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.

Authors:
Mohammad H Forouzanfar Lily Alexander H Ross Anderson Victoria F Bachman Stan Biryukov Michael Brauer Richard Burnett Daniel Casey Matthew M Coates Aaron Cohen Kristen Delwiche Kara Estep Joseph J Frostad K C Astha Hmwe H Kyu Maziar Moradi-Lakeh Marie Ng Erica Leigh Slepak Bernadette A Thomas Joseph Wagner Gunn Marit Aasvang Cristiana Abbafati Ayse Abbasoglu Ozgoren Foad Abd-Allah Semaw F Abera Victor Aboyans Biju Abraham Jerry Puthenpurakal Abraham Ibrahim Abubakar Niveen M E Abu-Rmeileh Tania C Aburto Tom Achoki Ademola Adelekan Koranteng Adofo Arsène K Adou José C Adsuar Ashkan Afshin Emilie E Agardh Mazin J Al Khabouri Faris H Al Lami Sayed Saidul Alam Deena Alasfoor Mohammed I Albittar Miguel A Alegretti Alicia V Aleman Zewdie A Alemu Rafael Alfonso-Cristancho Samia Alhabib Raghib Ali Mohammed K Ali François Alla Peter Allebeck Peter J Allen Ubai Alsharif Elena Alvarez Nelson Alvis-Guzman Adansi A Amankwaa Azmeraw T Amare Emmanuel A Ameh Omid Ameli Heresh Amini Walid Ammar Benjamin O Anderson Carl Abelardo T Antonio Palwasha Anwari Solveig Argeseanu Cunningham Johan Arnlöv Valentina S Arsic Arsenijevic Al Artaman Rana J Asghar Reza Assadi Lydia S Atkins Charles Atkinson Marco A Avila Baffour Awuah Alaa Badawi Maria C Bahit Talal Bakfalouni Kalpana Balakrishnan Shivanthi Balalla Ravi Kumar Balu Amitava Banerjee Ryan M Barber Suzanne L Barker-Collo Simon Barquera Lars Barregard Lope H Barrero Tonatiuh Barrientos-Gutierrez Ana C Basto-Abreu Arindam Basu Sanjay Basu Mohammed O Basulaiman Carolina Batis Ruvalcaba Justin Beardsley Neeraj Bedi Tolesa Bekele Michelle L Bell Corina Benjet Derrick A Bennett Habib Benzian Eduardo Bernabé Tariku J Beyene Neeraj Bhala Ashish Bhalla Zulfiqar A Bhutta Boris Bikbov Aref A Bin Abdulhak Jed D Blore Fiona M Blyth Megan A Bohensky Berrak Bora Başara Guilherme Borges Natan M Bornstein Dipan Bose Soufiane Boufous Rupert R Bourne Michael Brainin Alexandra Brazinova Nicholas J Breitborde Hermann Brenner Adam D M Briggs David M Broday Peter M Brooks Nigel G Bruce Traolach S Brugha Bert Brunekreef Rachelle Buchbinder Linh N Bui Gene Bukhman Andrew G Bulloch Michael Burch Peter G J Burney Ismael R Campos-Nonato Julio C Campuzano Alejandra J Cantoral Jack Caravanos Rosario Cárdenas Elisabeth Cardis David O Carpenter Valeria Caso Carlos A Castañeda-Orjuela Ruben E Castro Ferrán Catalá-López Fiorella Cavalleri Alanur Çavlin Vineet K Chadha Jung-Chen Chang Fiona J Charlson Honglei Chen Wanqing Chen Zhengming Chen Peggy P Chiang Odgerel Chimed-Ochir Rajiv Chowdhury Costas A Christophi Ting-Wu Chuang Sumeet S Chugh Massimo Cirillo Thomas K D Claßen Valentina Colistro Mercedes Colomar Samantha M Colquhoun Alejandra G Contreras Cyrus Cooper Kimberly Cooperrider Leslie T Cooper Josef Coresh Karen J Courville Michael H Criqui Lucia Cuevas-Nasu James Damsere-Derry Hadi Danawi Lalit Dandona Rakhi Dandona Paul I Dargan Adrian Davis Dragos V Davitoiu Anand Dayama E Filipa de Castro Vanessa De la Cruz-Góngora Diego De Leo Graça de Lima Louisa Degenhardt Borja del Pozo-Cruz Robert P Dellavalle Kebede Deribe Sarah Derrett Don C Des Jarlais Muluken Dessalegn Gabrielle A deVeber Karen M Devries Samath D Dharmaratne Mukesh K Dherani Daniel Dicker Eric L Ding Klara Dokova E Ray Dorsey Tim R Driscoll Leilei Duan Adnan M Durrani Beth E Ebel Richard G Ellenbogen Yousef M Elshrek Matthias Endres Sergey P Ermakov Holly E Erskine Babak Eshrati Alireza Esteghamati Saman Fahimi Emerito Jose A Faraon Farshad Farzadfar Derek F J Fay Valery L Feigin Andrea B Feigl Seyed-Mohammad Fereshtehnejad Alize J Ferrari Cleusa P Ferri Abraham D Flaxman Thomas D Fleming Nataliya Foigt Kyle J Foreman Urbano Fra Paleo Richard C Franklin Belinda Gabbe Lynne Gaffikin Emmanuela Gakidou Amiran Gamkrelidze Fortuné G Gankpé Ron T Gansevoort Francisco A García-Guerra Evariste Gasana Johanna M Geleijnse Bradford D Gessner Pete Gething Katherine B Gibney Richard F Gillum Ibrahim A M Ginawi Maurice Giroud Giorgia Giussani Shifalika Goenka Ketevan Goginashvili Hector Gomez Dantes Philimon Gona Teresita Gonzalez de Cosio Dinorah González-Castell Carolyn C Gotay Atsushi Goto Hebe N Gouda Richard L Guerrant Harish C Gugnani Francis Guillemin David Gunnell Rahul Gupta Rajeev Gupta Reyna A Gutiérrez Nima Hafezi-Nejad Holly Hagan Maria Hagstromer Yara A Halasa Randah R Hamadeh Mouhanad Hammami Graeme J Hankey Yuantao Hao Hilda L Harb Tilahun Nigatu Haregu Josep Maria Haro Rasmus Havmoeller Simon I Hay Mohammad T Hedayati Ileana B Heredia-Pi Lucia Hernandez Kyle R Heuton Pouria Heydarpour Martha Hijar Hans W Hoek Howard J Hoffman John C Hornberger H Dean Hosgood Damian G Hoy Mohamed Hsairi Guoqing Hu Howard Hu Cheng Huang John J Huang Bryan J Hubbell Laetitia Huiart Abdullatif Husseini Marissa L Iannarone Kim M Iburg Bulat T Idrisov Nayu Ikeda Kaire Innos Manami Inoue Farhad Islami Samaya Ismayilova Kathryn H Jacobsen Henrica A Jansen Deborah L Jarvis Simerjot K Jassal Alejandra Jauregui Sudha Jayaraman Panniyammakal Jeemon Paul N Jensen Vivekanand Jha Fan Jiang Guohong Jiang Ying Jiang Jost B Jonas Knud Juel Haidong Kan Sidibe S Kany Roseline Nadim E Karam André Karch Corine K Karema Ganesan Karthikeyan Anil Kaul Norito Kawakami Dhruv S Kazi Andrew H Kemp Andre P Kengne Andre Keren Yousef S Khader Shams Eldin Ali Hassan Khalifa Ejaz A Khan Young-Ho Khang Shahab Khatibzadeh Irma Khonelidze Christian Kieling Daniel Kim Sungroul Kim Yunjin Kim Ruth W Kimokoti Yohannes Kinfu Jonas M Kinge Brett M Kissela Miia Kivipelto Luke D Knibbs Ann Kristin Knudsen Yoshihiro Kokubo M Rifat Kose Soewarta Kosen Alexander Kraemer Michael Kravchenko Sanjay Krishnaswami Hans Kromhout Tiffany Ku Barthelemy Kuate Defo Burcu Kucuk Bicer Ernst J Kuipers Chanda Kulkarni Veena S Kulkarni G Anil Kumar Gene F Kwan Taavi Lai Arjun Lakshmana Balaji Ratilal Lalloo Tea Lallukka Hilton Lam Qing Lan Van C Lansingh Heidi J Larson Anders Larsson Dennis O Laryea Pablo M Lavados Alicia E Lawrynowicz Janet L Leasher Jong-Tae Lee James Leigh Ricky Leung Miriam Levi Yichong Li Yongmei Li Juan Liang Xiaofeng Liang Stephen S Lim M Patrice Lindsay Steven E Lipshultz Shiwei Liu Yang Liu Belinda K Lloyd Giancarlo Logroscino Stephanie J London Nancy Lopez Joannie Lortet-Tieulent Paulo A Lotufo Rafael Lozano Raimundas Lunevicius Jixiang Ma Stefan Ma Vasco M P Machado Michael F MacIntyre Carlos Magis-Rodriguez Abbas A Mahdi Marek Majdan Reza Malekzadeh Srikanth Mangalam Christopher C Mapoma Marape Marape Wagner Marcenes David J Margolis Christopher Margono Guy B Marks Randall V Martin Melvin B Marzan Mohammad T Mashal Felix Masiye Amanda J Mason-Jones Kunihiro Matsushita Richard Matzopoulos Bongani M Mayosi Tasara T Mazorodze Abigail C McKay Martin McKee Abigail McLain Peter A Meaney Catalina Medina Man Mohan Mehndiratta Fabiola Mejia-Rodriguez Wubegzier Mekonnen Yohannes A Melaku Michele Meltzer Ziad A Memish Walter Mendoza George A Mensah Atte Meretoja Francis Apolinary Mhimbira Renata Micha Ted R Miller Edward J Mills Awoke Misganaw Santosh Mishra Norlinah Mohamed Ibrahim Karzan A Mohammad Ali H Mokdad Glen L Mola Lorenzo Monasta Julio C Montañez Hernandez Marcella Montico Ami R Moore Lidia Morawska Rintaro Mori Joanna Moschandreas Wilkister N Moturi Dariush Mozaffarian Ulrich O Mueller Mitsuru Mukaigawara Erin C Mullany Kinnari S Murthy Mohsen Naghavi Ziad Nahas Aliya Naheed Kovin S Naidoo Luigi Naldi Devina Nand Vinay Nangia K M Venkat Narayan Denis Nash Bruce Neal Chakib Nejjari Sudan P Neupane Charles R Newton Frida N Ngalesoni Jean de Dieu Ngirabega Grant Nguyen Nhung T Nguyen Mark J Nieuwenhuijsen Muhammad I Nisar José R Nogueira Joan M Nolla Sandra Nolte Ole F Norheim Rosana E Norman Bo Norrving Luke Nyakarahuka In-Hwan Oh Takayoshi Ohkubo Bolajoko O Olusanya Saad B Omer John Nelson Opio Ricardo Orozco Rodolfo S Pagcatipunan Amanda W Pain Jeyaraj D Pandian Carlo Irwin A Panelo Christina Papachristou Eun-Kee Park Charles D Parry Angel J Paternina Caicedo Scott B Patten Vinod K Paul Boris I Pavlin Neil Pearce Lilia S Pedraza Andrea Pedroza Ljiljana Pejin Stokic Ayfer Pekericli David M Pereira Rogelio Perez-Padilla Fernando Perez-Ruiz Norberto Perico Samuel A L Perry Aslam Pervaiz Konrad Pesudovs Carrie B Peterson Max Petzold Michael R Phillips Hwee Pin Phua Dietrich Plass Dan Poenaru Guilherme V Polanczyk Suzanne Polinder Constance D Pond C Arden Pope Daniel Pope Svetlana Popova Farshad Pourmalek John Powles Dorairaj Prabhakaran Noela M Prasad Dima M Qato Amado D Quezada D Alex A Quistberg Lionel Racapé Anwar Rafay Kazem Rahimi Vafa Rahimi-Movaghar Sajjad Ur Rahman Murugesan Raju Ivo Rakovac Saleem M Rana Mayuree Rao Homie Razavi K Srinath Reddy Amany H Refaat Jürgen Rehm Giuseppe Remuzzi Antonio L Ribeiro Patricia M Riccio Lee Richardson Anne Riederer Margaret Robinson Anna Roca Alina Rodriguez David Rojas-Rueda Isabelle Romieu Luca Ronfani Robin Room Nobhojit Roy George M Ruhago Lesley Rushton Nsanzimana Sabin Ralph L Sacco Sukanta Saha Ramesh Sahathevan Mohammad Ali Sahraian Joshua A Salomon Deborah Salvo Uchechukwu K Sampson Juan R Sanabria Luz Maria Sanchez Tania G Sánchez-Pimienta Lidia Sanchez-Riera Logan Sandar Itamar S Santos Amir Sapkota Maheswar Satpathy James E Saunders Monika Sawhney Mete I Saylan Peter Scarborough Jürgen C Schmidt Ione J C Schneider Ben Schöttker David C Schwebel James G Scott Soraya Seedat Sadaf G Sepanlou Berrin Serdar Edson E Servan-Mori Gavin Shaddick Saeid Shahraz Teresa Shamah Levy Siyi Shangguan Jun She Sara Sheikhbahaei Kenji Shibuya Hwashin H Shin Yukito Shinohara Rahman Shiri Kawkab Shishani Ivy Shiue Inga D Sigfusdottir Donald H Silberberg Edgar P Simard Shireen Sindi Abhishek Singh Gitanjali M Singh Jasvinder A Singh Vegard Skirbekk Karen Sliwa Michael Soljak Samir Soneji Kjetil Søreide Sergey Soshnikov Luciano A Sposato Chandrashekhar T Sreeramareddy Nicolas J C Stapelberg Vasiliki Stathopoulou Nadine Steckling Dan J Stein Murray B Stein Natalie Stephens Heidi Stöckl Kurt Straif Konstantinos Stroumpoulis Lela Sturua Bruno F Sunguya Soumya Swaminathan Mamta Swaroop Bryan L Sykes Karen M Tabb Ken Takahashi Roberto T Talongwa Nikhil Tandon David Tanne Marcel Tanner Mohammad Tavakkoli Braden J Te Ao Carolina M Teixeira Martha M Téllez Rojo Abdullah S Terkawi José Luis Texcalac-Sangrador Sarah V Thackway Blake Thomson Andrew L Thorne-Lyman Amanda G Thrift George D Thurston Taavi Tillmann Myriam Tobollik Marcello Tonelli Fotis Topouzis Jeffrey A Towbin Hideaki Toyoshima Jefferson Traebert Bach X Tran Leonardo Trasande Matias Trillini Ulises Trujillo Zacharie Tsala Dimbuene Miltiadis Tsilimbaris Emin Murat Tuzcu Uche S Uchendu Kingsley N Ukwaja Selen B Uzun Steven van de Vijver Rita Van Dingenen Coen H van Gool Jim van Os Yuri Y Varakin Tommi J Vasankari Ana Maria N Vasconcelos Monica S Vavilala Lennert J Veerman Gustavo Velasquez-Melendez N Venketasubramanian Lakshmi Vijayakumar Salvador Villalpando Francesco S Violante Vasiliy Victorovich Vlassov Stein Emil Vollset Gregory R Wagner Stephen G Waller Mitchell T Wallin Xia Wan Haidong Wang JianLi Wang Linhong Wang Wenzhi Wang Yanping Wang Tati S Warouw Charlotte H Watts Scott Weichenthal Elisabete Weiderpass Robert G Weintraub Andrea Werdecker K Ryan Wessells Ronny Westerman Harvey A Whiteford James D Wilkinson Hywel C Williams Thomas N Williams Solomon M Woldeyohannes Charles D A Wolfe John Q Wong Anthony D Woolf Jonathan L Wright Brittany Wurtz Gelin Xu Lijing L Yan Gonghuan Yang Yuichiro Yano Pengpeng Ye Muluken Yenesew Gökalp K Yentür Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Z Younis Zourkaleini Younoussi Chuanhua Yu Maysaa E Zaki Yong Zhao Yingfeng Zheng Maigeng Zhou Jun Zhu Shankuan Zhu Xiaonong Zou Joseph R Zunt Alan D Lopez Theo Vos Christopher J Murray

Lancet 2015 Dec 11;386(10010):2287-323. Epub 2015 Sep 11.

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.

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December 2015
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