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

Collaborators, GBD 2013 Risk Factors and Forouzanfar, M.H. and Alexander, L. and Bachman, V.F. and Biryukov, S. and Brauer, M. and Casey, D. and Coates, M.M. and Delwiche, K. and Estep, K. and Frostad, J.J. and Astha, K.C. and Kyu, H.H. and Moradi-Lakeh, M. and Ng, M. and Slepak, E. and Thomas, B.A. and Wagner, J. and Achoki, T. and Atkinson, C. and Barber, R.M. and Cooperrider, K. and Dandona, L. and Dicker, D. and Flaxman, A.D. and Fleming, T.D. and Foreman, K.J. and Gakidou, E. and Hay, S.I. and Heuton, K.R. and Iannarone, M.L. and Ku, T. and Larson, H.J. and Lim, S.S. and Lopez, A.D. and Lozano, R. and MacIntyre, M.F. and Margono, C. and McLain, A. and Mokdad, A.H. and Mullany, E.C. and Murray, C.J.L. and Naghavi, M. and Nguyen, G. and Pain, A.W. and Richardson, L. and Robinson, M. and Sandar, L. and Stephens, N. and Temesgen, A.M. and Thomson, B. and Vos, T. and Wan, X. and Wang, H. and Wurtz, B. and Ebel, B.E. and Ellenbogen, R.G. and Wright, J.L. and Alfonso-Cristancho, R. and Anderson, B.O. and Jensen, P.N. and Quistberg, D.A. and Riederer, A. and Vavilala, M.S. and Zunt, J.R. and Anderson, H.R. and Pourmalek, F. and Brauer, M. and Gotay, C.C. and Burnett, R. and Shin, H.H. and Weichenthal, S. and Cohen, A. and Moradi-Lakeh, M. and Knudsen, A. and Aasvang, G. and Kinge, J.M. and Skirbekk, V. and Vollset, S. and Abbafati, C. and Abbasoglu Ozgoren, A. and �avlin, A. and Kucuk Bicer, B. and Abd-Allah, F. and Abera, S.F. and Melaku, Y.A. and Abera, S.F. and Aboyans, V. and Abraham, B. and Puthenpurakal Abraham, J. and Abraham, J.P. and Thorne-Lyman, A.L. and Ding, E.L. and Fahimi, S. and Khatibzadeh, S. and Wagner, G.R. and Bukhman, G. and Campos-Nonato, I.R. and Feigl, A.B. and Salomon, J.A. and Benzian, H. and Abubakar, I. and Abu-Rmeileh, N.M.E. and Lozano, R. and Aburto, T.C. and Avila, M.A. and Barquera, S. and Barrientos-Gutierrez, T. and Campos-Nonato, I.R. and Campuzano, J.C. and Cantoral, A.J. and Contreras, A.G. and Cuevas-Nasu, L. and De, V. and García-Guerra, F.A. and Gomez Dantes, H. and Gonzalez de Cosio, T. and González-Castell, D. and Heredia-Pi, I.B. and Hernandez, L. and Jauregui, A. and Medina, C. and Mejia-Rodriguez, F. and Montañez Hernandez, J.C. and Pedraza, L.S. and Pedroza, A. and Quezada, A.D. and Salvo, D. and Sanchez, L.M. and Sánchez-Pimienta, T.G. and Servan-Mori, E.E. and Shamah Levy, T. and Téllez Rojo, M.M. and Villalpando, S. and Adelekan, A. and Adofo, K. and Adou, A.K. and Adsuar, J.C. and Fra Paleo, U. and Afshin, A. and Micha, R. and Mozaffarian, D. and Shahraz, S. and Shangguan, S. and Singh, G.M. and Agardh, E.E. and Al Khabouri, M.J. and Al Lami, F.H. and Alam, S. and Naheed, A. and Alasfoor, D. and Albittar, M.I. and Alegretti, M.A. and Cavalleri, F. and Aleman, A.V. and Colistro, V. and Alemu, Z.A. and Alhabib, S. and Chen, Z. and Gething, P. and Ali, R. and Bennett, D.A. and Briggs, A.D.M. and Hay, S.I. and Rahimi, K. and Scarborough, P. and Simard, E.P. and Ali, M.K. and Argeseanu Cunningham, S. and Liu, Y. and Narayan, K.M.V. and Omer, S.B. and Alla, F. and Guillemin, F. and Allebeck, P. and Roy, N. and Kivipelto, M. and Weiderpass, E. and Fereshtehnejad, S. and Havmoeller, R. and Sindi, S. and Allen, P.J. and Alsharif, U. and Endres, M. and Nolte, S. and Papachristou, C. and Alvarez, E. and Alvis-Guzman, N. and Paternina Caicedo, A.J. and Amankwaa, A.A. and Amare, A.T. and Hoek, H.W. and Gansevoort, R.T. and Amare, A.T. and Yenesew, M. and Ameh, E.A. and Ameli, O. and Amini, H. and Amini, H. and Tanner, M. and Amini, H. and Ammar, W. and Harb, H.L. and Antonio, C.A.T. and Faraon, E.A. and Panelo, C.A. and Anwari, P. and Arnlöv, J. and Larsson, A. and Arnlöv, J. and Arsic Arsenijevic, V.S. and Arsic Arsenijevic, V.S. and Artaman, A. and Asghar, R.J. and Assadi, R. and Atkins, L.S. and Awuah, B. and Laryea, D.O. and Badawi, A. and Bahit, M.C. and Bakfalouni, T. and Balakrishnan, K. and Balalla, S. and Feigin, V.L. and Te Ao, B.J. and Dandona, L. and Balu, R. and Dandona, R. 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(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.

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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 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 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.

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