---
domain: health
tags: [harmonism, wheel-of-harmony, wheel-of-health, health, mortality, chronic-disease, metabolic, cancer, epidemiology, longevity]
content_layer: bridge
doctrinal_status: clear
breadth: full
depth: developed
craft: muddy
published: "2026-09-26"
updated: "2026-09-27"
canonical_url: https://harmonism.io/wheel-of-harmony/health/causes-of-death-and-chronic-disease
site: Harmonia — harmonism.io
---
# Causes of Death and Chronic Disease — What Shortens a Life Now

*Part of the [[Wheel of Health]]. Read with [[Root-Cause-of-Disease|The Root Cause of Disease]], which holds the ontology this map is read against, and [[Health-Longevity-Biggest-Levers|The Biggest Levers]], which ranks the inputs against it.*

---

Eight of the ten causes that kill the most people on earth are chronic diseases, and each of them develops for decades before it kills. A heart attack arrives in a minute and has been building in the arteries since early adulthood. The kidney loses function for years before it fails. The tumour found at fifty-five began as a clone of cells long before anyone could feel it. An early death from these diseases is the end of a process that could have been measured, and often slowed or stopped, while there was still time.

The [[Wheel of Health]] works on the few inputs that decide whether those processes run, in the years before they reach an organ's limit.

---

## 1. What People Die Of

About 60 million people died in 2023, and 44.8 million of them, three in four, died of noncommunicable disease ([GBD 2023 Causes of Death Collaborators](https://doi.org/10.1016/S0140-6736(25)01917-8), *Lancet*, 2025). The certificate names an organ. Grouped instead by the disease process behind them, the same deaths fall into seven blocks, with the ten leading single causes placed inside them:

| Disease process | Leading causes within it | Deaths, 2023 | Share of all deaths |
|---|---|---|---|
| Heart and blood vessels | ischaemic heart disease 8.91 m · stroke 6.79 m · hypertensive heart disease 1.49 m | 19.2 million | 32% |
| Cancer, all sites | lung 2.04 m · colorectal 1.11 m | 10.6 million | 18% |
| Infection, childbirth and undernutrition | lower respiratory infections 2.50 m · neonatal disorders 1.63 m · tuberculosis 1.01 m | 10.3 million | 17% |
| Injury | road injuries 1.34 m | 4.9 million | 8% |
| Metabolic organ failure | diabetes 2.00 m · chronic kidney disease 1.52 m · cirrhosis 1.28 m | 4.8 million | 8% |
| Chronic lung disease | chronic obstructive pulmonary disease 3.43 m | 4.2 million | 7% |
| Brain degeneration | Alzheimer's disease and other dementias 2.21 m | 2.2 million | 4% |

Sources: cardiovascular total from [GBD 2023, *JACC*, 2025](https://doi.org/10.1016/j.jacc.2025.08.015); chronic respiratory total from [GBD 2023, *Nature Medicine*, 2026](https://www.nature.com/articles/s41591-025-04077-9); cancer and the infection block are GBD's own groupings (neoplasms; communicable, maternal, neonatal and nutritional diseases); injury is the 2023 total less its noncommunicable and communicable deaths; metabolic organ failure is the sum of its three causes. The remaining 6% is spread across digestive, neurological, mental and other conditions.

Heart attack and stroke are, for the most part, one disease reaching two organs: arteries damaged by blood pressure, ApoB-carrying lipoproteins, blood sugar and smoke, which close in the heart of one person and in the brain of another. With hypertensive heart disease they account for 17.2 million deaths, and the vascular block alone kills almost one person in three. Cancer adds another 10.6 million, so two disease processes account for half of all deaths on earth.

The five chronic blocks together (vessels, cancer, metabolic organs, lungs and brain) account for about 41 million deaths: two in three of all deaths, and more than nine in ten of the noncommunicable ones. They are less separate than their rows. People with diabetes and failing kidneys most often die of heart attack and stroke and are counted there, so the metabolic row understates its own weight. Half of the dementia commission's modifiable risk factors are vascular or metabolic (§ 2). Cirrhosis runs through the fat stored in the liver, alongside alcohol and viral hepatitis. Chronic lung disease is the exception, a disease of smoke and particulate air rather than of metabolism (§ 5).

The infection block is the old order of mortality, the leading cause of death in every society until the twentieth century, and it now accounts for one death in six. COVID-19, first by age-standardised rate in 2021, had fallen to twentieth by 2023.

A world average hides very different worlds. In low-income countries, eight of the ten leading causes of death in 2021 were still infections ([WHO](https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death)), and the mean age at death in sub-Saharan Africa was 36 to 38 years, against 75 to 81 in the high-income countries. The chronic diseases have arrived there as well, and they arrive younger. Of the 18 million people who died of a noncommunicable disease before seventy in 2021, 82% lived in low- and middle-income countries ([WHO](https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases)), and four in five cardiovascular deaths occur there.

Much of the world now carries both burdens at once, the infections of poverty and the diseases of plenty. The richest countries carry the second in its purest form. American deaths in 2024 were led by heart disease at 683,491 and cancer at 619,876 ([NCHS Data Brief 548](https://www.cdc.gov/nchs/products/databriefs/db548.htm)); in the European Union circulatory disease took 32.8% of deaths in 2023 and cancer 23.9% ([Eurostat](https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Causes_of_death_statistics)).

Death certificates are organised by organ, and a ranked list inherits their order. Grouped by process, the chronic causes reduce to five patterns, and followed one step upstream they share most of their drivers. That shared ground is what a person can act on.

---

## 2. What People Live With

Death certificates record the last event. The years before it are spent with conditions that rarely appear on them.

### The Metabolic Ground

The chronic diseases below the leading killers rest on a metabolic ground that has shifted faster than any death rate.

More than a billion people were living with obesity in 2022, adult obesity having more than doubled since 1990 ([NCD-RisC via WHO](https://www.who.int/news/item/01-03-2024-one-in-eight-people-are-now-living-with-obesity)). The International Diabetes Federation counts 589 million adults aged 20–79 with diabetes, one in nine, 43% of them undiagnosed, and 3.4 million diabetes deaths in 2024 ([IDF Diabetes Atlas, 11th edition](https://idf.org/news-and-resources/news/idf-diabetes-atlas-11th-edition/)); a broader biomarker definition from the NCD Risk Factor Collaboration finds 828 million, 445 million of those over thirty untreated (*Lancet*, 2024). Of 1.4 billion adults with hypertension, 44% do not know it and 23% have it controlled ([WHO](https://www.who.int/news-room/fact-sheets/detail/hypertension)). Every organ that stores what the body cannot burn shows the same slide. Fat in the liver, now named [metabolic dysfunction–associated steatotic liver disease](https://grokipedia.com/page/Non-alcoholic_fatty_liver_disease), rose from 25.3% of adults worldwide in studies from 1990–2006 to 38.0% in studies from 2016–2019 ([Younossi et al., *Hepatology*, 2023](https://doi.org/10.1097/HEP.0000000000000004)). Depending on the definition used, between 12.5% and 31.4% of the world's adults meet the criteria for [metabolic syndrome](https://grokipedia.com/page/Metabolic_syndrome), more in richer countries (Noubiap et al., *Diabetes Research and Clinical Practice*, 2022).

Where the whole picture has been measured together, it is worse than any single figure. Tufts researchers assessed five components of cardiometabolic health across American adults (adiposity, blood sugar, blood pressure, cholesterol and freedom from cardiovascular disease) and found 6.8% with all five at optimal levels in 2017–18 ([O'Hearn et al., *JACC*, 2022](https://now.tufts.edu/2022/07/05/only-7-american-adults-have-good-cardiometabolic-health)).

### The Slow Organ Failures

On that ground sits a band of diseases that kill slowly and disable for years before they do.

**Dementia** affected 57 million people in 2021, more than 60% of them in low- and middle-income countries, with nearly ten million new cases a year; it is the seventh cause of death worldwide ([WHO](https://www.who.int/news-room/fact-sheets/detail/dementia)). In 2024 the *Lancet* Commission on dementia identified fourteen modifiable risk factors, among them hypertension, diabetes, high LDL cholesterol, obesity, physical inactivity, smoking, excess alcohol, hearing loss and untreated vision loss, and estimated that addressing them could prevent or delay nearly half of all cases ([Livingston et al., 2024](https://www.eurekalert.org/news-releases/1052982)). Half the list is the metabolic and vascular ground described above, read in the brain.

**Chronic kidney disease** reached 788 million adults in 2023 and the ninth place among the world's causes of death, with 1.48 million deaths ([GBD CKD Collaborators, *Lancet*, 2025](https://doi.org/10.1016/S0140-6736(25)01853-7)). Its age-standardised prevalence rose only 3.5% since 1990, so most of the growth is an ageing population; what the count hides is that diabetes and hypertension remain the leading causes of the disease, and that impaired kidney function accounts for 11.5% of cardiovascular deaths.

**Chronic liver disease** killed 1.28 million people through cirrhosis in 2023, and liver cancer another half million. Its two drivers are the fat stored in the liver and the alcohol the liver is asked to clear. Until September 2026 this corpus's own list of levers told readers to *avoid excess alcohol*; the list now reads zero, because no quantity of ethanol spares the liver, and the liver is where that shows first.

**Multimorbidity**, two or more chronic conditions at once, affects 37.2% of adults worldwide and 51.0% of those over sixty ([Chowdhury et al., *eClinicalMedicine*, 2023](https://doi.org/10.1016/j.eclinm.2023.101860)).

Across 183 countries, the gap between the years people live and the years they live in health widened over two decades to 9.6 years; in the United States, which spends more on medicine than any country on earth, it reached 12.4, the widest measured ([Garmany and Terzic](https://newsnetwork.mayoclinic.org/discussion/the-global-divide-between-longer-life-and-good-health/), *JAMA Network Open*, 2024). That gap is made of these years.

---

## 3. What Is Changing

### Counts and Rates

Two numbers travel under the same headline and mean opposite things. A **count** is how many people died of a cause or were diagnosed with it; it rises whenever the population grows or ages. An **age-standardised rate** removes both effects and asks whether a person of a given age is more or less likely to die of it than a person of the same age was before. Cardiovascular deaths worldwide rose from 13.1 million in 1990 to 19.2 million in 2023, while the age-standardised cardiovascular death rate fell by a third, from 322 to 215 per 100,000 ([GBD 2023, *JACC*, 2025](https://doi.org/10.1016/j.jacc.2025.08.015)).

More people die of heart disease because there are more old people; any given old person is less likely to.

Cancer follows the same pattern with one exception that matters. The world recorded close to 20 million new cancers and 9.7 million cancer deaths in 2022, lung cancer first by both measures ([GLOBOCAN 2022, Bray et al.](https://doi.org/10.3322/caac.21834)). Worldwide, age-standardised cancer mortality fell 23.9% between 1990 and 2023, by a third in upper-middle-income countries and by 27.3% in high-income ones. In lower-middle-income countries it rose 16.6%, and in low-income countries it rose as well, though with wide uncertainty ([GBD 2023 Cancer Collaborators](https://doi.org/10.1016/S0140-6736(25)01635-6), *Lancet*, 2025). The poorer countries are adopting the diet, the tobacco and the sedentary work of the rich faster than they are acquiring the screening and the treatment, and their cancer rates show it. [[Cancer-Prevention|Cancer — The Harmonism Protocol]] sets out what the terrain can do against the disease wherever it is growing.

### The Metabolic Shift

The largest shift of all is metabolic, and Global Burden of Disease risk-factor data give it its shape. Between 2000 and 2021, disability-adjusted life years attributable to metabolic risks (high blood pressure, high blood sugar, high body-mass index, high LDL) rose 49.4%, while those attributable to behavioural risks fell 20.7% and to environmental and occupational risks 22.0% ([*Lancet*, 2024](https://doi.org/10.1016/S0140-6736(24)00933-4)). Dirty water, tobacco smoke and the workplace were the killers of the twentieth century, and their share is shrinking.

The body's own chemistry is replacing them.

One counter-trend deserves its place. American adult obesity held at 40.3% from 2013 to 2023, although severe obesity rose from 7.7% to 9.7% ([CDC Data Brief 508](https://www.cdc.gov/nchs/products/databriefs/db508.htm)). A plateau at four in ten is still a plateau at four in ten.

### The Stall in Heart Deaths

Inside the good news of the rich countries sits the signal that matters most. Alan Lopez and Tim Adair examined 23 high-income countries and found that the long decline in cardiovascular death at ages 35–74 had slowed to under 2% a year in more than half of them, and that American rates had begun to rise ([*International Journal of Epidemiology*, 2019](https://doi.org/10.1093/ije/dyz143)). In England, under-75 cardiovascular deaths rose each year from 2020 to 2022 to their highest level since 2011 ([British Heart Foundation](https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2024/january/early-heart-disease-deaths-rise-to-14-year-high)). Statins, stents and the collapse of smoking bought half a century of falling heart deaths. The most plausible reading of the stall is that the populations those treatments served became metabolically worse faster than the drugs could compensate. What medicine does before, during and after a heart attack is set out at [[Medical-Interventions-Preventing-Death#1. Heart and Blood Vessels|Medical Interventions]].

### Cancer in the Young

The clearest sign of disease arriving earlier is cancer in adults under fifty, and it is also the clearest case of a count misread as a rate. Headlines quote a 79% rise in early-onset cancer worldwide between 1990 and 2019 ([Zhao et al., *BMJ Oncology*, 2023](https://doi.org/10.1136/bmjonc-2023-000049)). It is a count of cases in people under fifty, and much of it is population growth; deaths in the same group rose 27.7%. Its authors were more careful than the headlines. Stronger evidence comes from comparing generations. Using American registry data, Sung and colleagues found that 17 of 34 cancers rise with each successive birth cohort: a person born in 1990 carries 3.56 times the small-intestine cancer incidence of a person born in 1955 at the same age, 2.92 times the kidney cancer incidence and 2.61 times the pancreatic ([*Lancet Public Health*, 2024](https://doi.org/10.1016/S2468-2667(24)00156-7)).

Then the counter-evidence, also American. H. Gilbert Welch and colleagues took the eight fastest-rising early-onset cancers (thyroid, anus, kidney, small intestine, colorectum, endometrium, pancreas and myeloma) and showed that their combined incidence roughly doubled after 1992 while their combined mortality sat at 5.9 deaths per 100,000 in both 1992 and 2022 ([*JAMA Internal Medicine*, 2025](https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2839347)). More scanning finds more small thyroid nodules and incidental kidney masses, many of which would never have killed anyone. Their reading is [overdiagnosis](https://grokipedia.com/page/Overdiagnosis), and for thyroid and kidney it is persuasive. Overall American cancer mortality under fifty fell 44% between 1990 and 2023 ([American Cancer Society](https://pressroom.cancer.org/under-50-mortality-declines)).

Two cancers survive every correction, because their death rates climb with their diagnoses.

**Colorectal cancer** is rising in young adults across the world. Incidence at ages 25–49 rose in 27 of 50 countries and territories over their most recent decade of data, fastest in New Zealand and Chile at about 4% a year ([Sung et al., *Lancet Oncology*, 2025](https://www.eurekalert.org/news-releases/1067953)). Deaths at those ages rose in 18 of 49 countries, by more than 3% a year in Paraguay, Uruguay, Chile and the United Kingdom, often while rates in older adults fell (Sung et al., *Journal of the National Cancer Institute*, 2026). In the United States it is now the leading cause of cancer death under fifty, up from fifth in the early 1990s. **Endometrial cancer** rises the same way in the American data, mortality and incidence climbing together at about 2% a year.

The colorectal rise now has a mechanism. Díaz-Gay and colleagues sequenced 981 colorectal tumours from 11 countries on four continents and found the mutational fingerprint of [colibactin](https://grokipedia.com/page/Colibactin), a DNA-damaging toxin made by certain strains of *E. coli* in the gut, 3.3 times more often in patients diagnosed before forty than after seventy, and more often in countries where the disease is common ([*Nature*, 2025](https://www.nature.com/articles/s41586-025-09025-8)). Colibactin laid its damage down early in the tumour's history, and the authors trace it to exposure in childhood.

A cancer diagnosed at thirty-eight may have begun in a gut colonised at six.

Read with that care, the finding is exact. Diagnoses are rising across many sites, and for most of them the rise is the scanner. Deaths are falling overall in the rich countries. For the colon, and for the endometrium where it has been measured, more young people are dying, and both are cancers whose risk tracks the metabolic and microbial state of the body: obesity, insulin resistance and excess oestrogen for the endometrium, obesity, diet and the gut's bacterial ecology for the colon. That pairing is inference from the evidence, and it points in one direction.

---

## 4. One Terrain, Read at Different Organs

[[Harmonism]] holds that chronic disease is a single condition expressed through many organs: a body pulled out of alignment with the order that sustains it, which [[Root-Cause-of-Disease|The Root Cause of Disease]] names disharmony and traces to three rivers, toxic load, chronic infection and metabolic disharmony. Two decades of epidemiology have read that doctrine at population scale. Follow the leading causes back one step each. Heart attack and stroke run through blood pressure, ApoB-carrying particles, insulin resistance and vascular inflammation. Colorectal and endometrial cancer in the young, and the obesity-associated cancers of the liver, kidney and pancreas, run through insulin, inflammation and the gut's bacterial ecology. Half of the dementia commission's modifiable list is vascular and metabolic. Kidney failure runs through diabetes and hypertension. Fatty liver is the metabolic ground stored in the organ that processes it. Six organs, four or five upstream drivers, and the same drivers each time. [[Inflammation-Chronic-Disease#The Disease Cascade: How Inflammation Becomes Specific Disease|Inflammation and Chronic Disease]] traces how chronic inflammation becomes each specific disease.

Three traditions saw the pattern long before the registries did, and their testimony stands as tradition, not trial evidence. The [Charaka Samhita](https://grokipedia.com/page/Charaka_Samhita), the founding text of Ayurveda, gives a chapter to the diseases of over-nourishment (*santarpaṇa*): heavy, sweet and unctuous food, new wine, a sedentary life and sleep by day produce diabetes (*prameha*), obesity (*sthaulya*), skin disease, anaemia, swelling and obstructed channels ([*Sūtrasthāna* 23](https://www.carakasamhitaonline.com/index.php/Santarpaniya_Adhyaya)). Galen attributed morbid obesity to a surplus of blood and humours from overeating and idleness. Chinese medicine describes a phlegm-damp constitution, and a meta-analysis of 29 modern studies found it carries 1.74 times the risk of metabolic syndrome ([*Integrative Medicine Research*](https://www.sciencedirect.com/science/article/pii/S2095754820300934)). Working without a laboratory, they described the cluster the laboratory now measures, and located its cause in the same place: more going in than the body's order can transform.

---

## 5. Where the Single Root Stops

A convergence that admits no exception is a slogan, and this one has five.

**LDL and Lp(a).** ApoB-carrying particles cause atherosclerosis in metabolically healthy bodies too, and Lp(a) is set almost entirely by genetics. [[Health-Longevity-Biggest-Levers|The Biggest Levers]] treats both as targets in their own right, and [[Medical-Interventions-Preventing-Death#Lipids and the Artery|Medical Interventions]] treats them medically where the levers do not reach.

**Smoke and air.** Particulate air pollution was the single largest risk factor for lost healthy life worldwide in 2021, at 8.0% of disability-adjusted life years, and smoking was third. Chronic obstructive pulmonary disease, the third cause of death on the planet, is overwhelmingly their disease, and nearly nine in ten of its deaths before seventy occur in low- and middle-income countries. Both are toxic load in the plainest sense, and both arrive from outside the body's metabolism.

**Copying error.** Cristian Tomasetti and Bert Vogelstein estimated in *Science* in 2017 that about two thirds of the driver mutations in human cancers arise from random errors in cell division rather than from environment or inheritance ([Tomasetti et al., 2017](https://www.science.org/doi/10.1126/science.aaf9011)); Wu and colleagues, in *Nature* the previous year, put the extrinsic share at 70–90% ([Wu et al., 2016](https://www.nature.com/articles/nature16166)). [[Cancer-Prevention|The cancer protocol]] holds that terrain decides whether a mutation becomes a disease, whatever produced it. How much of cancer incidence any terrain can prevent remains open.

**Early life.** The colibactin fingerprint was laid down in childhood, and a long line of work after David Barker places part of adult chronic disease in nutrition and exposure before birth and in the first years. An adult's terrain is partly inherited from a childhood the adult did not choose. Its practical weight falls on parents more than on patients.

**Injury and despair.** Road injuries killed about 1.16 million people and are the leading cause of death between the ages of five and twenty-nine ([WHO](https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries)). Suicide took 727,000 lives in 2021 and ranks third among causes of death at fifteen to twenty-nine ([WHO](https://www.who.int/news-room/fact-sheets/detail/suicide)). Deaths from drug use disorders more than doubled between 1990 and 2023, one of the few causes whose age-standardised rate rose, by 42.4%, and in high-income North America death rates at ages 30–39 rose by half between 2011 and 2023, driven by suicide, overdose and alcohol. These are not metabolic deaths, and no lever on the body page answers them. They belong to [[Wheel of Presence|Presence]], to meaning and to the relationships that hold a life, and the corpus meets them at [[Suicidal Ideation and the Loss of Meaning]] and [[Addiction]].

---

## 6. What the Map Asks of a Life

The map ranks the work. Two eliminations come first because two of the five exceptions above, smoke and ethanol, are chosen daily: [[Health-Longevity-Biggest-Levers|The Biggest Levers]] sets both at zero. Fitness, food and sleep come next because they move the metabolic ground under the heart, the colon, the liver, the kidney and the brain at once. No other intervention reaches that many rows of the table.

Markers move before diagnoses.

Waist-to-height ratio, fasting insulin, blood pressure averaged over a week, ApoB, liver enzymes: each moves years before any organ fails, and [[Monitor]] reads them on a rhythm. Those numbers are how a silently opening healthspan gap becomes visible while it can still be closed.

Medicine enters at its thresholds. [[Medical-Interventions-Preventing-Death|Medical Interventions]] sets out where: blood pressure that will not come down, diabetes, a coronary calcium score, an arrhythmia. One consequence of the colorectal trend belongs on this page because it saves lives now. Screening begins at forty-five in the United States and at fifty or later in much of the world, and the rise is in people younger than that. Rectal bleeding, a lasting change in bowel habit, unexplained iron-deficiency anaemia or abdominal pain in a thirty-year-old are investigated, not attributed to haemorrhoids and sent home. Abnormal uterine bleeding is read the same way.

---

Registries measure departure from [[Glossary of Terms#Logos|Logos]] in the only units they have: deaths per hundred thousand, years lived with disability, the fraction of adults whose chemistry is still intact. What they record is a civilisation that has learned to keep the body alive long after it has stopped keeping the body in order. The nine and a half years between a long life and a healthy one, twelve in the country that spends most on medicine, are the distance between those two achievements. The [[Wheel of Health]], turned as a whole, is how an individual closes that distance for one body.

---

*See also: [[Heart Health]], [[Root-Cause-of-Disease|The Root Cause of Disease]], [[Health-Longevity-Biggest-Levers|The Biggest Levers]], [[Medical-Interventions-Preventing-Death|Medical Interventions]], [[Monitor]], [[Inflammation-Chronic-Disease|Inflammation and Chronic Disease]], [[Cancer-Prevention|Cancer]], [[Diabetes-Protocol|Type 2 Diabetes]], [[Alcohol]]*