A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

May combine two claims.

In 2010, alcohol use ranked third among risk factors for worldwide disease burden, contributing 5.5% (95% UI 5.0-5.9) of global DALYs.

“and alcohol use (5·5% [5·0–5·9])”

May combine two claims.

Alcohol use was the top risk in 2010 for Eastern Europe, most of Latin America, and southern sub-Saharan Africa.

“The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use”

May combine two claims.

An internal validation found that dietary-pattern effects predicted from single-factor relative risks closely matched the observed effects; in four large cohorts covering seven patterns, the mean ratio of predicted to measured risk reduction was 0.98.

“Results of this internal validation study show that overall, estimation of the effect of dietary pattern based on the RRs reported for single risk factors was much the same as the effect reported in the study; across four large cohort studies of seven dietary patterns the average ratio for the estimated RR reduction compared with the measured RR reduction was 0·98.”

May combine two claims.

Diets low in fruits and diets high in sodium were the most prominent dietary risks in 2010.

“with the most prominent dietary risks being diets low in fruits and those high in sodium.”

May combine two claims.

After converting to ischaemic heart disease effects via blood pressure and cholesterol relative risks, the mean predicted-to-observed risk reduction ratio was 1.07 overall and 0.85 without fish.

“When translated into an effect using the RRs of blood pressure and cholesterol for ischaemic heart disease, the average ratio of the estimated to measured RR reduction was 1·07 for all components and 0·85 when excluding fish”

May combine two claims.

In the water and sanitation meta-regression, improved water and improved sanitation each had a significant effect relative to unimproved conditions.

“Our analysis showed a significant effect of both improved water and improved sanitation compared with unimproved water and sanitation”

May combine two claims.

Seafood omega-3 effects were smaller in randomised trials than in observational studies, though this difference was not significant (p=0.057).

“The effect of seafood omega-3 fatty acids tended to be lower in randomised controlled trials than in observational studies, however, this difference was not statistically significant (p=0·057).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

High total cholesterol accounted for 2.0 million deaths and 1.6% of global DALYs in 2010.

“high total cholesterol (2·0 million [1·6 million to 2·5 million] deaths and 1·6% [1·3–2·0] of DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Alcohol and drug use accounted for 5.0 million deaths and 6.5% of DALYs in 2010.

“as well as alcohol and drug use (5·0 million [4·7 million to 5·3 million] deaths and 6·5% [6·0–7·0] of DALYs) were substantial in 2010.”

May combine two claims.

In southern Latin America, high body-mass index accounted for almost 10% of overall disease burden in 2010, and is the leading risk factor in southern Latin America and Australasia.

“In southern Latin America, high body-mass index accounted for almost 10% of overall disease burden in 2010, and is the leading risk factor in southern Latin America and Australasia.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

High body-mass index accounted for 3.4 million deaths and 3.8% of global DALYs in 2010.

“followed by high body-mass index (3·4 million [2·8 million to 4·0 million deaths] and 3·8% [3·1–4·4] of global DALYs in 2010)”

May combine two claims.

Other child mortality risks, including nonexclusive and discontinued breastfeeding, micronutrient deficiencies, and unimproved water and sanitation, also fell.

“Other risks for child mortality, such as nonexclusive and discontinued breastfeeding, micronutrient deficiencies, and unimproved water and sanitation, have also fallen.”

May combine two claims.

The absolute burden of risk factors for non-communicable disease does not increase with increasing mean age at death; its magnitude is lower in high-income regions than in sub-Saharan Africa and south Asia.

“However, the absolute burden of risk factors for non-communicable disease does not increase with increasing mean age at death. Rather, its magnitude is lower in high-income regions than in sub-Saharan Africa and south Asia (figure 6C, D), showing the double burden of communicable and non-communicable disease in regions early in the epidemiological transition.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Alcohol use accounted for 4.9 million deaths and 5.5% of global DALYs in 2010.

“alcohol use which accounted for 4·9 million (4·5 million to 5·2 million) deaths and 5·5% (5·0–5·9) of global DALYs in 2010.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Physical inactivity and low physical activity accounted for 3.2 million deaths and 2.8% of global DALYs in 2010.

“Physical inactivity and low physical activity accounted for 3·2 million (2·7 million to 3·7 million) deaths, and 2·8% (2·4–3·2) of DALYs in 2010.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Other environmental risks accounted for 0.7 million deaths and 0.6% of global DALYs in 2010.

“and other environmental risks (0·7 million [0·6 million to 0·9 million] deaths and 0·6% [0·5–0·8] DALYs).”

May combine two claims.

In south Asia, childhood underweight was still the fourth leading risk factor in 2010, with its share of disease burden more than halved from 11.9% in 1990 to 4.0% in 2010.

“Childhood underweight was still the fourth leading risk factor in 2010, despite its share of disease burden having more than halved from 11·9% [95% UI 10·1–14·4] of DALYs in 1990, to 4·0% [3·2–4·9] in 2010.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets low in fruits accounted for 4.9 million deaths and 4.2% of global DALYs in 2010.

“diets low in fruits (4·9 million [3·8 million to 5·9 million] deaths and 4·2% [3·3–5·0] of global DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Occupational risk factors accounted for 0.9 million deaths and 2.5% of global DALYs in 2010.

“occupational risk factors accounted for 0·9 million (0·7 million to 1·1 million) deaths and 2·5% (2·0–3·0) of global DALYs in 2010”

Probably not a substantial claim: may not pass S3 (load-bearing).

The global disease burden attributable to high body-mass index increased from 52 million to 94 million DALYs between 1990 and 2010.

“the global disease burden attributable to high body-mass index increased from 52 million to 94 million DALYs”

Probably not a substantial claim: may not pass S3 (load-bearing).

Unimproved water and sanitation accounted for almost 1% of disease burden in 2010.

“with unimproved water and sanitation accounting for almost 1%”

May combine two claims.

Among non-communicable disease risks, high blood pressure, high body-mass index, high fasting plasma glucose, alcohol use, and dietary risks increased in relative importance.

“Of the non-communicable disease risks, high blood pressure, high body-mass index, high fasting plasma glucose, alcohol use, and dietary risks have increased in relative importance.”

May combine two claims.

The effects of multiple risk factors are not a simple addition of their individual effects and are often smaller than their sums, especially for cardiovascular diseases.

“The effects of multiple risk factors are not a simple addition of the individual effects and are often smaller than their sums,156 especially for cardiovascular diseases, which are affected by several risk factors (eg, table 2).”

• cites [156] Rothman, 1976, Causes, Am J Epidemiol sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets low in vegetables accounted for 1.8 million deaths and 1.5% of global DALYs in 2010.

“low in vegetables (1·8 million [1·2 million to 2·3 million]; 1·5% [1·0–2·1])”

May combine two claims.

In southern sub-Saharan Africa, alcohol use was the leading risk factor in 2010, followed by high blood pressure and high body-mass index.

“In 2010, alcohol use was the leading risk factor in southern sub-Saharan Africa, followed by high blood pressure and high bodymass index (figure 6).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Unimproved water and sanitation accounted for 0.3 million deaths and 0.9% of DALYs in 2010.

“unimproved water and sanitation, (0·3 million [0 to 0·6 million] deaths and 0·9% [0·04–1·6] DALYs)”

May combine two claims.

High blood pressure is a leading risk in high-income Asia Pacific (8.5% of disease burden) and central Europe (18.9%).

“High blood pressure is a leading risk for health in high-income Asia Pacific (accounting for 8·5% [95% UI 7·1–10·1] of disease burden) and central Europe (18·9% [16·8–20·8])”

May combine two claims.

The five leading risk factors in 2010 were high blood pressure, tobacco smoking including second-hand smoke, alcohol use, household air pollution, and diets low in fruits.

“the five leading risk factors in 2010 (high blood pressure, tobacco smoking including secondhand smoke, alcohol use, household air pollution, and diets low in fruits)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets low in nuts and seeds accounted for 2.5 million deaths and 2.1% of global DALYs in 2010.

“low in nuts and seeds (2·5 million [1·6 million to 3·2 million]; 2·1% [1·3–2·7])”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Sexual abuse and violence accounted for 0.2 million deaths and 0.9% of DALYs in 2010.

“sexual abuse and violence (0·2 million [0·1 million to 0·3 million] deaths and 0·9% [0·7–1·2] DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing).

Among children younger than 5 years, household air pollution from solid fuels accounted for 6.3% of global DALYs in 2010.

“and household air pollu tion from solid fuels (6·3% [4·4–8·1]).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Household air pollution from solid fuels accounted for 3.5 million deaths and 4.5% of global DALYs in 2010.

“Household air pollution from solid fuels accounted for 3·5 million (2·7 million to 4·4 million) deaths and 4·5% (3·4–5·3) of global DALYs in 2010”

Probably not a substantial claim: may not pass S3 (load-bearing).

The global disease burden attributable to high fasting plasma glucose increased from 56 million to 89 million DALYs between 1990 and 2010.

“that of high fasting plasma glucose increased from 56 million to 89 million DALYs over this period.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Suboptimal breastfeeding accounted for 0.5 million deaths and 1.9% of global DALYs in 2010.

“and suboptimal breast feeding (0·5 million [0·3 million to 0·8 million]; 1·9% [1·2–2·7])”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Ambient ozone pollution accounted for 0.2 million deaths and 0.1% of global DALYs in 2010.

“(0·2 million [0·1 million to 0·3 million] deaths and 0·1% [0·03–0·2] of global DALYs in 2010).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Low bone mineral density accounted for 0.2 million deaths and 0.21% of global DALYs in 2010.

“low bone mineral density (0·2 million [0·1 million to 0·2 million] deaths and 0·21% [0·17–0·25] of DALYs).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Globally, high blood pressure accounted for more than 20% of all health loss in adults aged 70 years and older in 2010, and around 15% in those aged 50-69 years.

“Globally, high blood pressure accounted for more than 20% of all health loss in adults aged 70 years and older in 2010, and around 15% in those aged 50–69 years.”

May combine two claims.

Among children younger than 5 years, childhood underweight was the leading risk factor worldwide in 2010, accounting for 12.4% of global DALYs.

“Among children younger than 5 years, childhood underweight was the leading risk factor worldwide in 2010 (12·4% [10·4–14·7] of global DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets low in whole grains accounted for 1.7 million deaths and 1.6% of global DALYs in 2010.

“low in whole grains (1·7 million [1·3 million to 2·1 million]; 1·6% [1·3–1·9])”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Iron deficiency accounted for 0.1 million deaths and 1.9% of global DALYs in 2010.

“followed by iron deficiency (0·1 million [0·09 million to 0·14 million]; 1·9% [1·4–2·6])”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

High fasting plasma glucose accounted for 3.4 million deaths and 3.6% of global DALYs in 2010.

“high fasting plasma glucose (3·4 million [2·9 million to 3·7 million] deaths and 3·6% [3·1–4·0] of DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets low in seafood omega-3 fatty acids accounted for 1.4 million deaths and 1.1% of global DALYs in 2010.

“low in seafood omega-3 fatty acids (1·4 million [1·0 million to 1·8 million]; 1·1% [0·8–1·5])”

Probably not a substantial claim: may not pass S3 (load-bearing).

Vitamin A and zinc deficiencies among children accounted for less than 0.8% of disease burden.

“Vitamin A and zinc deficiencies amongst children accounted for less than 0·8% of the disease burden.”

May combine two claims.

Alcohol use accounted for 7.4% of disease burden among men and 3.0% among women in 2010.

“For alcohol use, these sex differences were similarly sub stantial: 7·4% (third) versus 3·0% (eighth).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Diets high in sodium accounted for 4.0 million deaths and 2.5% of global DALYs in 2010.

“diets high in sodium (4·0 million [3·4 million to 4·6 million]; 2·5% [1·7–3·3])”

May combine two claims.

In a post-hoc sensitivity analysis excluding dust, global DALYs attributable to ambient particulate matter pollution decreased by 2%, with large effects in north Africa and the Middle East.

“For ambient particulate matter pollution, we also did a post-hoc sensitivity analysis excluding the effects of dust, which had a small effect worldwide—attributable global DALYs decreased by 2%—but large effects in north Africa and Middle East.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Tobacco smoking including second-hand smoke accounted for 6.3 million deaths and 6.3% of DALYs in 2010.

“The burdens of disease attributable to tobacco smoking including second-hand smoke (6·3 million [5·4 million to 7·0 million] deaths and 6·3% [5·5–7·0] of DALYs)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Child and maternal undernutrition was responsible for 1.4 million deaths and 6.7% of global DALYs in 2010.

“Child and maternal undernutrition was responsible for the next largest attributable burden of the risk factor clusters (1·4 million [1·2 million to 1·7 million] deaths; 6·7% [5·7–7·7] of global DALYs in 2010)”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Ambient particulate matter pollution accounted for 3.1 million deaths and 3.1% of global DALYs in 2010.

“ambient particulate matter pollution accounted for 3·1 million (2·7 million to 3·5 million) deaths and 3·1% (2·7–3·4) of global DALYs.”

May combine two claims.

High blood pressure, high body-mass index, and high fasting plasma glucose are leading risk factors for disease worldwide, with blood pressure having large effects in all regions including low-income sub-Saharan Africa and south Asia.

“High blood pressure, high body-mass index, and high fasting plasma glucose are leading risk factors for disease worldwide, with blood pressure having large effects on population health in all regions, including low-income regions in sub-Saharan Africa and south Asia.”

May combine two claims.

Worldwide, childhood wasting accounted for 0.7 million deaths in 2010, childhood stunting for 0.9 million, compared with 0.9 million for childhood underweight; the effects of these risks cannot be added.

“worldwide, childhood wasting accounted for 0·7 million deaths in 2010, and childhood stunting for 0·9 million deaths, compared with 0·9 million deaths for childhood under weight (the effects of these risks cannot be added).”

May combine two claims.

The analysis shows a large burden of disease attributable to primary and secondary tobacco smoking and to household and ambient particulate matter pollution.

“Our analysis shows the large burden of disease attributable to primary and secondary tobacco smoking and to particulate matter pollution in household and ambient environments.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The high alcohol burden in eastern Europe was identified in the 2000 comparative risk assessment, but data for consumption patterns and effects were weaker then; now they are supported by more surveys and epidemiological studies.

“The high burden in eastern Europe was also identified in the 2000 comparative risk assessment but the data for patterns of alcohol consumption and their effects were weaker, whereas now they are supported by more surveys and epidemiological studies.182”

• cites [182] Rehm, 2010, The relation between different dimensions of alcohol consumption and burden of disease: an overview, Addiction sourceNot checked yet

  Not checked in the free run.

May combine two claims.

This study's approach, calculating attributable burden by cause and age group and accounting for exposure in four categories, estimated 3.2 million attributable deaths in 2010 (2.7 million to 3.7 million), 56% of what is attributed to tobacco smoking when second-hand smoke is excluded.

“By contrast, our approach—calculating attributable burden by cause and age group, and accounting for exposure in four categories—estimated substantially fewer attributable deaths: 3·2 million (2·7 million to 3·7 million) in 2010, 56% of what we attribute to tobacco smoking when second-hand smoke is excluded.”

May combine two claims.

The burden attributable to alcohol use increased substantially in eastern Europe since 1990, mainly because of a rise in the effects of heavy drinking on cardiovascular diseases.

“The burden attributable to alcohol use has increased substantially in eastern Europe since 1990, mainly because of a rise in the effects of heavy drinking on cardiovascular diseases.181”

• cites [181] Zaridze, 2009, Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies, Int J Epidemiol sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The global burden attributable to tobacco smoking including second-hand smoke changed little, with decreases in high-income regions offset by increases in south east Asia and, to a lesser extent, east and south Asia.

“The global burden of disease attributable to tobacco smoking including second-hand smoke has changed little, with decreases in high-income regions offset by increases in regions such as south east Asia and, to a lesser extent, east and south Asia.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For zinc deficiency, Black and colleagues estimated 453,000 deaths versus this study's 120,000.

“for zinc deficiency, the differences are similarly large (453 000 vs 120 000).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Estimated child deaths caused by underweight changed across studies: GBD 1990 estimated 5.9 million deaths in 1990; the 2000 comparative risk assessment estimated 3.7 million; 2004 estimates were 1.9 million; GBD 2010 estimated 2.3 million for 1990 and 0.9 million for 2010.

“in GBD 1990 it was estimated to be 5·9 million deaths in 1990,180 in the comparative risk assessment study for 2000 as 3·7 million deaths,7 and 1·9 million deaths in 2004.10 In GBD 2010 we estimated 2·3 million deaths for 1990 and 0·9 million deaths for 2010.”

• cites [180] Murray, 1996Not checked yet

  Not checked in the free run.

• cites [7] Ezzati, 2002, Selected major risk factors and global and regional burden of disease, Lancet sourceNot checked yet

  Not checked in the free run.

• cites [10] Black, 2008, Maternal and child undernutrition: global and regional exposures and health consequences, Lancet sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The analysis did not find a significantly improved effect of water quality interventions, consistent with Cairncross and colleagues.

“Similarly, we did not find a significantly improved effect of water quality interventions, consistent with the findings reported by Cairncross and colleagues,128”

• cites [128] Cairncross, 2010, Water, sanitation and hygiene for the prevention of diarrhoea, Int J Epidemiol sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The burden of high total cholesterol is lower than in the 2000 comparative risk assessment because effects on ischaemic stroke were negligible at old ages when data were pooled, and because exposure fell in high-income countries.

“In contrast to these risks, the burden of high total cholesterol is lower than that estimated in the 2000 comparative risk assessment, because the effects on ischaemic stroke were negligible at old ages when data from the Asia-Pacific Cohort Studies Collaboration and Prospective Studies Collaboration were pooled,68,185 and because exposure has fallen in high-income countries.67”

• cites [68] Zhang, 2003, Cholesterol, coronary heart disease, and stroke in the Asia Pacific region, Int J Epidemiol sourceNot checked yet

  Not checked in the free run.

• cites [185] Lewington, 2007, Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55 000 vascular deaths, Lancet sourceNot checked yet

  Not checked in the free run.

• cites [67] Farzadfar, 2011, National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3·0 million participants, Lancet sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Black and colleagues estimated 668,000 deaths from vitamin A deficiency in 2004; this study estimated 168,000 for 2005.

“For example, Black and colleagues estimated 668 000 deaths caused by vitamin A deficiency in 2004; we estimated a quarter (168 000 deaths) for 2005”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

If quantifiable, unsafe sexual practices would probably account for a large fraction of global health burden; the direct burden of HIV is 3.3% of DALYs in 2010 and other sexually transmitted infections account for 0.4% of DALYs.

“If quantifiable, unsafe sexual practices would probably account for a large fraction of global health burden; the direct burden of HIV is 3·3% of DALYs in 2010; other sexually transmitted infections account for 0·4% of DALYs.”

May combine two claims.

Most leading risk factors except high body-mass index and high fasting plasma glucose have decreased in at least some regions and countries, showing that substantial reduction of their effect through targeted prevention strategies is feasible.

“Coupled with evidence of their present burden, most of the leading risk factors, except high body-mass index and high fasting plasma glucose, have decreased in at least some regions and countries, showing that substantial reduction of their effect through targeted prevention strategies is feasible.”

Probably not a substantial claim: may not pass S3 (load-bearing).

After that, WHO produced estimates for selected risks with the same methods, updated exposures, and some revised effect sizes.

“Since this work, WHO has provided estimates for some risks by the same methods but with updated exposures and some updates of the effect sizes for each risk.8”

• cites [8] 2009Not checked yet

  Not checked in the free run.

May combine two claims.

Beneficial dietary factors are usually positively correlated with one another and inversely correlated with harmful dietary factors.

“Protective dietary risk factors such as consumption of fruits, vegetables, and whole grains, tend to be positively correlated with each other and negatively correlated with harmful dietary risk factors such as consumption of processed meat.”

Classified as probably not a substantial claim.

For water and sanitation, a meta-regression of 119 studies adjusted for intervention and baseline group features.

“We did a meta-regression of 119 studies that was designed to adjust for intervention and baseline group characteristics.”

May combine two claims.

The effect sizes used controlled for measured confounders but did not control for variables on the causal pathway.

“We used effect sizes that had been adjusted for measured confounders but not for factors along the causal pathway.”

May combine two claims.

Re-analysing the zinc trials for disease-specific outcomes reduced their statistical power and produced 95% confidence intervals that included 1.0.

“Re-Analysis of the same trials for disease-specific outcomes, which is necessary to extrapo late effects to populations with different causes of death, reduced their statistical power and gave 95% CIs that spanned 1·0.”

• cites [36] Yakoob, 2011, Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria, BMC Public Health sourceNot checked yet

  Not checked in the free run.

• cites [153] Sazawal, 2007, Effect of zinc supplementation on mortality in children aged 1–48 months: a community-based randomised placebo-controlled trial, Lancet sourceNot checked yet

  Not checked in the free run.

May combine two claims.

GBD 1990 was the earliest global and regional comparative risk assessment, covering ten major risks and their attributable mortality and DALYs.

“The Global Burden of Disease Study (GBD) 1990 provided the first global and regional comparative assessment of mortality and disability adjusted life-years (DALYs) attributable to ten major risk factors.3”

• cites [3] Murray, 1996Not checked yet

  Not checked in the free run.

May combine two claims.

A cited systematic review of randomised trials on seafood omega-3 supplements found no significant effects for several outcomes but a significant effect on death from ischaemic heart disease.

“A systematic review143 of randomised clinical trials of supplementation with seafood omega-3 fatty acids reported non-significant effects on several outcomes, and a significant effect for mortality from ischaemic heart disease—the primary outcome in GBD 2010.”

• cites [143] Rizos, 2012, Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis, JAMA sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Similar national comparative risk assessments were done in Australia, Iran, Japan, Mexico, South Africa, Thailand, the USA, and Vietnam.

“National comparative risk assessments (including in Australia, Iran, Japan, Mexico, South Africa, Thailand, USA, and Vietnam) have also been undertaken with similar approaches.11–16”

• cites [11] Danaei, 2009, The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors, PLoS Med sourceNot checked yet

  Not checked in the free run.

• cites [12] Stevens, 2008, Characterizing the epidemiological transition in Mexico: national and subnational burden of diseases, injuries, and risk factors, PLoS Med sourceNot checked yet

  Not checked in the free run.

• cites [13] Begg, 2008, Burden of disease and injury in Australia in the new millennium: measuring health loss from diseases, injuries and risk factors, Med J Aust sourceNot checked yet

  Not checked in the free run.

• cites [14] Norman, 2007, A comparative risk assessment for South Africa in 2000: towards promoting health and preventing disease, S Afr Med JNot checked yet

  Not checked in the free run.

• cites [15] Ikeda, 2012, Adult mortality attributable to preventable risk factors for non-communicable diseases and injuries in Japan: a comparative risk assessment, PLoS Med sourceNot checked yet

  Not checked in the free run.

• cites [16] Farzadfar, 2011, National and subnational mortality effects of metabolic risk factors and smoking in Iran: a comparative risk assessment, Popul Health Metr sourceNot checked yet

  Not checked in the free run.

May combine two claims.

These shifts are linked to population ageing, lower under-5 mortality, altered cause-of-death composition, and changing risk exposures.

“These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For seafood omega-3, the main estimate combined randomised trials and observational studies, and a sensitivity analysis used only the randomised trial estimate.

“Therefore, we used the effect size based on the combination of randomised clinical trials and observational studies but also did a sensitivity analysis with the effect size based on randomised clinical trials.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Murray and Lopez introduced a global comparative risk assessment framework, which supported a 2000 assessment of 26 risks.

“Subsequently, Murray and Lopez4 proposed a framework for global comparative risk assessment, which laid the basis for assessment of 26 risks in 2000.5–7”

• cites [4] Murray, 1999, On the comparable quantification of health risks: lessons from the Global Burden of Disease Study, Epidemiology sourceNot checked yet

  Not checked in the free run.

• cites [5] 2002Not checked yet

  Not checked in the free run.

• cites [6] Ezzati, 2004Not checked yet

  Not checked in the free run.

• cites [7] Ezzati, 2002, Selected major risk factors and global and regional burden of disease, Lancet sourceNot checked yet

  Not checked in the free run.

May combine two claims.

How far this epidemiological transition has gone, and which risks now lead, differ widely by region.

“The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Exposure analyses adjusted for study features including whether data were national or subnational and the measurement instruments used.

“Finally, each analysis accounted for important study characteristics such as national versus subnational representativeness, and the measures and instruments used for measuring exposure.”

Classified as probably not a substantial claim. May combine two claims. The quote only partly states this claim.

Risk-outcome pairs were included if they were likely important, had enough exposure data, had strong causal evidence, and could be generalised or extrapolated.

“The inclusion criteria for each risk–outcome pair that we applied were: 1) the likely importance of a risk factor to disease burden or policy based on previous work; 2) availability of sufficient data and methods to enable estimation of exposure distributions by country for at least one of the study periods (1990 and 2010);”

May combine two claims.

In pooled cardiovascular risk studies, relative risk falls with age, and this inverse relationship is approximately log-linear.

“Pooled epidemiological studies of cardiovascular disease risks show that the RR decreases with age, and that the inverse age association is roughly log-linear.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Simulation analyses produced the uncertainty estimates for relative risks.

“Uncertainty in the RR was generated by simulation analyses.152”

• cites [152] King, 2000, Making the most of statistical analyses: improving interpretation and presentation, Am J Pol Sci sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Uncertainty was represented by 1000 draws from the posterior distributions of exposure, relative risk, and each relevant outcome for each age, sex, country, and year.

“To represent uncertainty in the estimates we used simulation analysis to take 1000 draws from the posterior distribution of exposure, RR, and each relevant outcome for each age, sex, country, year.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Draws from posterior distributions for exposure categories showing a protective effect were included in the uncertainty analysis.

“we have included in the uncertainty analysis draws from the posterior distribution for those exposure categories that show a protective effect.”

Classified as probably not a substantial claim.

The quantification of risk factors represents the effects of each individual risk factor while holding all other independent factors constant.

“Quantification of risk factors in this analysis represents the effects of each individual risk factor, holding all other independent factors constant.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The mean rank for a risk factor was not necessarily equivalent to the rank of the mean deaths or mean DALYs attributable to that risk factor.

“The mean of the ranks for a risk factor was not necessarily equivalent to the rank of the mean deaths or mean DALYs attributable to the risk factor.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Draws from posterior distributions were included when the mean values showed a dose-response relation.

“We have included draws from these posterior distributions if the mean values show a dose–response relation.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The combined effects of physiological risk factors are probably large.

“However, the combined effects of physiological risk factors are probably large, with high blood pressure the leading single risk factor globally”

Probably not a substantial claim: may not pass S3 (load-bearing).

The 95% uncertainty intervals were calculated as the 2.5th and 97.5th percentiles of the 1000 draws.

“The 95% uncertainty intervals (95% UI) were calculated as the 2·5th and 97·5th percentiles of the 1000 draws.”

May combine two claims.

The overall shift in risk factor burden resulted from population ageing, reductions in under-5 mortality, and changes in risk factor exposure.

“This overall shift has arisen from a combintion of the ageing population, substantial achievements in lowering mortality of children aged younger than 5 years, and changes in risk factor exposure.”

May combine two claims.

Risk factors included in a cluster are not necessarily independent; for example, a substantial part of the burden attributable to high body-mass index is mediated through high blood pressure and high fasting plasma glucose.

“However, risk factors included in a cluster are not necessarily independent; for example, a substantial part of the burden attributable to high body-mass index is mediated through high blood pressure and high fasting plasma glucose.”

• AssumptionThe authors state this as an assumption: Risk factors within a cluster are independent, with no mediation, exposure correlation, or effect-size modification between them.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Risk factor exposures might be correlated at the individual level, especially household air pollution and ambient particulate matter pollution, which might have common sources.

“Others act together and risk factor exposures might be correlated at the individual level,155 especially household air pollution and ambient particulate matter pollution, which might have common sources.”

• cites [155] Ezzati, 2003, Estimates of global and regional potential health gains from reducing multiple major risk factors, Lancet sourceNot checked yet

  Not checked in the free run.

• AssumptionThe authors state this as an assumption: Risk factors within a cluster are independent, with no mediation, exposure correlation, or effect-size modification between them.

Probably not a substantial claim: may not pass S3 (load-bearing).

Neonatal vitamin A deficiency was excluded because it is the subject of three ongoing randomised trials.

“Furthermore, we excluded neonatal vitamin A deficiency since it is the subject of three ongoing randomised trials.”

Classified as probably not a substantial claim.

As a result of reassessment, the analysis was restricted to improved water and improved sanitation compared with unimproved sources following MDG definitions.

“As a result of this reassessment, we restricted our analysis to improved water and improved sanitation compared with unimproved sources following the MDG definitions.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Regional heterogeneity underestimates even greater differences in exposure to and health effects of risk factors at national and subnational levels.

“This regional heterogeneity underestimates even greater differences in exposure to, and health effects of, risk factors in national and subnational populations.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The integrated exposure-response curve does not address how different sources of particulate matter interact in terms of effects and overlapping exposures.

“Our integrated exposure–response curve, however, does not address how different sources of particulate matter interact in terms of effects and overlapping exposures.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The real burden from water and sanitation could be underestimated if well-implemented household connections and water quality interventions have larger effects than improved water sources alone, and if combined poor water and sanitation has a larger effect than a simple interaction of individual effects.

“The real burden from water and sanitation could therefore be underestimated if well-implemented household connect ions and water quality interventions have a larger effect than improved water sources alone, and if the combination of poor water and sanitation has a larger effect than a sample interaction of individual effects.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Historical demographic analyses suggest that introducing piped water into cities in the late 19th and early 20th centuries had a large beneficial effect on mortality.

“Historical demographic analyses suggest that the introduction of piped water into cities in the late 19th and early 20th centuries had a large beneficial effect on mortality.174”

• cites [174] Preston, 1978, Urban French mortality in the nineteenth century, Popul Stud (Camb) sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

That study used effect sizes for all-cause mortality from cohorts mainly in North America and Europe and applied them to deaths at all ages.

“used effect sizes for all-cause mortality obtained from cohorts of adults mainly from North America and Europe and applied these effects to deaths at all ages.”

Probably not a substantial claim: may not pass S3 (load-bearing).

That number was widely quoted and equated with deaths attributable to tobacco smoking.

“This number, which has been widely quoted and equated with the number of deaths attributable to tobacco smoking,187”

• cites [187] Das, 2012, Rethinking our approach to physical activity, Lancet sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The theoretical-minimum-risk exposure distribution was selected based on values reported in randomised trials; studies of populations with low cardiovascular disease prevalence suggest benefits likely continue to lower levels.

“The theoretical-minimum-risk exposure distribution was selected on the basis of values reported in randomised trials; studies of populations with low prevalence of cardiovascular disease suggest that benefits are likely to continue to lower levels.158”

• cites [158] Elliott, 1996, Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group, BMJ sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Interventions in previous studies might not have achieved full efficacy because of implementation quality.

“However, the interventions used in previous studies might not have achieved their full efficacy because of the quality of implementation.”

May combine two claims.

These improvements come from systematic analysis of underweight data, major modification of relative risks after the 2006 WHO standard change, and differences in total and cause-specific mortality estimates.

“These improvements come from systematic analysis of the available data on underweight, a major modification of RRs after the change in the WHO standard in 2006, and differences in estimates of total and cause-specific mortality.”

May combine two claims.

That approach assumes the cause distribution is the same in all populations irrespective of region and age structure, and extends effects to people younger than cohort members including infants and children.

“This approach not only assumes that the cause distribution is the same in all populations, irrespective of region and age structure, but also extends the effects to people younger than those in the cohort study, including to infants and children.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The set of diet components was expanded from a combined fruits and vegetables category in the 2000 comparative risk assessment to 15 components in GBD 2010.

“We have expanded the set of components of diet included from a combined category of fruits and vegetables in the 2000 comparative risk assessment to 15 components in GBD 2010”

Probably not a substantial claim: may not pass S3 (load-bearing).

The burden attributable to childhood wasting and childhood stunting was assessed.

“We have also assessed the burden attributable to childhood wasting and childhood stunting.”

May combine two claims.

Black and colleagues' estimates were based on 10.3 million child deaths worldwide, itself based on WHO estimates of global child deaths for 2004.

“First, the estimates of Black and colleagues were based on 10·3 million child deaths worldwide, itself based on WHO estimates of global child deaths for 2004.”

May combine two claims.

Household and ambient particulate matter exposures are related, and alternative cooking and heating fuels would benefit both solid fuel users and non-users in the same community.

“Therefore the two exposures are related, and alternative cooking and heating fuels would have benefits for people who currently use solid fuels as well as those who do not, but live in the same community.173”

• cites [173] Zhou, 2011, Household and community poverty, biomass use, and air pollution in Accra, Ghana, Proc Natl Acad Sci USA sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The proportion of the population who are vitamin A or zinc deficient was quantified instead of classifying whole countries as exposed or non-exposed.

“Furthermore, we quantified the proportion of the population who are vitamin A or zinc deficient instead of classing whole countries as exposed or non-exposed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The worldwide increase in body-mass index and blood glucose is of particular concern because of the absence of effective interventions.

“The worldwide increase in body-mass index and blood glucose is of particular concern in view of the absence of effective interventions.62,74”

• cites [62] Danaei, 2011, National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants, Lancet sourceNot checked yet

  Not checked in the free run.

• cites [74] Finucane, 2011, National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants, Lancet sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Other evidence shows that effects diminish with increasing exposure for active smoking, a pattern incorporated into the exposure-response curves.

“Other evidence161 shows that the effects diminish with increasing exposure for active smoking, a pattern incorporated into our exposure– response curves.”

• cites [161] Ambrose, 2004, The pathophysiology of cigarette smoking and cardiovascular disease: an update, J Am Coll Cardiol sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The relatively small burden estimated for 2010 is partly related to decreases in diarrhoeal disease mortality since 1990 and partly to differences in distributions of deaths by underlying cause.

“The relatively small burden estimated for 2010 is partly related to decreases in diarrhoeal disease mortality since 1990, and partly to differences in the distributions of deaths by underlying cause of death.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A recent study estimated 5.3 million deaths attributable to physical inactivity in 2008.

“A recent study estimated that 5·3 million deaths were attributable to physical inactivity in 2008.186”

• cites [186] Lee, 2012, Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy, Lancet sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

An updated meta-analysis of quasi-experimental and experimental studies was done.

“We have also done an updated meta-analysis of quasi experimental and experimental studies.”

May combine two claims.

The discrepancy shows the importance of comparable risk factor assessments and of estimating attributable burden while accounting for differences in underlying disease and injury patterns across populations.

“This discrepancy shows the importance of comparable risk factor assessments and the importance of estimation of attributable burden taking into account differences in underlying disease and injury patterns across populations.”

May combine two claims.

Risks were excluded if insufficient information exists to estimate exposure or if evidence of effect sizes is scarce.

“Fifth, we have excluded risks for which insufficient information exists to enable estimation of exposure, or for which the evidence of effect sizes is scarce.”

May combine two claims.

Confounding could not be controlled in observational studies of late initiation of breastfeeding, which is associated with increased neonatal mortality.

“Similarly, we have been unable to control for confounding in observational studies of late initiation of breastfeeding, which is associated with an increased risk of neonatal mortality.”

Classified as probably not a substantial claim. May combine two claims. The quote only partly states this claim.

Study strengths include a more comprehensive set of risk factors than previous global or national analyses, consistent analyses in 1990 and 2010, more exposure data, improved methods for missing and incomparable data, emphasis on comparability, and use of theoretical-minimum-risk exposure distribution.

“The strengths of our study include a more comprehensive set of risk factors than any previous global or national analysis, consistent analyses in 1990, and 2010, which enables assessment of changes in risk factor burden, the incorporation of substantially more data for risk-factor exposure, improved methods to deal with missing and incomparable data, strong emphasis on comparability of methods”

May combine two claims.

Evidence from randomised controlled trials does not exist for several dietary components with large attributable burden, including fruits, vegetables, and nuts and seeds, although evidence for intermediate outcomes exists.

“Also, evidence from randomised controlled trials does not exist for several of the dietary components with a large attributable burden—fruits, vegetables, and nuts and seeds—although, as previously noted, evidence from randomised controlled trials does exist for inter mediate outcomes.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Results should be interpreted with caution, particularly because of debate about the effects of seafood omega-3 fatty acids.

“However, we stress that these results should still be interpreted with caution, particularly because of the debate surrounding the effects of seafood omega-3 fatty acids.143,188”

• cites [143] Rizos, 2012, Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis, JAMA sourceNot checked yet

  Not checked in the free run.

• cites [188] Hu, 2012, Omega-3 fatty acids and secondary prevention of cardiovascular disease—is it just a fish tale?: Comment on ‘efficacy of omega-3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease’, Arch Intern Med sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The large body of epidemiological evidence for cardiovascular risk factors shows a relation between age and the effect size of risk factors for cardiovascular disease.

“Similarly, the large body of epidemiological evidence for cardiovascular risk factors shows a relation between age and the effect size of risk factors for cardiovascular disease.”

May combine two claims.

For some risk factors, less direct measures of exposure were used; for example, household air pollution was measured by household fuel use rather than personal particulate matter exposure, while blood pressure has direct biological measurements.

“More importantly, for some risk factors we have less direct measures of exposure than for others. For example, for household air pollution from solid fuels we measured exposure on the basis of household fuel use rather than personal exposure to particulate matter; for other risks, such as blood pressure, we have direct biological measurements of exposure.”

Probably not a substantial claim: may not pass S2 (checkable).

The principal advantage of a comprehensive and comparable scientific assessment of disease burden caused by different risk factors is that it provides the evidence base for informing policy discussion.

“The principal advantage of doing a comprehensive and comparable scientific assessment of disease burden caused by different risk factors is that it provides the evidence base for informing discussion about policy.”

May combine two claims.

Combining epidemiological evidence for effect sizes across different periods could mask underlying temporal changes in risk; no data presently exist to examine the extent to which effect sizes might change over time.

“Fourth, we have combined epidemiological evidence for effect sizes using studies across different periods, which could mask underlying temporal changes in risk; no data presently exist to enable an examination of the extent to which effect sizes might change over time.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

The size of attributable risk factor burden does not equal priority for action because prioritisation also depends on availability, cost, and effectiveness of intervention strategies.

“Finally, it is important to stress that the size of the attributable risk factor burden does not equal priority for action since prioritisation also depends on availability, cost, and effectiveness of inter vention strategies to reduce exposures to these risks.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Infants who are too ill or weak to breastfeed are more likely to die.

“Infants who might too ill or weak to breastfeed are more likely to die.”

Probably not a substantial claim: may not pass S2 (checkable).

Public policy to improve population health will be more effective if it addresses the major causes of disease burden.

“Public policy to improve the health of populations will be more effective if it addresses the major causes of disease burden.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The validity of using the combined effect size could change as new evidence accumulates.

“However, the validity of this approach could change as new evidence accumulates.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Empirical assessments show that the pooled effect of risks and interventions trends toward a null result over time; this pattern could apply to seafood omega-3 because earlier observational effect sizes were larger than recent randomised controlled trial effects.

“Empirical assessments show that the pooled effect of risks and interventions trends towards a null result over time189,190 and this pattern could apply to seafood omega-3 fatty acids since the earlier, primarily observational effect sizes tended to show a larger effect than did the more recent randomised controlled trials.”

• cites [189] Ioannidis, 2005, Why most published research findings are false, PLoS Med sourceNot checked yet

  Not checked in the free run.

• cites [190] Ioannidis, 2005, Contradicted and initially stronger effects in highly cited clinical research, JAMA sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The extended diet analysis does not include saturated fat beyond its replacement by polyunsaturated fats.

“The extended analysis of components of diet does not include saturated fat beyond its replacement by polyunsaturated fats.”

May combine two claims.

No large-scale trials of interventions for high body-mass index measuring cause-specific deaths have been done, although effects on disease incidence have been investigated in trials.

“For example, no large-scale trials have been done of interventions for high body-mass index that measured cause-specific deaths although effects on disease incidence have been investigated in trials.193”

• cites [193] Knowler, 2002, Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin, N Engl J Med sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Observational studies indicate there might be no benefits if saturated fat reduction is associated with an increase in carbohydrates, supported by the absence of benefits from a low fat diet in the Women's Health Initiative.

“However, observational studies indicate that there might be no benefits if saturated fat reduction is associated with an increase in carbohydrates,91 which is also supported by the absence of benefits from a low fat diet in the Women’s Health Initiative.192”

• cites [91] Jakobsen, 2009, Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies, Am J Clin Nutr sourceNot checked yet

  Not checked in the free run.

• cites [192] Howard, 2006, Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial, JAMA sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Ecological studies suggest that saturated fat intake is a significant risk factor for mortality from ischaemic heart disease.

“Ecological studies suggest that saturated fat intake is a significant risk factor for mortality from ischaemic heart disease.191”

• cites [191] Slattery, 1988, Trends in coronary heart disease mortality and food consumption in the United States between 1909 and 1980, Am J Clin Nutr sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Age-related changes in effect size might be present for outcomes other than cardiovascular disease.

“Such age-related changes might be present for other outcomes.”

May combine two claims.

The pooled effect of risks and interventions trends toward a null result over time, implying that risks with few studies might have their effect overestimated compared with risks with a large evidence base.

“As noted, the pooled effect of risks and interventions trends towards the null result over time;189,190 the implication being that risks for which only a few studies have been done might have their effect overestimated compared with risks for which a large body of evidence exists.”

• cites [189] Ioannidis, 2005, Why most published research findings are false, PLoS Med sourceNot checked yet

  Not checked in the free run.

• cites [190] Ioannidis, 2005, Contradicted and initially stronger effects in highly cited clinical research, JAMA sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Low birthweight was not a disease outcome in GBD 2010 but is associated with increased risk of neonatal mortality.

“Low birthweight was not a disease outcome in GBD 2010 but is associated with an increased risk of neonatal mortality.”