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

Forouzanfar, Mohammad H. and Alexander, Lily and Anderson, H. Ross and Bachman, Victoria F. and Biryukov, Stan and Brauer, Michael and Burnett, Richard and Casey, Daniel and Coates, Matthew M. and Cohen, Aaron and Delwiche, Kristen and Estep, Kara and Frostad, Joseph J. and KC, Astha and Kyu, Hmwe H. and Moradi-Lakeh, Maziar and Ng, Marie and Slepak, Erica Leigh and Thomas, Bernadette A. and Wagner, Joseph and Aasvang, Gunn Marit and Abbafati, Cristiana and Ozgoren, Ayse Abbasoglu and Abd-Allah, Foad and Abera, Semaw F. and Aboyans, Victor and Abraham, Biju and Abraham, Jerry Puthenpurakal and Abubakar, Ibrahim and Abu-Rmeileh, Niveen M. E. and Aburto, Tania C. and Achoki, Tom and Adelekan, Ademola and Adofo, Koranteng and Adou, Arsène K. and Adsuar, José C. and Afshin, Ashkan and Agardh, Emilie E. and Al Khabouri, Mazin J. and Al Lami, Faris H. and Alam, Sayed Saidul and Alasfoor, Deena and Albittar, Mohammed I. and Alegretti, Miguel A. and Aleman, Alicia V. and Alemu, Zewdie A. and Alfonso-Cristancho, Rafael and Alhabib, Samia and Ali, Raghib and Ali, Mohammed K. and Alla, François and Allebeck, Peter and Allen, Peter J. and Alsharif, Ubai and Alvarez, Elena and Alvis-Guzman, Nelson and Amankwaa, Adansi A. and Amare, Azmeraw T. and Ameh, Emmanuel A. and Ameli, Omid and Amini, Heresh and Ammar, Walid and Anderson, Benjamin O. and Antonio, Carl Abelardo T. and Anwari, Palwasha and Cunningham, Solveig Argeseanu and Arnlöv, Johan and Arsenijevic, Valentina S. 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Bin and Blore, Jed D. and Blyth, Fiona M. and Bohensky, Megan A. and Başara, Berrak Bora and Borges, Guilherme and Bornstein, Natan M. and Bose, Dipan and Boufous, Soufiane and Bourne, Rupert R. and Brainin, Michael and Brazinova, Alexandra and Breitborde, Nicholas J. and Brenner, Hermann and Briggs, Adam D. M. and Broday, David M. and Brooks, Peter M. and Bruce, Nigel G. and Brugha, Traolach S. and Brunekreef, Bert and Buchbinder, Rachelle and Bui, Linh N. and Bukhman, Gene and Bulloch, Andrew G. and Burch, Michael and Burney, Peter G. 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Paternina and Patten, Scott B. and Paul, Vinod K. and Pavlin, Boris I. and Pearce, Neil and Pedraza, Lilia S. and Pedroza, Andrea and Stokic, Ljiljana Pejin and Pekericli, Ayfer and Pereira, David M. and Perez-Padilla, Rogelio and Perez-Ruiz, Fernando and Perico, Norberto and Perry, Samuel A. L. and Pervaiz, Aslam and Pesudovs, Konrad and Peterson, Carrie B. and Petzold, Max and Phillips, Michael R. and Phua, Hwee Pin and Plass, Dietrich and Poenaru, Dan and Polanczyk, Guilherme V. and Polinder, Suzanne and Pond, Constance D. and Pope, C. Arden and Pope, Daniel and Popova, Svetlana and Pourmalek, Farshad and Powles, John and Prabhakaran, Dorairaj and Prasad, Noela M. and Qato, Dima M. and Quezada, Amado D. and Quistberg, D. Alex A. and Racapé, Lionel and Rafay, Anwar and Rahimi, Kazem and Rahimi-Movaghar, Vafa and Rahman, Sajjad Ur and Raju, Murugesan and Rakovac, Ivo and Rana, Saleem M. and Rao, Mayuree and Razavi, Homie and Reddy, K. Srinath and Refaat, Amany H. and Rehm, Jürgen and Remuzzi, Giuseppe and Ribeiro, Antonio L. and Riccio, Patricia M. and Richardson, Lee and Riederer, Anne and Robinson, Margaret and Roca, Anna and Rodriguez, Alina and Rojas-Rueda, David and Romieu, Isabelle and Ronfani, Luca and Room, Robin and Roy, Nobhojit and Ruhago, George M. and Rushton, Lesley and Sabin, Nsanzimana and Sacco, Ralph L and Saha, Sukanta and Sahathevan, Ramesh and Sahraian, Mohammad Ali and Salomon, Joshua A. and Salvo, Deborah and Sampson, Uchechukwu K. and Sanabria, Juan R. and Sanchez, Luz Maria and Sánchez-Pimienta, Tania G. and Sanchez-Riera, Lidia and Sandar, Logan and Santos, Itamar S. and Sapkota, Amir and Satpathy, Maheswar and Saunders, James E. and Sawhney, Monika and Saylan, Mete I. and Scarborough, Peter and Schmidt, Jürgen C. and Schneider, Ione J. 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C. and Stathopoulou, Vasiliki and Steckling, Nadine and Stein, Dan J. and Stein, Murray B. and Stephens, Natalie and Stöckl, Heidi and Straif, Kurt and Stroumpoulis, Konstantinos and Sturua, Lela and Sunguya, Bruno F. and Swaminathan, Soumya and Swaroop, Mamta and Sykes, Bryan L. and Tabb, Karen M. and Takahashi, Ken and Talongwa, Roberto T. and Tandon, Nikhil and Tanne, David and Tanner, Marcel and Tavakkoli, Mohammad and Te Ao, Braden J. and Teixeira, Carolina M. and Téllez Rojo, Martha M. and Terkawi, Abdullah S. and Texcalac-Sangrador, José Luis and Thackway, Sarah V. and Thomson, Blake and Thorne-Lyman, Andrew L. and Thrift, Amanda G. and Thurston, George D. and Tillmann, Taavi and Tobollik, Myriam and Tonelli, Marcello and Topouzis, Fotis and Towbin, Jeffrey A. and Toyoshima, Hideaki and Traebert, Jefferson and Tran, Bach X. and Trasande, Leonardo and Trillini, Matias and Trujillo, Ulises and Dimbuene, Zacharie Tsala and Tsilimbaris, Miltiadis and Tuzcu, Emin Murat and Uchendu, Uche S. and Ukwaja, Kingsley N. and Uzun, Selen B. and van de Vijver, Steven and Van Dingenen, Rita and van Gool, Coen H. and van Os, Jim and Varakin, Yuri Y. and Vasankari, Tommi J. and Vasconcelos, Ana Maria N. and Vavilala, Monica S. and Veerman, Lennert J. and Velasquez-Melendez, Gustavo and Venketasubramanian, N. and Vijayakumar, Lakshmi and Villalpando, Salvador and Violante, Francesco S. and Vlassov, Vasiliy Victorovich and Vollset, Stein Emil and Wagner, Gregory R. and Waller, Stephen G. and Wallin, Mitchell T. and Wan, Xia and Wang, Haidong and Wang, JianLi and Wang, Linhong and Wang, Wenzhi and Wang, Yanping and Warouw, Tati S. and Watts, Charlotte H. and Weichenthal, Scott and Weiderpass, Elisabete and Weintraub, Robert G. and Werdecker, Andrea and Wessells, K. Ryan and Westerman, Ronny and Whiteford, Harvey A. and Wilkinson, James D. and Williams, Hywel C. and Williams, Thomas N. and Woldeyohannes, Solomon M. and Wolfe, Charles D. A. and Wong, John Q. and Woolf, Anthony D. and Wright, Jonathan L. and Wurtz, Brittany and Xu, Gelin and Yan, Lijing L. and Yang, Gonghuan and Yano, Yuichiro and Ye, Pengpeng and Yenesew, Muluken and Yentür, Gökalp K. and Yip, Paul and Yonemoto, Naohiro and Yoon, Seok-Jun and Younis, Mustafa Z. and Younoussi, Zourkaleini and Yu, Chuanhua and Zaki, Maysaa E. and Zhao, Yong and Zheng, Yingfeng and Zhou, Maigeng and Zhu, Jun and Zhu, Shankuan and Zou, Xiaonong and Zunt, Joseph R. and Lopez, Alan D. and Vos, Theo and Murray, Christopher J. (2015) 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. The Lancet, 386 (10010). pp. 2287-2323. ISSN 0140-6736

Full content URL: http://dx.doi.org/10.1016/S0140-6736(15)00128-2

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Abstract

Summary
Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the fi rst of a series of
annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able 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 fi rst 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 fi ltration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression
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 quantifi ed 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.

Keywords:Human genetics, JCOpen
Subjects:C Biological Sciences > C420 Human Genetics
Divisions:College of Social Science > School of Psychology
ID Code:22913
Deposited On:03 Aug 2016 09:36

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