Preventive Gastroenterology: An Ounce of Prevention or Pounds of Cure to Curb Gastrointestinal Diseases

BURDEN OF GASTROINTESTINAL DISEASES As per the data published from the Global Burden of Disease (GBD) study in 2023, digestive diseases constitute a major and complex public health challenge worldwide, accounting for the billions of prevalent and incident cases, millions of deaths and hundreds of millions of disability-adjusted life years (DALYs) in 2019.[1,2] The overall burden is characterised by notable disparities based on socioeconomic factors, showing a general inverse relationship with a country’s Sociodemographic Index (SDI).[1,2] This pattern is influenced by variations in predominant causes; for instance, enteric infections remain a leading cause of death and DALYs in low-SDI regions, while in high-SDI countries, non-communicable digestive diseases, particularly colorectal cancer and inflammatory bowel disease (IBD), contribute significantly to mortality and disability rates.[1,3] Although age-standardised rates for mortality and DALYs saw a global decline between 1990 and 2019 due to improvements in sanitation and care, the absolute number of cases and total DALYs continue to rise, driven by population growth and ageing demographics.[1,2] These trends underscore the ongoing, evolving nature of the digestive disease burden worldwide and highlight the critical need for region-specific public health policies and interventions.[1,3] The composition of this burden is complex, with liver diseases and gastrointestinal cancers being primary drivers of mortality and long-term disability globally.[1,2] Cirrhosis and other chronic liver diseases contributed most significantly to DALYs worldwide and ranked highest in age-standardised prevalence rates, with alcohol use cited as a leading risk factor globally.[1-3] Digestive cancers, including those affecting the colorectum, stomach, pancreas and liver, represent the substantial causes of death, particularly in higher-income nations where colorectal cancer emerged as the dominant cause of digestive disease mortality.[1-3] Furthermore, upper digestive system diseases constituted the second-largest proportion of total DALYs from digestive illnesses.[2,3] The burden was generally higher in males, often correlating with higher rates of alcohol consumption and other risk behaviours, and peaked in the 50–59 years’ age group for DALYs, highlighting the profound impact of these conditions on the working-age population and the need for targeted preventative strategies.[1-3] COMMON GASTROINTESTINAL DISEASES The common gastrointestinal diseases contributing to the global burden, as analysed by the GBD study published in 2023, encompass a wide range of conditions across different organ systems.[1-3] Major non-communicable diseases driving the burden include cirrhosis and other chronic liver diseases, often linked to alcohol use, and a number of gastrointestinal cancers such as colorectal, stomach, pancreatic, oesophageal and liver cancers.[1-3] Infectious causes remain a significant contributor globally, particularly enteric infections, which were the primary driver of incidence, deaths and DALYs worldwide.[3] Other prevalent conditions cited in the analyses include IBD, upper digestive system diseases (which include peptic ulcer disease and gastro-oesophageal reflux disease [GERD]), pancreatitis, gall bladder and biliary diseases, appendicitis and intestinal obstructions, all contributing to the overall public health challenge presented by digestive illnesses.[1,2] ROLE OF PREVENTION IN GASTROINTESTINAL DISEASES The prevention plays a critical and multifaceted role in addressing the global burden of digestive diseases, offering the most effective long-term strategies for curbing morbidity, mortality and disability. Public health efforts focused on improving sanitation and hygiene, alongside widespread vaccination against infectious agents such as the hepatitis B virus and rotavirus, have been demonstrably effective in reducing the incidence of enteric infections and viral-related cirrhosis, especially in the lower-income regions.[1-3] Alongside these broad public health measures, lifestyle modifications are crucial. Promoting healthy dietary habits that are rich in fibre while limiting processed foods, managing body weight to mitigate the rise of non-alcoholic fatty liver disease (NAFLD) and strongly advocating for the cessation of tobacco and reduction of excessive alcohol consumption are the key strategies cited in GBD-related analyses to combat the leading causes of chronic liver disease, gastrointestinal cancers and upper digestive system disorders.[4-7] In addition to primary prevention, secondary prevention through early detection and screening is vital, particularly for conditions with poor prognoses when diagnosed late, such as gastrointestinal cancers.[4-7] The GBD study emphasises the importance of screening programmes for colorectal cancer, with recent guideline changes in some high-income countries reflecting the growing incidence in younger populations.[5-7] Similarly, screening for chronic liver disease in high-risk groups, such as those with metabolic syndrome or chronic alcohol use, can enable early intervention and prevent the progression to decompensated cirrhosis and liver cancer.[4] The ongoing rise in cases of NAFLD and alcohol-associated cirrhosis highlights the need for renewed focus on primary prevention targeting metabolic risk factors and harmful alcohol consumption, as these trends threaten to offset gains made in controlling viral hepatitis through vaccination and antiviral therapies.[1-4] Preventive gastroenterology has been recognised as an interesting and rewarding field that offers promising opportunities to reduce the burden of gastrointestinal diseases through early intervention and health promotion.[8] It emphasises the integral role of preventive gastroenterology in not only managing existing diseases but also in implementing strategies to avert disease onset by focusing on patient education, lifestyle modifications and community-level awareness programmes. They highlighted that the sub-speciality encourages proactive health behaviours and regular screening, thereby facilitating the early diagnosis and better outcomes.[8] For example, Hofmann described ursodeoxycholic acid therapy as a milestone that allows for dissolution of cholesterol gallstones without surgical intervention, representing a paradigm shift from reactive surgical treatment to proactive medical management. This therapy offers a non-invasive preventive strategy, particularly beneficial for patients unfit for surgery, thus exemplifying the preventive ethos in gastroenterology by targeting disease before complications arise.[9] Similarly, the emerging concept of preventive hepatology is a critical approach to curb the increasing burden of liver diseases globally. Preventive hepatology incorporates primordial, primary and secondary prevention strategies, including vaccination, lifestyle modification, early detection and management of metabolic and alcohol-related risks to halt disease progression and reduce liver-related morbidity and mortality. It advocates for specialised preventive hepatology clinics integrated within community and primary healthcare systems, which could provide targeted counselling, screening and longitudinal follow-up, aligning closely with the goals of preventive gastroenterology.[10] PREVENTIVE GASTROENTEROLOGY AS A SUB-SPECIALTY Clinical and surgical departments are equipped to manage complicated and critical cases of gastrointestinal diseases. However, an additional preventive gastroenterology sub-speciality can use the opportunity to educate and counsel patients and screen, counsel and educate accompanying family members who often go undiagnosed for many gastrointestinal diseases, especially GERD, IBD, gastroenteritis, hepatitis, steatotic liver diseases, pancreatitis, etc., which are mainly asymptomatic. Residents from general medicine and gastroenterology can be posted in these clinics under the overall leadership of a community/preventive medicine physician to ensure that care is person-/family-centred with structured longitudinal follow-up. This sub-speciality must also regularly undertake health awareness, education and promotion activities in the community through satellite preventive gastroenterology clinics at primary health centres. For this, capacity of the primary care physician must also be ensured. Initiating academic courses such as post-graduate fellowship and diploma or certificate courses will help build a new cadre of residents with knowledge and skills for different levels of prevention for gastrointestinal diseases. Preventive gastroenterology will be a sub-speciality focused on lowering patients’ risk for developing gastrointestinal diseases and also for preventing the complications and sequelae in patients who already have gastrointestinal diseases. Cutting-edge research, like community-based large cohort studies, will be the mandate of this sub-speciality. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.