014), other countries of America (Borruel et al., 2010; Dantés-Gómez et al., 2011; Ministerio de Salud, 2010; Universidad Católica de Chile, 2008), and other parts of the world (Hay et al., 2017; Kyu et al., 2018; Lang et al., 2018; Melaku et al., 2018; Noordhout et al., 2018). Regarding years lived with disability (YLD) produced by NCD in Orinoquia, these were 2.8 times higher than those produced by CMNND and 6.5 times more years than those caused by the ECI.

Regarding YLD – suboptimal health status – due to non-fatal effects of disease, NCD were also consolidated as the group with the greatest effects on the health gap in Orinoquia, with predominance in women. These results did not differ from studies in the country, such as those carried out in Medellín for septennium 2006-2012 (Grisales et al., 2016), for Colombia, national estimations for 2005 and 2010 (Acosta-Ramírez, Peñaloza, and Rodríguez-García, 2008 and Peñaloza et al., 2014) and Latin America and the Caribbean, Institute for Health Metrics and Evaluation (IHME) for 2017 (IHME, 2021a).

The superiority of NCD in the contribution to the burden of disease (DALYs) by premature deaths (YLL) and by the generation of disability (YLD) has been explained as an effect of population aging and the world’s economic and industrial development (Acosta, 2013), which has changed population profiles of the health gap, moving from a disease burden that was mainly caused by communicable diseases to population profiles where the health gap is mainly generated by NCD (Hay et al., 2017; Lang et al., 2018; Rodríguez-García et al., 2017; Rodríguez-Vargas, Martínez-Almanza, Pría-Barros, and Menéndez-Jiménez, 2004; Vos et al., 2020). Population aging is a demographic and social condition defined by the decrease in the birth rate and the increase in elderly people due to the increase in life expectancy (Ochoa-Vázquez, et al., 2019; Ramos et al., 2014). In terms of the burden of disease, this behavior has been presented as the first cause for the world from 2010 to 2019 (Hay et al., 2017; James et al., 2018; Murray et al., 2012; Vos et al., 2020).

The predominance of NCD in premature mortality (YLL) and disability (YLD) as a cause of disease burden is not uncommon and is part of the world’s health profile in the 21^st century because its multiple causes are being amplified. Such causes include socioeconomic development, urbanization, industrialization, lifestyle change, control over infectious diseases, and increased life expectancy along with recognized risk factors, such as substance use, obesity, hypertension and sedentary lifestyle (Acosta, 2013; Martínez, 2016; Ramos et al., 2014). In addition to the aforementioned, clinical characteristics of chronicity and the defects of health systems are added (Landrove-Rodríguez et al., 2018).

For Orinoquia, DALYs due to NCD increased by age from 50 years of age. This behavior was recurrent for Colombia in 2017 (IHME, 2021b), Latin America (IHME, 2021a; Vos et al., 2020), and other parts of the world (James et al., 2018; Kyu et al., 2018; Vos et al., 2020). The fact that the age groups that are most affected by NCD are those over 50 years of age has been linked to the natural physiological deterioration and the accumulation of exposure to NCD triggers (Martínez, 2016). This involvement was also observed in the group of individuals under 50 years of age, specifically in women. This is due to the increase in neoplasms at an early age (Fitzmaurice et al., 2017; Global Burden of Disease Cancer Collaboration, 2018; Vos et al., 2020); additionally, disparities by sex have been identified as a product of differences in risk exposure, occupational profiles and specific screening programs (Martínez, 2016; Pardo and Cendales, 2018; Salas Zapata and Grisales Romero, 2010).

Regarding subgroups of disease that constitute NCD, neoplasms and cardiovascular diseases were highlighted for their contribution to premature mortality along with musculoskeletal disorders and neurological disorders for their contribution to days lived with a suboptimal state of health. In neoplasms and cardiovascular disease subgroups, more than 95% of DALYs were originated from premature mortality (YLL); additionally, neoplasms in Orinoquia affected mainly women aged 25 to 74 years. Predominance in women in this age group was similar to findings described in Colombian studies performed in the departments of Nariño (Rocha-Buelvas et al., 2014), Santander (Esquiaqui-Felipe et al., 2012), and Medellin (Grisales et al., 2016). Predominance of neoplasms in women at an early age could be explained by the burden generated by breast and cervical cancer as these represented the main types of cancer in women in Orinoquia, who have access to screening programs for early detection, which allows greater detection of these illnesses at young ages (Díaz, Piñeros, and Sánchez, 2005; Murillo et al., 2009; Pardo and Cendales, 2018; Salas Zapata and Grisales Romero, 2010).

The health gap caused by neoplasms is similar to that found in Colombia for measurements made by the IHME for 2017 and 2019 (IHME, 2021b; Vos et al., 2020) and in the study carried out in Medellin (Grisales et al., 2016). Besides, it is comparable to the world’s situation, where neoplasms occupied the first causes of DALYs and YLL worldwide (Fitzmaurice et al., 2017, 2019; Vos et al., 2020). It is important to discuss that the similarity in the contribution of neoplasms to the health gap between the territories mentioned is part of a global trend. The burden originated by the neoplasms have increased worldwide since 1990 and are expected to continue in the process of epidemiological transition due to aging and exposure to carcinogenic factors (Fitzmaurice et al., 2017). Therefore, neoplasms are recognized as a threat to Colombian and human development (Ospina, et al., 2015). The fact that the majority of DALYs due to neoplasms In Orinoquia are caused by premature death is a common situation in the world, as reported in a systematic analysis of DALYs due to neoplasms carried out for 195 countries by factors related to detection and care (Global Burden of Disease Cancer Collaboration, 2018).

According to the contribution to total DALYs, the subgroup for cardiovascular diseases came in first place in Orinoquia, especially in people over 50 years of age and with predominance in men, which was similar to findings in related studies in Medellín (Grisales et al., 2016), Colombia, Latin America, and other parts of the world (Peñaloza et al., 2014; Dantés-Gómez et al., 2011; Vos et al., 2020). The particular similarity in the great gap caused by cardiovascular diseases (DALYs) and in premature mortality (YLL) denotes unique global causes in populations where disease burden studies have been carried out (Cuadras and Rovira, 2014; Hay et al., 2017; James et al., 2018; Lang et al., 2018; Vos et al., 2020). Cardiovascular disease is not only attributed to population growth and aging (Rodríguez, Machado, and Luna, 2018) but also to biological, environmental, and socioeconomic factors that have an influence on lifestyles that promote risk factors, such as alcohol and tobacco use and high-calorie foods. In addition, inequalities and cultural differences that hinder access to health services and healthy foods and generate physical inactivity, which leads to obesity (Fernández-González and Figuerola, 2018; García, 2018; Gómez, 2011; González, et al., 2020; Mejía-Merino and Arango-Álzate, 2012), also increase the odds for cardiovascular disease. The aforementioned emphasizes the need for regional policies to intervene a problem that it is expected to continue to increase (Acosta, 2013; Fortich and Gutiérrez, 2011).

Ischemic heart diseases, which are from the subgroup of cardiovascular diseases, had an important contribution to the burden of disease in the study period, taking second place in Orinoquia; which was similar to findings reported by IHME for Colombia, where ischemic heart disease was the second leading cause of DALYs in 2017 and in 2019 (IHME, 2021b; IHME., 2021) It was comparable to findings reported for Latin America and the Caribbean, where it was the first leading cause (IHME, 2021a), and for the world, as the second cause of DALYs in 2019 (Vos et al., 2020). Concerning premature mortality, YLL, ischemic heart diseases were the second cause of YLL in the world in 2010 and the first in 2019, especially from 50 years of age (Murray et al., 2012; Vos et al., 2020). Similar behavior was found in Orinoquia with predominance in men and in group ages from 50 years of age, and it was found in Colombia as a part of the NCD group. This behavior and the similarity between territories like Colombia (which includes the Orinoquia), Latin America, and other parts of the world can be explained by the presence of common factors in all territories such as aging, lifestyles, and environmental factors (Albala, 2020; Belasco and Okuno, 2019; Cardona and Peláez, 2012; Nieto and Alonso, 2007; Rivillas, et al., 2017; Rodríguez et al., 2018). In addition, for ischemic disease, eating habits are described (Ballesteros-Vásquez, et al., 2012; Cabezas-Zábala, Hernández-Torres, and Vargas-Zárate, 2016). The consumption of substances such as alcohol, tobacco, and sodium along with sedentary lifestyles and obesity are mentioned as the main promoters of morbidity and mortality from ischemic heart disease (Acosta, 2013; Evans-Meza, Pérez-Fallas, & Bonilla-Carrión, 2019; Núñez-González, et al., 2018), which translates into the burden of disease described.

It is important to note that results reported by Peñaloza et al (Peñaloza et al., 2014) for Colombia are dissimilar to the findings mentioned for Orinoquia and its departments. In that study, ischemic heart diseases occupied the thirteenth position in the cause of DALYs. This difference may be related to the metric applied by Peñaloza, who applied discount rates on the burden based on age and a lower life expectancy, which causes a much greater underestimation of the burden in advanced diseases, as is the case of ischemic heart disease.

Regarding disability in NCD, two subgroups were remarkable in the region: musculoskeletal and neurological disorders. This was similar to what was found for Colombia in 2017 and 2019 (IHME, 2021), in Latin America (IHME, 2021a), other countries in the world in global burden measurements for 2010 and 2019 (Murray et al., 2012; Vos et al., 2020). The large volume of disability originated by these subgroups is related to their chronicity, low mortality, high prevalence, and involvement in activities of daily life of the people affected (Martínez-Plaza, 2009; Ramírez-Perdomo, Salazar-Parra, and Perdomo-Romero, 2017).

Musculoskeletal disorders are one of the most important problems in human occupational health worldwide due to sequelae and chronic pain without mortality, hence its great impact on the generation of disability (Martínez-Plaza, 2009). In this subgroup, dorsopathies were in the first place in Orinoquia, especially among people aged between 25 and 49 years, a situation comparable to that of Colombia, Latin America, and other parts of the world (IHME, 2021a; IHME, 2021; Murray et al., 2012; Vos et al., 2020). These disorders have been classified as an occupational health problem that occurs at productive ages but has also become frequent in the general population in unpaid activities (Barreda-Castillo and Bazan, 2019; Casado-Morales, Moix-Queraltó, and Vidal-Fernández, 2008), becoming a disability problem (Carvalho-Rodrigues and da Costa, 2018). This similarity in musculoskeletal disorders and dorsopathies in Orinoquia, Colombia and the world is due to the presence of common factors that facilitate the occurrence of these disorders, such as physical (strength, repetition, and postures) and psychosocial factors such as high workload (Arenas-Ortiz and Cantú-Gómez, 2013; Casado-Morales et al., 2008; Chaves-García, 2014; Márquez-Gómez, 2015). These factors are described as common in Colombia, Latin America, and other parts of the world (Arenas-Ortiz and Cantú-Gómez, 2013; Bautista-Sánchez and Jímenez-Santiago, 2014; Oliveira, et al., 2021).

Among neurological disorders, migraines produced the greatest disability, especially in the population aged between 10 and 49 years, similar to findings for in Colombia, Latin America, and other parts of the world (IHME, 2021a, 2021b; Vos et al., 2020). High levels of disability come from its chronicity, impairment in the abilities to carry out activities of daily living in affected individuals, and a high demand for health and care services (Ramírez-Perdomo et al., 2017; Sáez Ruiz, 2017). Concerning migraines and their occurrence, factors such as obesity and a sedentary lifestyle, smoking, and alcohol consumption are mentioned (Le et al., 2011; Molarius, Tegelberg, and Öhrvik, 2008; Peterlin et al., 2013; Winter et al., 2011), factors that are common for all territories.

ECI accounted for 25% of the burden and were positioned as the second cause of DALYs in the Orinoquia. The important contribution of ECI to DALYs is mainly caused by premature mortality in the young population, corresponding to 82% of DALYs. (Bejarano Castro, et al., 2006), highlighting their lethality, hence the importance of prevention. The position of ECI is similar to findings reported in DALYs measurements for Colombia by IHME in 2017 and 2019 (IHME, 2021b; Vos et al., 2020). Comparable results were obtained in Medellín (Grisales et al., 2016); however, it is relevant to point out differences between the proportions reached. In Orinoquia, they caused 24% of DALYs; according to the IHME report for Colombia in 2017, ECI caused 18.48%, which is superior to results reported in Medellín in the department of Antioquia, where the report was 5.9%. Another Colombian territory with measurements of the burden of disease originated by ECI is Bucaramanga, in the department of Santander, with a DALYs rate caused by ECI for 2017 of 1,200 DALYs per 100,000 inhabitants (Casadiegos-Patiño, Esquiaqui-Felipe, and Serrano-Diaz, 2021), which is exceeded more than 3 times by the rate calculated for Orinoquia in this study.

The differences found in this study and compared to Medellín and Bucaramanga could be related to the metrics used in these studies, which were different from the ones used in this study, with the consequent underestimation of YLL in Medellín and Bucaramanga, main source of DALYs by ECI (Rodríguez-García et al., 2017); therefore, it is necessary to be measured with the magnitudes of the estimates by the different metric approaches used although the pattern is consistent.

To contrast these findings, it is very important to specify the two causal pathways that include these ECI subgroups of injuries, which are intentional injuries, are related to violence (self-injuries and interpersonal violence), and caused the most YLL and unintentional injuries that are related to incidents (road traffic and unintentional injuries) (Castañeda-Porras and Segura, 2018; Concha-Eastman and Clavel-Arcas, 2008) and caused more YLD. These two pathways denote a great difference to understand the behavior of ECI due to their origin and lethality.

Findings on the greater number of YLL occurred in intentional ECI evidenced the greater lethality due to the severity of the injury over unintentional injuries (Bejarano Castro et al., 2006) and a predominance in men aged between 10 and 49 years, results that are similar to studies in Colombia (Acosta-Ramírez et al., 2008; Casadiegos-Patiño et al., 2021; Grisales et al., 2016; IHME, 2021), Latin American countries such as Brazil, Mexico, Peru, Chile, Uruguay (Borruel et al., 2010; Ministerio de Salud, 2010; Universidad Católica de Chile, 2008; Velásquez et al., 2009), and other countries of the world (James et al., 2018; Kyu et al., 2018; Roth et al., 2018; Vos et al., 2020). Disease groups’ behavior by age is consistent with the natural history of the disease. The occurrence of ECI has been related to cultural patterns such as the consumption of psychoactive substances (both illegal and legal, such as alcohol) and masculinity, which, along with weapon carrying, are generators of violence (Bejarano Castro et al., 2006; Granados, 2017; Ramírez, 2006).

In unintentional ECI (subgroup of unintentional injuries and road traffic injuries), the age range of occurrence was extended to between 10 and 74 years of age. Although the predominance of men persisted, the proportion of women increased almost twice compared to the proportion reached by women in intentional ECI. Changes in premature mortality and the affected population group could be explained by the nature of the injuries that caused it. These included falls, burns, poisoning, drowning, and blows (Vos et al., 2020), which do not cause premature mortality due to their severity but do cause non-fatal effects (disability). This behavior is derived from aspects described for Colombia, such as age, lifestyle, and work conditions (Timarán-Pereira, Calderón-Romero, and Hidalgo-Troya, 2017).

Due to differences among available measurements, more clarity is required to compare results originated from this study to Colombia’s profile. According to IHME, the proportion of ECI in 2005 and 2010 for Colombia was 22.79% and 21.7% respectively (IHME, 2021b), placing ECI as second group causing DALYs. On the other hand, reports of national studies on the percentage of total DALYs caused by ECI in Colombia were 9% in 2005 (Acosta-Ramírez et al., 2008) and 8% in 2010 (Peñaloza et al., 2014), placing ECI as the third cause of DALYs. It is essential to highlight that such comparisons between this research on Orinoquia and studies carried out in Colombia in 2005 and 2010 should be made with discretion since the latter used 1993 metrics, which is affected by the underestimation of indicators. In this context, in the last study published by IHME in 2019, a similar metric to that used in this study was applied; and results on ECI are comparable, placing ECI as the second cause of DALYs and YLL (Vos et al., 2020). Regarding ECI worldwide, this group was established as the third cause of DALYs and YLL (Hay et al., 2017; Kyu et al., 2018; Mboi et al., 2018; Noordhout et al., 2018; Vos et al., 2016, 2020).

Among ECI, at Level 3, two types of injuries stood out in the Orinoquia due to their magnitude on DALYs and YLL; first, interpersonal violence, followed by road traffic injuries, which is a usual behavior described for Colombia, for Latin America, and for other parts of the world (Murray et al., 2012; Porras Cataño and Grisales-Romero, 2021; Vos et al., 2020). Interpersonal violence, manifested as homicide or attempted homicide, is the first cause of DALYs, a situation that comes from a violent society as has been described for Colombia (Bejarano Castro et al., 2006; Marquina, 2017) either due to daily conflicts or political causes (Martínez, 2016). Other authors propose that it arises from the presence of a masculine identity (rivalry, competition, and justification of superiority over other men) that tends to solve problems, discrepancies, and disagreements through violence (Cano and Rojido, 2017; Ramírez, 2006), alcohol consumption, and weapon carrying (Bejarano Castro et al., 2006). Other explanations include precarious jobs and unemployment, leading to criminality and gender roles with a dominant man in a context of violence (Dávila-Cervantes and Pardo-Montaño, 2018; Granados, 2017; Vazsonyi, Clifford-Wittekind, Belliston, and Van Loh, 2019). These findings are consistent with other studies for 2017 and 2019, where interpersonal violence was placed as the first cause of YLL in Colombia (IHME, 2021b; Vos et al., 2020). However, it is important to mention that the prevalence of interpersonal violence found in this study is a serious phenomenon, which contrasts with world figures which showed that it was far from being part of the top two causes of YLL in 2010 and 2019. Interpersonal violence barely becomes the 18^th cause of YLL in the world, 26^th of DALYs, and 42^nd of YLD (Murray et al., 2012; Vos et al., 2020).

Road traffic injuries that took second place in Orinoquia had a behavior that is similar to that of the country (IHME, 2021b) but that contrast with the position they reached in the world between thirteenth place in 2010 and fourteen in 2019 (Murray et al., 2012; Vos et al., 2020). The fundamental factors for safe driving recognized are the person, the vehicle, the road, and traffic rules; but the main variable causing traffic incidents is the person. For Colombia, risk behaviors have been described as road traffic injury generators: crossing without looking, speeding, driving under the influence of alcohol, driving on the wrong side of the road, failure to obey traffic signals, among others (Bejarano Castro et al., 2006). There is also a biological factor related to the reproductive stage to take into account, where individuals take risks and execute risk behaviors such as the aforementioned (Norza-Céspedes et al., 2014).

CMNND were the group of diseases that caused the least burden in the Orinoquia, a situation that is similar for Colombia, Latin America, and the Caribbean, but not in the global burden, where CMNND placed second. When analyzing the position of CMNND in the countries of the world using classifications that measure development or wealth such as the Socio-Demographic Index¹ used by IHME or income levels defined by the World Bank, it is possible to observe a gradient in the proportion of CMNND. These decrease with an increase in the development or the wealth of a country, thus, changes of position in the classification. For instance: CMNND originate 58.8% of DALYs in low-income countries, being the first cause of DALYs; in lower-middle income countries, they produced 35% and were placed in second position as causes of DALYs. On the other hand, in upper-middle income and high-income countries, they produced 9.9% and 4.6% respectively, and CMNND are being located as the third cause (IHME, 2021d). It is concluded that findings from different studies allow us to note that economic factors may influence the contribution of CMNND to total DALYs (Berlinguer, 2007; Méndez, 2018; Ortega, 2019; Vargas, 2019), and this would explain our findings.

Among CMNND, respiratory infections, sexually transmitted infections (STI), and enteric infections subgroups were remarkable by their contribution to DALYs (YLL, YLD). These findings are consistent with the results found for Colombia and other parts of the world, since these subgroups are part of the first cases within CMNND (Dantés-Gómez et al., 2011; Murray et al., 2012; Peñaloza et al., 2014; Porras Cataño and Grisales-Romero, 2021; Vos et al., 2020). Enteric infections are recognized as one of the main causes of morbidity and mortality in developing countries (Cáceres, et al., 2005), where poverty and sanitation problems (drinking water and sewerage) contribute significantly to the occurrence and greater involvement of early childhood (Mariños-Anticona, et al., 2014). In Colombia, multidimensional poverty index (MPI) is applied, which measures access to sanitation, drinking water and sewerage, and access barriers for early childhood to health care and services (Moreno-Gómez, Duarte-Gómez, and Barrientos-Gutiérrez, 2017; Salazar, Cuervo, and Pinzón, 2011). On this scale, Orinoquia has MPI scores ranging from 19.1% to 63.3% in its different departments (DANE, 2019), which could be accounting for the figures achieved in Orinoquia in 2018.

Finally, findings on the superiority of the fatal effects of YLL compared to the non-fatal effects of YLD component in their contributions to the burden of disease are similar to measurements of the global burden estimated by IHME for Colombia and other parts of the world, with a greater contribution of YLL to DALYs (Hay et al., 2017; James et al., 2018; Kyu et al., 2018; Vos et al., 2017, 2020), highlighting that premature mortality, which comes from diseases or injuries with high lethality or deficiencies in care of health systems (Cainzos-Achirica and Bilal, 2021; Dumoy, 2013; Laroze, 2018), is the main source of the health gap of humanity due to the volume of years it produces.

When analyzing by sex, differences between YLL and YLD became evident in Orinoquia, as well as in the rest of Colombia and other parts of the world. Women live longer in suboptimal states of health (i.e., YLD), while men die more and at an earlier age than women (i.e., YLL; Dantés-Gómez et al., 2011; Grisales et al., 2016; Hay et al., 2017; IHME, 2021c; James et al., 2018; Lang et al., 2018; Peñaloza et al., 2014; Vos et al., 2020). This result is expected due to reasons exposed in previous paragraphs which demonstrate that men are more affected by diseases and injuries with greater lethality (interpersonal violence, self-injuries, and road traffic injuries), while women are more affected by non-communicable diseases that produce a greater disability (Dantés-Gómez et al., 2011; Grisales et al., 2016; Hay et al., 2017; IHME, 2021c; James et al., 2018; Lang et al., 2018; Peñaloza et al., 2014; Vos et al., 2020).

It is important to note that in studies carried out in Colombia, the proportion of DALYs that derived from YLL is lower if compared to what was found in this study, where YLL contribute 84%. In 2010, YLL represented only 21.6% of the burden in Colombia (Peñaloza et al., 2014), and in Medellín for the septennium of 2006-2012, they only represented 13% (Grisales et al., 2016). These differences could be explained by the use of the GBD 1993 metric in these studies with a standard life expectancy of 82.5 years for women and 80 years for men and discount rates affecting weighting factors (WF) used to estimate YLL. WF, when using 1993 metric, was from 33.13 and 33.01 for women and men, respectively, at 0 years of age, up to 0.57 and 0.52 to 100 years of age, while in this study, without discount rates and a standard life expectancy of 92 years, a WF of 90.1 in the group of 0-4 years and 1.94 in the group of 100-104 years was produced. Therefore, this difference in the metrics would be responsible for the discrepancies (World Health Organization, 2013, 2017), as what happened in the measurement of global YLL for 2011. It is estimated that it caused an underestimation of 62% of YLL, causing changes in the relative contribution to YLL and DALYs.

Conclusions

The greatest loss of DALYs in Orinoquia comes from NCD, mainly by neoplasms and cardiovascular disease, which increase with age. The demographic transition for the territory is evident by the greater involvement caused by NCD. Although when grouping causes (diseases and injuries) of DALYs, NCDs are the main contributors to the burden of disease of the territory, when discriminating by specific cause of illness or injury, interpersonal violence is constituted as the main cause of DALYs in Orinoquia, principally affecting young men.

Furthermore, it is important to highlight differences found by sex and age that should lead to policies and programs with differential approaches; the burden of disease in men comes mainly from premature mortality (YLL) due to ECI, while in women, the burden comes from NCD by disability (YLD). Based on life cycles, differences in the causes of DALYs were also found, such as greater involvement by CMNND in children, ECI in adolescents and young people, and NCD in adults and the elderly.

Now, it is important to emphasize that in DALYs that occurred in Orinoquia, YLL surpassed by a great difference YLD in the burden of disease, highlighting that premature mortality is a problem that requires priority and immediate attention in these territories.