Abstract

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

GBDRisk Factors Collaborators Forouzanfar MH Alexander L Anderson HR Bachman VF Biryukov S Brauer M Burnett R Casey D Coates MM Cohen A Delwiche K Estep K Frostad JJ Astha KC Kyu HH Moradi-Lakeh M Ng M Slepak EL Thomas BA Wagner J Aasvang GM Abbafati C Abbasoglu Ozgoren A Abd-Allah F Abera SF Aboyans V Abraham B Abraham JP Abubakar I Abu-Rmeileh NM Aburto TC Achoki T Adelekan A Adofo K Adou AK Adsuar JC Afshin A Agardh EE Al Khabouri MJ Al Lami FH Alam SS Alasfoor D Albittar MI Alegretti MA Aleman AV Alemu ZA Alfonso-Cristancho R Alhabib S Ali R Ali MK Alla F Allebeck P Allen PJ Alsharif U Alvarez E Alvis-Guzman N Amankwaa AA Amare AT Ameh EA Ameli O Amini H Ammar W Anderson BO Antonio CA Anwari P Argeseanu Cunningham S Arnlov J Arsenijevic VS Artaman A Asghar RJ Assadi R Atkins LS Atkinson C Avila MA Awuah B Badawi A Bahit MC Bakfalouni T Balakrishnan K Balalla S Balu RK Banerjee A Barber RM Barker-Collo SL Barquera S Barregard L Barrero LH Barrientos-Gutierrez T Basto-Abreu AC Basu A Basu S Basulaiman MO Batis Ruvalcaba C Beardsley J Bedi N Bekele T Bell ML Benjet C Bennett DA Benzian H Bernabe E Beyene TJ Bhala N Bhalla A Bhutta ZA Bikbov B Bin Abdulhak AA Blore JD Blyth FM Bohensky MA Bora Basara B Borges G Bornstein NM Bose D Boufous S Bourne RR Brainin M Brazinova A Breitborde NJ Brenner H Briggs AD Broday DM Brooks PM Bruce NG Brugha TS Brunekreef B Buchbinder R Bui LN Bukhman G Bulloch AG Burch M Burney PG Campos-Nonato IR Campuzano JC Cantoral AJ Caravanos J Cardenas R Cardis E Carpenter DO Caso V Castaneda-Orjuela CA Castro RE Catala-Lopez F Cavalleri F Cavlin A Chadha VK Chang JC Charlson FJ Chen H Chen W Chen Z Chiang PP Chimed-Ochir O Chowdhury R Christophi CA Chuang TW Chugh SS Cirillo M Classen TK Colistro V Colomar M Colquhoun SM Contreras AG Cooper C Cooperrider K Cooper LT Coresh J Courville KJ Criqui MH Cuevas-Nasu L Damsere-Derry J Danawi H Dandona L Dandona R Dargan PI Davis A Davitoiu DV Dayama A de Castro EF De la Cruz-Gongora V De Leo D de Lima G Degenhardt L del Pozo-Cruz B Dellavalle RP Deribe K Derrett S Des Jarlais DC Dessalegn M deVeber GA Devries KM Dharmaratne SD Dherani MK Dicker D Ding EL Dokova K Dorsey ER Driscoll TR Duan L Durrani AM Ebel BE Ellenbogen RG Elshrek YM Endres M Ermakov SP Erskine HE Eshrati B Esteghamati A Fahimi S Faraon EJ Farzadfar F Fay DF Feigin VL Feigl AB Fereshtehnejad SM Ferrari AJ Ferri CP Flaxman AD Fleming TD Foigt N Foreman KJ Paleo UF Franklin RC Gabbe B Gaffikin L Gakidou E Gamkrelidze A Gankpe FG Gansevoort RT Garcia-Guerra FA Gasana E Geleijnse JM Gessner BD Gething P Gibney KB Gillum RF Ginawi IA Giroud M Giussani G Goenka S Goginashvili K Gomez Dantes H Gona P Gonzalez de Cosio T Gonzalez-Castell D Gotay CC Goto A Gouda HN Guerrant RL Gugnani HC Guillemin F Gunnell D Gupta R Gupta R Gutierrez RA Hafezi-Nejad N Hagan H Hagstromer M Halasa YA Hamadeh RR Hammami M Hankey GJ Hao Y Harb HL Haregu TN Haro JM Havmoeller R Hay SI Hedayati MT Heredia-Pi IB Hernandez L Heuton KR Heydarpour P Hijar M Hoek HW Hoffman HJ Hornberger JC Hosgood HD Hoy DG Hsairi M Hu G Hu H Huang C Huang JJ Hubbell BJ Huiart L Husseini A Iannarone ML Iburg KM Idrisov BT Ikeda N Innos K Inoue M Islami F Ismayilova S Jacobsen KH Jansen HA Jarvis DL Jassal SK Jauregui A Jayaraman S Jeemon P Jensen PN Jha V Jiang F Jiang G Jiang Y Jonas JB Juel K Kan H Kany Roseline SS Karam NE Karch A Karema CK Karthikeyan G Kaul A Kawakami N Kazi DS Kemp AH Kengne AP Keren A Khader YS Khalifa SE Khan EA Khang YH Khatibzadeh S Khonelidze I Kieling C Kim D Kim S Kim Y Kimokoti RW Kinfu Y Kinge JM Kissela BM Kivipelto M Knibbs LD Knudsen AK Kokubo Y Kose MR Kosen S Kraemer A Kravchenko M Krishnaswami S Kromhout H Ku T Kuate Defo B Kucuk Bicer B Kuipers EJ Kulkarni C Kulkarni VS Kumar GA Kwan GF Lai T Lakshmana Balaji A Lalloo R Lallukka T Lam H Lan Q Lansingh VC Larson HJ Larsson A Laryea DO Lavados PM Lawrynowicz AE Leasher JL Lee JT Leigh J Leung R Levi M Li Y Li Y Liang J Liang X Lim SS Lindsay MP Lipshultz SE Liu S Liu Y Lloyd BK Logroscino G London SJ Lopez N Lortet-Tieulent J Lotufo PA Lozano R Lunevicius R Ma J Ma S Machado VM MacIntyre MF Magis-Rodriguez C Mahdi AA Majdan M Malekzadeh R Mangalam S Mapoma CC Marape M Marcenes W Margolis DJ Margono C Marks GB Martin RV Marzan MB Mashal MT Masiye F Mason-Jones AJ Matsushita K Matzopoulos R Mayosi BM Mazorodze TT McKay AC McKee M McLain A Meaney PA Medina C Mehndiratta MM Mejia-Rodriguez F Mekonnen W Melaku YA Meltzer M Memish ZA Mendoza W Mensah GA Meretoja A Mhimbira FA Micha R Miller TR Mills EJ Misganaw A Mishra S Mohamed Ibrahim N Mohammad KA Mokdad AH Mola GL Monasta L Montanez Hernandez JC Montico M Moore AR Morawska L Mori R Moschandreas J Moturi WN Mozaffarian D Mueller UO Mukaigawara M Mullany EC Murthy KS Naghavi M Nahas Z Naheed A Naidoo KS Naldi L Nand D Nangia V Narayan KM Nash D Neal B Nejjari C Neupane SP Newton CR Ngalesoni FN Ngirabega Jde D Nguyen G Nguyen NT Nieuwenhuijsen MJ Nisar MI Nogueira JR Nolla JM Nolte S Norheim OF Norman RE Norrving B Nyakarahuka L Oh IH Ohkubo T Olusanya BO Omer SB Opio JN Orozco R Pagcatipunan RS, Jr Pain AW Pandian JD Panelo CI Papachristou C Park EK Parry CD Paternina Caicedo AJ Patten SB Paul VK Pavlin BI Pearce N Pedraza LS Pedroza A Pejin Stokic L Pekericli A Pereira DM Perez-Padilla R Perez-Ruiz F Perico N Perry SA Pervaiz A Pesudovs K Peterson CB Petzold M Phillips MR Phua HP Plass D Poenaru D Polanczyk GV Polinder S Pond CD Pope CA Pope D Popova S Pourmalek F Powles J Prabhakaran D Prasad NM Qato DM Quezada AD Quistberg DA Racape L Rafay A Rahimi K Rahimi-Movaghar V Rahman SU Raju M Rakovac I Rana SM Rao M Razavi H Reddy KS Refaat AH Rehm J Remuzzi G Ribeiro AL Riccio PM Richardson L Riederer A Robinson M Roca A Rodriguez A Rojas-Rueda D Romieu I Ronfani L Room R Roy N Ruhago GM Rushton L Sabin N Sacco RL Saha S Sahathevan R Sahraian MA Salomon JA Salvo D Sampson UK Sanabria JR Sanchez LM Sanchez-Pimienta TG Sanchez-Riera L Sandar L Santos IS Sapkota A Satpathy M Saunders JE Sawhney M Saylan MI Scarborough P Schmidt JC Schneider IJ Schottker B Schwebel DC Scott JG Seedat S Sepanlou SG Serdar B Servan-Mori EE Shaddick G Shahraz S Levy TS Shangguan S She J Sheikhbahaei S Shibuya K Shin HH Shinohara Y Shiri R Shishani K Shiue I Sigfusdottir ID Silberberg DH Simard EP Sindi S Singh A Singh GM Singh JA Skirbekk V Sliwa K Soljak M Soneji S Soreide K Soshnikov S Sposato LA Sreeramareddy CT Stapelberg NJ Stathopoulou V Steckling N Stein DJ Stein MB Stephens N Stockl H Straif K Stroumpoulis K Sturua L Sunguya BF Swaminathan S Swaroop M Sykes BL Tabb KM Takahashi K Talongwa RT Tandon N Tanne D Tanner M Tavakkoli M Te Ao BJ Teixeira CM Tellez Rojo MM Terkawi AS Texcalac-Sangrador JL Thackway SV Thomson B Thorne-Lyman AL Thrift AG Thurston GD Tillmann T Tobollik M Tonelli M Topouzis F Towbin JA Toyoshima H Traebert J Tran BX Trasande L Trillini M Trujillo U Dimbuene ZT Tsilimbaris M Tuzcu EM Uchendu US Ukwaja KN Uzun SB van de Vijver S Van Dingenen R van Gool CH van Os J Varakin YY Vasankari TJ Vasconcelos AM Vavilala MS Veerman LJ Velasquez-Melendez G Venketasubramanian N Vijayakumar L Villalpando S Violante FS Vlassov VV Vollset SE Wagner GR Waller SG Wallin MT Wan X Wang H Wang J Wang L Wang W Wang Y Warouw TS Watts CH Weichenthal S Weiderpass E Weintraub RG Werdecker A Wessells KR Westerman R Whiteford HA Wilkinson JD Williams HC Williams TN Woldeyohannes SM Wolfe CD Wong JQ Woolf AD Wright JL Wurtz B Xu G Yan LL Yang G Yano Y Ye P Yenesew M Yentur GK Yip P Yonemoto N Yoon SJ Younis MZ Younoussi Z Yu C Zaki ME Zhao Y Zheng Y Zhou M Zhu J Zhu S Zou X Zunt JR Lopez AD Vos T Murray CJ
Lancet. 2015;3862287-323

Permenent descriptor

BACKGROUND: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS: All risks combined account for 57.2% (95% uncertainty interval [UI] 55.8-58.5) of deaths and 41.6% (40.1-43.0) of DALYs. Risks quantified account for 87.9% (86.5-89.3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11.3 million deaths and 241.4 million DALYs, high systolic blood pressure for 10.4 million deaths and 208.1 million DALYs, child and maternal malnutrition for 1.7 million deaths and 176.9 million DALYs, tobacco smoke for 6.1 million deaths and 143.5 million DALYs, air pollution for 5.5 million deaths and 141.5 million DALYs, and high BMI for 4.4 million deaths and 134.0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING: Bill & Melinda Gates Foundation.