Temporal Trends, Cross-Country Inequality, and Future Burden of Mortality and DALYs Attributable to High Fasting Plasma Glucose in South Asia, 1990–2050: Forecasting, Validation, and Benchmarking Analysis Using the Global Burden of Disease 2023 Study

Abstract

Background & Objective: High fasting plasma glucose (HFPG) is a major modifiable metabolic risk factor for cardiovascular disease, chronic kidney disease, premature mortality, and disability. South Asia faces a growing cardiometabolic burden, yet long-term country-level trends, inequalities, and future HFPG-attributable burden remain insufficiently characterized. We assessed temporal trends, cross-country inequality, uncertainty-aware rankings, and projected mortality and disability-adjusted life-year (DALY) burden attributable to HFPG across South Asia. Methodology: We analyzed Global Burden of Disease 2023 estimates for Bangladesh, Bhutan, India, Nepal, Pakistan, and South Asia from 1990–2023. Age-standardized HFPG-attributable mortality and DALY rates were evaluated using estimated annual percentage change and joinpoint regression. Inequality was quantified using absolute gaps, highest-to-lowest rate ratios, and coefficients of variation, with benchmarking against the lowest-burden country. Country rankings were assessed using 1,000 Monte Carlo simulations. For 36 location–outcome–sex series, autoregressive integrated moving average, exponential smoothing, and random-walk-with-drift models were compared using an eight-year hold-out period and refitted to forecast burden through 2050. Results: From 1990 to 2023, regional age-standardized mortality increased from 63.7 to 85.1 per 100,000 and DALY rates from 1,872.0 to 2,485.0, with average annual increases of 0.91% and 0.90%, respectively. In 2023, Pakistan had the highest DALY rate (2,637.2; 95% UI, 2,142.6–3,215.2), 43.0% above Bhutan, while India had the highest mortality rate (87.4; 95% UI, 71.9–104.6), 39.5% above Nepal. Relative inequality narrowed but persisted: DALY and mortality coefficients of variation declined from 18.4% to 16.8% and 18.1% to 14.4%, respectively. Pakistan ranked highest for DALYs in 60.5% of simulations and India for mortality in 69.4%. By 2050, regional DALY and mortality rates are projected to reach 3,134.0 and 107.9 per 100,000, increases of 25.0% and 25.7% from 2024. India is projected to experience the largest increase. Validation showed a median mean absolute percentage error of 1.34%; no series exceeded 5%, and 34 of 36 models showed no significant residual autocorrelation. Conclusion: HFPG-attributable mortality and disability are rising across South Asia despite modest narrowing of relative inequality. The projected burden through 2050 supports country-specific prevention, earlier glycaemic detection, sustained cardiometabolic care, and equity-focused health-system planning. Key Words: Fasting Plasma Glucose, DALY’s, South Asia.