PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

30 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceItaly was the sole country achieving an age-adjusted decline (-4.7%), though its unadjusted DALYs still increased, falling slightly 2011–2016 then rising 2016–2021. This near-universal parallel increase in both unadjusted and adjusted rates, unlike the mixed trajectories seen in cancer and cardiovascular disease, confirms that the diabetes epidemic reflects genuine deterioration in metabolic health beyond demographic change alone, pointing to systemic failures in addressing the upstream determinants of metabolic disease. The acceleration is particularly striking in countries that otherwise show strong NCD performance. Canada, despite having the lowest overall NCD burden, experienced one of the largest diabetes increases (+21.3% age-adjusted), suggesting that even well-resourced health systems struggle to counter the metabolic disease epidemic. Similarly, Germany’s diabetes burden rose 22.5% on an age-adjusted basis despite its sophisticated healthcare infrastructure. Japan, despite its world- leading life expectancy, saw a 14.8% age-adjusted increase (IHME, 2023). Poland likewise demonstrates the interconnected nature of the metabolic crisis, documenting parallel rises in diabetes, obesity, and kidney disease. Diabetes-related amputation rates ranged from 2.5 per 100,000 population in Italy to 8.5 in Germany in 2021 (OECD, 2023b). Between 2011–2021, most countries showed modest reductions, although the rate in Poland increased from 6.3 to 8.6 per 100,000 (OECD, 2023b). The persistent variation suggests differences in diabetes management quality and preventive foot care services. Poland likewise demonstrates the interconnected nature of the metabolic crisis, documenting parallel rises in diabetes, obesity, and kidney disease. Indicators of metabolic health also highlight some concerning trends. The percentage of Japanese women aged 40–79 with total cholesterol levels of 240 mg/dL or higher increased from 22% in 2010 to 25% in 2019, a 13.6% relative increase (MHLW, 2024b). Daily salt intake among Japanese adults remains at 9.8g, nearly double the WHO recommended maximum of 5.0g, despite decades of public health messaging about sodium reduction (WHO, 2025f). The early onset of metabolic dysfunction particularly concerns policymakers. Italy reports that among overweight and obese children, 30% show dyslipidaemia, 50% have hepatic steatosis, and 10% have hypertension (Italian Ministry of Health 2024). When metabolic disease processes begin early in life, they have implications for future disease burden that current adult-focused interventions cannot address. Chronic kidney disease Chronic kidney disease, often a consequence of longstanding diabetes and hypertension, presents a mixed picture that varies dramatically by country. As shown in Figure 12, unadjusted CKD DALYs increased in seven of eight countries between 2011 and 2021. Greece experienced the most extreme deterioration: a 134% unadjusted increase from 475 to 1,110 DALYs per 100,000, alongside a 68.6% age-adjusted increase, likely reflecting healthcare system strain during the economic crisis combined with improved diagnosis and reporting. France and Italy showed unadjusted increases with essentially flat age-adjusted rates (-1.6% and +3.4% respectively), suggesting demographic factors primarily drive their observed burden. Spain and Japan achieved age-adjusted declines (-14.1% and -10.3% respectively) despite unadjusted increases. Poland stands out as the sole success story, achieving both unadjusted decline and a substantial 26.8% age-adjusted reduction. Even countries with modest increases face mounting demands for dialysis and transplantation services that will strain health systems for decades. Spain exemplifies the problem of CKD’s lack of visibility: CKD affects approximately 15% of adults, yet over 50% of those affected remain unaware of their condition due to its asymptomatic early stages (Bernal-Delgado et al., 2024). This diagnostic gap is Europe-wide: France reports 95.5% of stage 3 CKD cases undiagnosed (Tangri et al., 2023), while Greece’s patients present predominantly at advanced stages with high rates of self-referral, indicating systematic failures in primary care detection. The economic implications are staggering: France, despite lower CKD prevalence than its