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Comparative Study
. 2015 Dec 5;386(10010):2287-323.
doi: 10.1016/S0140-6736(15)00128-2. Epub 2015 Sep 11.

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

GBD 2013 Risk Factors CollaboratorsMohammad H ForouzanfarLily AlexanderH Ross AndersonVictoria F BachmanStan BiryukovMichael BrauerRichard BurnettDaniel CaseyMatthew M CoatesAaron CohenKristen DelwicheKara EstepJoseph J FrostadK C AsthaHmwe H KyuMaziar Moradi-LakehMarie NgErica Leigh SlepakBernadette A ThomasJoseph WagnerGunn Marit AasvangCristiana AbbafatiAyse Abbasoglu OzgorenFoad Abd-AllahSemaw F AberaVictor AboyansBiju AbrahamJerry Puthenpurakal AbrahamIbrahim AbubakarNiveen M E Abu-RmeilehTania C AburtoTom AchokiAdemola AdelekanKoranteng AdofoArsène K AdouJosé C AdsuarAshkan AfshinEmilie E AgardhMazin J Al KhabouriFaris H Al LamiSayed Saidul AlamDeena AlasfoorMohammed I AlbittarMiguel A AlegrettiAlicia V AlemanZewdie A AlemuRafael Alfonso-CristanchoSamia AlhabibRaghib AliMohammed K AliFrançois AllaPeter AllebeckPeter J AllenUbai AlsharifElena AlvarezNelson Alvis-GuzmanAdansi A AmankwaaAzmeraw T AmareEmmanuel A AmehOmid AmeliHeresh AminiWalid AmmarBenjamin O AndersonCarl Abelardo T AntonioPalwasha AnwariSolveig Argeseanu CunninghamJohan ArnlövValentina S Arsic ArsenijevicAl ArtamanRana J AsgharReza AssadiLydia S AtkinsCharles AtkinsonMarco A AvilaBaffour AwuahAlaa BadawiMaria C BahitTalal BakfalouniKalpana BalakrishnanShivanthi BalallaRavi Kumar BaluAmitava BanerjeeRyan M BarberSuzanne L Barker-ColloSimon BarqueraLars BarregardLope H BarreroTonatiuh Barrientos-GutierrezAna C Basto-AbreuArindam BasuSanjay BasuMohammed O BasulaimanCarolina Batis RuvalcabaJustin BeardsleyNeeraj BediTolesa BekeleMichelle L BellCorina BenjetDerrick A BennettHabib BenzianEduardo BernabéTariku J BeyeneNeeraj BhalaAshish BhallaZulfiqar A BhuttaBoris BikbovAref A Bin AbdulhakJed D BloreFiona M BlythMegan A BohenskyBerrak Bora BaşaraGuilherme BorgesNatan M BornsteinDipan BoseSoufiane BoufousRupert R BourneMichael BraininAlexandra BrazinovaNicholas J BreitbordeHermann BrennerAdam D M BriggsDavid M BrodayPeter M BrooksNigel G BruceTraolach S BrughaBert BrunekreefRachelle BuchbinderLinh N BuiGene BukhmanAndrew G BullochMichael BurchPeter G J BurneyIsmael R Campos-NonatoJulio C CampuzanoAlejandra J CantoralJack CaravanosRosario CárdenasElisabeth CardisDavid O CarpenterValeria CasoCarlos A Castañeda-OrjuelaRuben E CastroFerrán Catalá-LópezFiorella CavalleriAlanur ÇavlinVineet K ChadhaJung-Chen ChangFiona J CharlsonHonglei ChenWanqing ChenZhengming ChenPeggy P ChiangOdgerel Chimed-OchirRajiv ChowdhuryCostas A ChristophiTing-Wu ChuangSumeet S ChughMassimo CirilloThomas K D ClaßenValentina ColistroMercedes ColomarSamantha M ColquhounAlejandra G ContrerasCyrus CooperKimberly CooperriderLeslie T CooperJosef CoreshKaren J CourvilleMichael H CriquiLucia Cuevas-NasuJames Damsere-DerryHadi DanawiLalit DandonaRakhi DandonaPaul I DarganAdrian DavisDragos V DavitoiuAnand DayamaE Filipa de CastroVanessa De la Cruz-GóngoraDiego De LeoGraça de LimaLouisa DegenhardtBorja del Pozo-CruzRobert P DellavalleKebede DeribeSarah DerrettDon C Des JarlaisMuluken DessalegnGabrielle A deVeberKaren M DevriesSamath D DharmaratneMukesh K DheraniDaniel DickerEric L DingKlara DokovaE Ray DorseyTim R DriscollLeilei DuanAdnan M DurraniBeth E EbelRichard G EllenbogenYousef M ElshrekMatthias EndresSergey P ErmakovHolly E ErskineBabak EshratiAlireza EsteghamatiSaman FahimiEmerito Jose A FaraonFarshad FarzadfarDerek F J FayValery L FeiginAndrea B FeiglSeyed-Mohammad FereshtehnejadAlize J FerrariCleusa P FerriAbraham D FlaxmanThomas D FlemingNataliya FoigtKyle J ForemanUrbano Fra PaleoRichard C FranklinBelinda GabbeLynne GaffikinEmmanuela GakidouAmiran GamkrelidzeFortuné G GankpéRon T GansevoortFrancisco A García-GuerraEvariste GasanaJohanna M GeleijnseBradford D GessnerPete GethingKatherine B GibneyRichard F GillumIbrahim A M GinawiMaurice GiroudGiorgia GiussaniShifalika GoenkaKetevan GoginashviliHector Gomez DantesPhilimon GonaTeresita Gonzalez de CosioDinorah González-CastellCarolyn C GotayAtsushi GotoHebe N GoudaRichard L GuerrantHarish C GugnaniFrancis GuilleminDavid GunnellRahul GuptaRajeev GuptaReyna A GutiérrezNima Hafezi-NejadHolly HaganMaria HagstromerYara A HalasaRandah R HamadehMouhanad HammamiGraeme J HankeyYuantao HaoHilda L HarbTilahun Nigatu HareguJosep Maria HaroRasmus HavmoellerSimon I HayMohammad T HedayatiIleana B Heredia-PiLucia HernandezKyle R HeutonPouria HeydarpourMartha HijarHans W HoekHoward J HoffmanJohn C HornbergerH Dean HosgoodDamian G HoyMohamed HsairiGuoqing HuHoward HuCheng HuangJohn J HuangBryan J HubbellLaetitia HuiartAbdullatif HusseiniMarissa L IannaroneKim M IburgBulat T IdrisovNayu IkedaKaire InnosManami InoueFarhad IslamiSamaya IsmayilovaKathryn H JacobsenHenrica A JansenDeborah L JarvisSimerjot K JassalAlejandra JaureguiSudha JayaramanPanniyammakal JeemonPaul N JensenVivekanand JhaFan JiangGuohong JiangYing JiangJost B JonasKnud JuelHaidong KanSidibe S Kany RoselineNadim E KaramAndré KarchCorine K KaremaGanesan KarthikeyanAnil KaulNorito KawakamiDhruv S KaziAndrew H KempAndre P KengneAndre KerenYousef S KhaderShams Eldin Ali Hassan KhalifaEjaz A KhanYoung-Ho KhangShahab KhatibzadehIrma KhonelidzeChristian KielingDaniel KimSungroul KimYunjin KimRuth W KimokotiYohannes KinfuJonas M KingeBrett M KisselaMiia KivipeltoLuke D KnibbsAnn Kristin KnudsenYoshihiro KokuboM Rifat KoseSoewarta KosenAlexander KraemerMichael KravchenkoSanjay KrishnaswamiHans KromhoutTiffany KuBarthelemy Kuate DefoBurcu Kucuk BicerErnst J KuipersChanda KulkarniVeena S KulkarniG Anil KumarGene F KwanTaavi LaiArjun Lakshmana BalajiRatilal LallooTea LallukkaHilton LamQing LanVan C LansinghHeidi J LarsonAnders LarssonDennis O LaryeaPablo M LavadosAlicia E LawrynowiczJanet L LeasherJong-Tae LeeJames LeighRicky LeungMiriam LeviYichong LiYongmei LiJuan LiangXiaofeng LiangStephen S LimM Patrice LindsaySteven E LipshultzShiwei LiuYang LiuBelinda K LloydGiancarlo LogroscinoStephanie J LondonNancy LopezJoannie Lortet-TieulentPaulo A LotufoRafael LozanoRaimundas LuneviciusJixiang MaStefan MaVasco M P MachadoMichael F MacIntyreCarlos Magis-RodriguezAbbas A MahdiMarek MajdanReza MalekzadehSrikanth MangalamChristopher C MapomaMarape MarapeWagner MarcenesDavid J MargolisChristopher MargonoGuy B MarksRandall V MartinMelvin B MarzanMohammad T MashalFelix MasiyeAmanda J Mason-JonesKunihiro MatsushitaRichard MatzopoulosBongani M MayosiTasara T MazorodzeAbigail C McKayMartin McKeeAbigail McLainPeter A MeaneyCatalina MedinaMan Mohan MehndirattaFabiola Mejia-RodriguezWubegzier MekonnenYohannes A MelakuMichele MeltzerZiad A MemishWalter MendozaGeorge A MensahAtte MeretojaFrancis Apolinary MhimbiraRenata MichaTed R MillerEdward J MillsAwoke MisganawSantosh MishraNorlinah Mohamed IbrahimKarzan A MohammadAli H MokdadGlen L MolaLorenzo MonastaJulio C Montañez HernandezMarcella MonticoAmi R MooreLidia MorawskaRintaro MoriJoanna MoschandreasWilkister N MoturiDariush MozaffarianUlrich O MuellerMitsuru MukaigawaraErin C MullanyKinnari S MurthyMohsen NaghaviZiad NahasAliya NaheedKovin S NaidooLuigi NaldiDevina NandVinay NangiaK M Venkat NarayanDenis NashBruce NealChakib NejjariSudan P NeupaneCharles R NewtonFrida N NgalesoniJean de Dieu NgirabegaGrant NguyenNhung T NguyenMark J NieuwenhuijsenMuhammad I NisarJosé R NogueiraJoan M NollaSandra NolteOle F NorheimRosana E NormanBo NorrvingLuke NyakarahukaIn-Hwan OhTakayoshi OhkuboBolajoko O OlusanyaSaad B OmerJohn Nelson OpioRicardo OrozcoRodolfo S Pagcatipunan JrAmanda W PainJeyaraj D PandianCarlo Irwin A PaneloChristina PapachristouEun-Kee ParkCharles D ParryAngel J Paternina CaicedoScott B PattenVinod K PaulBoris I PavlinNeil PearceLilia S PedrazaAndrea PedrozaLjiljana Pejin StokicAyfer PekericliDavid M PereiraRogelio Perez-PadillaFernando Perez-RuizNorberto PericoSamuel A L PerryAslam PervaizKonrad PesudovsCarrie B PetersonMax PetzoldMichael R PhillipsHwee Pin PhuaDietrich PlassDan PoenaruGuilherme V PolanczykSuzanne PolinderConstance D PondC Arden PopeDaniel PopeSvetlana PopovaFarshad PourmalekJohn PowlesDorairaj PrabhakaranNoela M PrasadDima M QatoAmado D QuezadaD Alex A QuistbergLionel RacapéAnwar RafayKazem RahimiVafa Rahimi-MovagharSajjad Ur RahmanMurugesan RajuIvo RakovacSaleem M RanaMayuree RaoHomie RazaviK Srinath ReddyAmany H RefaatJürgen RehmGiuseppe RemuzziAntonio L RibeiroPatricia M RiccioLee RichardsonAnne RiedererMargaret RobinsonAnna RocaAlina RodriguezDavid Rojas-RuedaIsabelle RomieuLuca RonfaniRobin RoomNobhojit RoyGeorge M RuhagoLesley RushtonNsanzimana SabinRalph L SaccoSukanta SahaRamesh SahathevanMohammad Ali SahraianJoshua A SalomonDeborah SalvoUchechukwu K SampsonJuan R SanabriaLuz Maria SanchezTania G Sánchez-PimientaLidia Sanchez-RieraLogan SandarItamar S SantosAmir SapkotaMaheswar SatpathyJames E SaundersMonika SawhneyMete I SaylanPeter ScarboroughJürgen C SchmidtIone J C SchneiderBen SchöttkerDavid C SchwebelJames G ScottSoraya SeedatSadaf G SepanlouBerrin SerdarEdson E Servan-MoriGavin ShaddickSaeid ShahrazTeresa Shamah LevySiyi ShangguanJun SheSara SheikhbahaeiKenji ShibuyaHwashin H ShinYukito ShinoharaRahman ShiriKawkab ShishaniIvy ShiueInga D SigfusdottirDonald H SilberbergEdgar P SimardShireen SindiAbhishek SinghGitanjali M SinghJasvinder A SinghVegard SkirbekkKaren SliwaMichael SoljakSamir SonejiKjetil SøreideSergey SoshnikovLuciano A SposatoChandrashekhar T SreeramareddyNicolas J C StapelbergVasiliki StathopoulouNadine StecklingDan J SteinMurray B SteinNatalie StephensHeidi StöcklKurt StraifKonstantinos StroumpoulisLela SturuaBruno F SunguyaSoumya SwaminathanMamta SwaroopBryan L SykesKaren M TabbKen TakahashiRoberto T TalongwaNikhil TandonDavid TanneMarcel TannerMohammad TavakkoliBraden J Te AoCarolina M TeixeiraMartha M Téllez RojoAbdullah S TerkawiJosé Luis Texcalac-SangradorSarah V ThackwayBlake ThomsonAndrew L Thorne-LymanAmanda G ThriftGeorge D ThurstonTaavi TillmannMyriam TobollikMarcello TonelliFotis TopouzisJeffrey A TowbinHideaki ToyoshimaJefferson TraebertBach X TranLeonardo TrasandeMatias TrilliniUlises TrujilloZacharie Tsala DimbueneMiltiadis TsilimbarisEmin Murat TuzcuUche S UchenduKingsley N UkwajaSelen B UzunSteven van de VijverRita Van DingenenCoen H van GoolJim van OsYuri Y VarakinTommi J VasankariAna Maria N VasconcelosMonica S VavilalaLennert J VeermanGustavo Velasquez-MelendezN VenketasubramanianLakshmi VijayakumarSalvador VillalpandoFrancesco S ViolanteVasiliy Victorovich VlassovStein Emil VollsetGregory R WagnerStephen G WallerMitchell T WallinXia WanHaidong WangJianLi WangLinhong WangWenzhi WangYanping WangTati S WarouwCharlotte H WattsScott WeichenthalElisabete WeiderpassRobert G WeintraubAndrea WerdeckerK Ryan WessellsRonny WestermanHarvey A WhitefordJames D WilkinsonHywel C WilliamsThomas N WilliamsSolomon M WoldeyohannesCharles D A WolfeJohn Q WongAnthony D WoolfJonathan L WrightBrittany WurtzGelin XuLijing L YanGonghuan YangYuichiro YanoPengpeng YeMuluken YenesewGökalp K YentürPaul YipNaohiro YonemotoSeok-Jun YoonMustafa Z YounisZourkaleini YounoussiChuanhua YuMaysaa E ZakiYong ZhaoYingfeng ZhengMaigeng ZhouJun ZhuShankuan ZhuXiaonong ZouJoseph R ZuntAlan D LopezTheo VosChristopher J Murray
Free PMC article
Comparative Study

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

GBD 2013 Risk Factors Collaborators et al. Lancet. .
Free PMC article

Abstract

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.

Figures

Figure 1
Figure 1. A more general causal web of the causes of health outcomes
Categories of causes included in this analysis shown in blue. GBD=Global Burden of Disease.
Figure 2
Figure 2. Tree maps of global deaths (A) and global DALYs (B) for GBD level 2 causes for all ages, both sexes combined in 2013
The fraction of each cause attributable to all risk factors combined is shown with dark shading. DALYs=disability-adjusted life-years. GBD=Global Burden of Disease. Chr Resp=chronic respiratory diseases. Diab + Urog + Haem=diabetes, urogenital, blood, and endocrine diseases. Diar + LRI + Oth=diarrhoea, lower respiratory, and other common infectious diseases. HIV + TB=HIV/AIDS and tuberculosis. Mental=mental and substance use disorders. MSK=musculoskeletal disorders. Neuro=neurological disorders. Nutr Def=nutritional deficiencies. Oth NCD=other non-communicable diseases. Other group I=other communicable, maternal, neonatal, and nutritional diseases. NTD + Malaria=neglected tropical diseases and malaria. Self-harm + IPV=self-harm and interpersonal violence. Trans Inj=transportation injuries. Unint Inj=unintentional injuries.
Figure 3
Figure 3. Proportion of all-cause DALYs attributable to behavioural, environmental and occupational, and metabolic risk factors and their overlaps for all ages in 2013
DALYs=disability-adjusted life-years. ∩=interaction.
Figure 4
Figure 4. Proportion of global all-cause DALYs attributable to behavioural, environmental and occupational, and metabolic risk factors and their overlaps, by age for both sexes combined in 2013
DALYs=disability-adjusted life-years. ∩=interaction.
Figure 5
Figure 5. Global DALYs attributed to level 2 risk factors in 2000 for both sexes combined (A) and global DALYs attributed to level 2 risk factors in 2013 for both sexes combined (B)
DALYs=disability-adjusted life-years.
Figure 6
Figure 6. Global DALYs attributed to level 2 risk factors in 2013 for sub-Saharan Africa for both sexes combined
DALYs=disability-adjusted life-years.
Figure 7
Figure 7. The 25 leading level 3 global risk factors for DALYs in both sexes combined in 2000 and 2013
Figure 8
Figure 8. Global maps for level 3 risk factors in 2013 of attributable DALYs for males (A) and females (B)
DALYs=disability-adjusted life-years. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. Isl=Islands.
Figure 9
Figure 9. The ten leading level 3 risks in 2013 in terms of DALYs by location for both sexes combined
The 15 leading risk factors are coloured. Subopt=Suboptimal. Occ=occupational. DALYs=disability-adjusted life-years. Bone mineral density=low bone mineral density. Handwashing=no handwashing with soap. Int partner violence=intimate partner violence. Nuts and seeds=diet low in nuts and seeds. Occ ergonomic=occupational ergonomic factors. Particulate matter=ambient particulate matter pollution. Physical activity=low physical activity. Processed meat=diet high in processed meat. Subopt breastfeeding=suboptimal breastfeeding. Sweetened beverages=diet high in sugar-sweetened beverages. Vegetables=diet low in vegetables.
Figure 9
Figure 9. The ten leading level 3 risks in 2013 in terms of DALYs by location for both sexes combined
The 15 leading risk factors are coloured. Subopt=Suboptimal. Occ=occupational. DALYs=disability-adjusted life-years. Bone mineral density=low bone mineral density. Handwashing=no handwashing with soap. Int partner violence=intimate partner violence. Nuts and seeds=diet low in nuts and seeds. Occ ergonomic=occupational ergonomic factors. Particulate matter=ambient particulate matter pollution. Physical activity=low physical activity. Processed meat=diet high in processed meat. Subopt breastfeeding=suboptimal breastfeeding. Sweetened beverages=diet high in sugar-sweetened beverages. Vegetables=diet low in vegetables.

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