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Cited by 2,701Cardiovascular Health and Risk FactorsGlobal Health and EpidemiologyOccupational Health and Global Justice

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

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Forouzanfar, Mohammad H, Alexander, Lily, Anderson, H Ross, Bachman, Victoria F, Biryukov, Stan, Brauer, Michael, Burnett, Richard, Casey, Daniel +713 more·2015·The Lancet
DOI 10.1016/s0140-6736(15)00128-2PMC PMC4685753
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Abstract

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.Funding Bill & Melinda Gates Foundation.

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Forouzanfar, M. H., Alexander, L., Anderson, H. R., Bachman, V. F., Biryukov, S., Brauer, M., Burnett, R., Casey, D., Coates, M. M., Cohen, A., Delwiche, K., Estep, K., Frostad, J. J., KC, A., Kyu, H. H., Moradi-Lakeh, M., Ng, M., Slepak, E. L., Thomas, B. A., Wagner, J., Aasvang, G. M., Abbafati, C., Ozgoren, A. A., Abd-Allah, F., Abera, S. F., Aboyans, V., Abraham, B., Abraham, J. P., Abubakar, I., Abu-Rmeileh, N. M. E., Aburto, T. C., Achoki, T., Adelekan, A., Adofo, K., Adou, A. K., Adsuar, J. C., Afshin, A., Agardh, E. E., Al Khabouri, M. J., Al Lami, F. H., Alam, S. S., Alasfoor, D., Albittar, M. I., Alegretti, M. A., Aleman, A. V., Alemu, Z. A., Alfonso-Cristancho, R., Alhabib, S., Ali, R., Ali, M. K., Alla, F., Allebeck, P., Allen, P. J., Alsharif, U., Alvarez, E., Alvis-Guzman, N., Amankwaa, A. A., Amare, A. T., Ameh, E. A., Ameli, O., Amini, H., Ammar, W., Anderson, B. O., Antonio, C. A. T., Anwari, P., Cunningham, S. A., Arnlöv, J., Arsenijevic, V. S. A., Artaman, A., Asghar, R. J., Assadi, R., Atkins, L. S., Atkinson, C., Avila, M. A., Awuah, B., Badawi, A., Bahit, M. C., Bakfalouni, T., Balakrishnan, K., Balalla, S., Balu, R. K., Banerjee, A., Barber, R. M., Barker-Collo, S. L., Barquera, S., Barregard, L., Barrero, L. H., Barrientos-Gutierrez, T., Basto-Abreu, A. C., Basu, A., Basu, S., Basulaiman, M. O., Ruvalcaba, C. B., Beardsley, J., Bedi, N., Bekele, T., Bell, M. L., Benjet, C., Bennett, D. A., Benzian, H., Bernabé, E., Beyene, T. J., Bhala, N., Bhalla, A., Bhutta, Z. A., Bikbov, B., Abdulhak, A. A. B., Blore, J. D., Blyth, F. M., Bohensky, M. A., Başara, B. B., Borges, G., Bornstein, N. M., Bose, D., Boufous, S., Bourne, R. R., Brainin, M., Brazinova, A., Breitborde, N. J., Brenner, H., Briggs, A. D. M., Broday, D. M., Brooks, P. M., Bruce, N. G., Brugha, T. S., Brunekreef, B., Buchbinder, R., Bui, L. N., Bukhman, G., Bulloch, A. G., Burch, M., Burney, P. G. J., Campos-Nonato, I. R., Campuzano, J. C., Cantoral, A. 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Affiliations
  • Maastricht University Medical Centre (NL)
  • University of Washington (US)
  • Royal Children's Hospital (AU)
  • Institute for Health Metrics and Evaluation (US)
  • Ateneo de Manila University (PH)
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2015-12
Volume
386
Issue
10010
Pages
2287-2323
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(15)00128-2
PMC
PMC4685753
OpenAlex
W3143437408
Cited by
2,701
References
82
Citations by year
2026: 55 · 2025: 103 · 2024: 159 · 2023: 161 · 2022: 208 · 2021: 286 · 2020: 303 · 2019: 297 · 2018: 342 · 2017: 439 · 2016: 319 · 2015: 21 · 2014: 1 · 2012: 1
FWCI
271.73
Type
journal article
Language
en
Open access
Licence
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  • The Lancet (publishedVersion)
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Funders
  • World Health Organization
  • Grand Challenges Canada
  • Conselho Nacional de Desenvolvimento Científico e Tecnológico
  • Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
  • Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul
  • Bill and Melinda Gates Foundation
  • Universidade de São Paulo
  • Public Health Foundation of India
  • Fundação de Amparo à Pesquisa do Estado de São Paulo
  • Novartis
  • Wellcome Trust (099876)
  • European Commission
  • Fundação Maria Cecilia Souto Vidigal
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
  • Health Sciences › Health Professions › Health Information Management › Global Health and Epidemiology
  • Social Sciences › Health › Occupational Health and Global Justice
Keywords
comparative risk assessment, modifiable risk factors, attributable burden, disability-adjusted life years, years of life lost, years lived with disability, handwashing behavior, child wasting, child stunting, unprotected sex, low glomerular filtration rate, body mass index, high systolic blood pressure, hypercholesterolemia
MeSH terms
Environmental Exposure, Female, Humans, Male, Metabolic Diseases, Nutritional Status, Occupational Diseases, Risk Factors, Sanitation, Global Health, Health Behavior, Occupational Exposure, Risk Assessment

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Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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