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

M. H. Forouzanfar, L. Alexander, V. F. Bachman, S. Biryukov, M. Brauer, D. Casey, M. M. Coates, K. Delwiche, K. Estep, J. J. Frostad, K. C. Astha, H. H. Kyu, M. Moradi-Lakeh, M. Ng, E. Slepak, B. A. Thomas, J. Wagner, T. Achoki, C. Atkinson, R. M. BarberK. Cooperrider, L. Dandona, D. Dicker, A. D. Flaxman, T. D. Fleming, K. J. Foreman, E. Gakidou, S. I. Hay, K. R. Heuton, M. L. Iannarone, T. Ku, H. J. Larson, S. S. Lim, A. D. Lopez, R. Lozano, M. F. MacIntyre, C. Margono, A. McLain, A. H. Mokdad, E. C. Mullany, C. J.L. Murray, M. Naghavi, G. Nguyen, A. W. Pain, L. Richardson, M. Robinson, L. Sandar, N. Stephens, A. M. Temesgen, B. Thomson, T. Vos, X. Wan, H. Wang, B. Wurtz, B. E. Ebel, R. G. Ellenbogen, J. L. Wright, R. Alfonso-Cristancho, B. O. Anderson, P. N. Jensen, D. A. Quistberg, A. Riederer, M. S. Vavilala, J. R. Zunt, H. R. Anderson, F. Pourmalek, C. C. Gotay, R. Burnett, H. H. Shin, S. Weichenthal, A. Cohen, A. Knudsen, G. Aasvang, J. M. Kinge, V. Skirbekk, S. Vollset, C. Abbafati, A. Abbasoglu Ozgoren, A. Çavlin, B. Kucuk Bicer, F. Abd-Allah, S. F. Abera, Y. A. Melaku, V. Aboyans, B. Abraham, J. Puthenpurakal Abraham, J. Puthenpurakal Abraham, A. L. Thorne-Lyman, E. L. Ding, S. Fahimi, S. Khatibzadeh, G. R. Wagner, G. Bukhman, I. R. Campos-Nonato, A. B. Feigl, J. A. Salomon, H. Benzian, I. Abubakar, N. M.E. Abu-Rmeileh, T. C. Aburto, M. A. Avila, S. Barquera, T. Barrientos-Gutierrez, J. C. Campuzano, A. J. Cantoral, A. G. Contreras, L. Cuevas-Nasu, V. De, F. A. García-Guerra, H. Gomez Dantes, T. Gonzalez de Cosio, D. González-Castell, I. B. Heredia-Pi, L. Hernandez, A. Jauregui, C. Medina, F. Mejia-Rodriguez, J. C. Montañez Hernandez, L. S. Pedraza, A. Pedroza, A. D. Quezada, D. Salvo, L. M. Sanchez, T. G. Sánchez-Pimienta, E. E. Servan-Mori, T. Shamah Levy, M. M. Téllez Rojo, S. Villalpando, A. Adelekan, K. Adofo, A. K. Adou, J. C. Adsuar, U. Fra Paleo, A. Afshin, R. Micha, D. Mozaffarian, S. Shahraz, S. Shangguan, G. M. Singh, E. E. Agardh, M. J. Al Khabouri, F. H. Al Lami, S. Alam, A. Naheed, D. Alasfoor, M. I. Albittar, M. A. Alegretti, F. Cavalleri, A. V. Aleman, V. Colistro, Z. A. Alemu, S. Alhabib, Z. Chen, P. Gething, R. Ali, D. A. Bennett, A. D.M. Briggs, K. Rahimi, P. Scarborough, E. P. Simard, M. K. Ali, S. Argeseanu Cunningham, Y. Liu, K. M.V. Narayan, S. B. Omer, F. Alla, F. Guillemin, P. Allebeck, N. Roy, M. Kivipelto, E. Weiderpass, S. Fereshtehnejad, R. Havmoeller, S. Sindi, P. J. Allen, U. Alsharif, M. Endres, S. Nolte, C. Papachristou, E. Alvarez, N. Alvis-Guzman, A. J. Paternina Caicedo, A. A. Amankwaa, A. T. Amare, H. W. Hoek, R. T. Gansevoort, M. Yenesew, E. A. Ameh, O. Ameli, H. Amini, M. Tanner, W. Ammar, H. L. Harb, C. A.T. Antonio, E. A. Faraon, C. A. Panelo, P. Anwari, J. Arnlöv, A. Larsson, V. S. Arsic Arsenijevic, A. Artaman, R. J. Asghar, R. Assadi, L. S. Atkins, B. Awuah, D. O. Laryea, A. Badawi, M. C. Bahit, T. Bakfalouni, K. Balakrishnan, S. Balalla, V. L. Feigin, B. J. Te Ao, R. Balu, R. Dandona, S. Goenka, G. Kumar, K. S. Murthy, K. Reddy, A. Banerjee, S. L. Barker-Collo, B. del Pozo-Cruz, L. Barregard, L. H. Barrero, A. C. Basto-Abreu, C. Batis Ruvalcaba, E. F. de Castro, N. Lopez, J. L. Texcalac, A. Basu, L. Gaffikin, S. Basu, M. O. Basulaiman, Z. A. Memish, J. Beardsley, N. Bedi, T. Bekele, M. L. Bell, J. J. Huang, C. Benjet, G. Borges, R. A. Gutiérrez, R. Orozco, L. Trasande, H. Hagan, E. Bernabé, C. D.A. Wolfe, T. J. Beyene, N. Bhala, S. Derrett, A. Bhalla, V. Jha, Z. A. Bhutta, M. I. Nisar, B. Bikbov, A. A. Bin Abdulhak, L. Vijayakumar, P. P. Chiang, J. D. Blore, P. M. Brooks, A. Lakshmana Balaji, S. M. Colquhoun, R. G. Weintraub, F. M. Blyth, A. Meretoja, M. A. Bohensky, B. Bora Basara, G. K. Yentür, M. R. Kose, A. Pekericli, S. B. Uzun, N. M. Bornstein, D. Bose, S. Boufous, L. Degenhardt, R. R. Bourne, M. Brainin, A. Brazinova, M. Majdan, N. J. Breitborde, B. Schöttker, H. Brenner, D. M. Broday, R. Lunevicius, N. G. Bruce, M. K. Dherani, D. Pope, T. S. Brugha, B. Brunekreef, H. Kromhout, R. Buchbinder, B. Gabbe, K. B. Gibney, A. G. Thrift, L. N. Bui, N. T. Nguyen, A. G. Bulloch, S. B. Patten, M. Tonelli, J. Wang, M. Burch, P. G.J. Burney, D. L. Jarvis, A. Rodriguez, L. Rushton, M. Soljak, T. N. Williams, J. Caravanos, D. Nash, R. Cárdenas, E. Cardis, M. J. Nieuwenhuijsen, D. Rojas-Rueda, D. O. Carpenter, R. Leung, V. Caso, C. A. Castañeda-Orjuela, R. E. Castro, F. Catalá-López, V. K. Chadha, J. Chang, J. G. Scott, D. G. Hoy, L. D. Knibbs, F. J. Charlson, H. E. Erskine, A. J. Ferrari, H. N. Gouda, L. J. Veerman, H. A. Whiteford, W. Chen, X. Zou, H. Chen, S. J. London, Y. Jiang, K. Takahashi, O. Chimed-Ochir, R. Chowdhury, J. Powles, C. A. Christophi, T. Chuang, S. S. Chugh, M. Cirillo, T. K.D. Claßen, A. Kraemer, M. Tobollik, M. Colomar, C. Cooper, L. T. Cooper, J. Coresh, K. Matsushita, B. X. Tran, K. J. Courville, M. H. Criqui, M. B. Stein, J. Damsere-Derry, H. Danawi, A. H. Refaat, P. I. Dargan, A. Davis, D. F.J. Fay, J. C. Schmidt, D. V. Davitoiu, A. Dayama, D. DeLeo, G. de Lima, V. M.P. Machado, J. R. Nogueira, C. M. Teixeira, R. P. Dellavalle, K. Deribe, W. Mekonnen, D. C. Des Jarlais, M. Dessalegn, G. A. deVeber, M. P. Lindsay, H. Hu, K. M. Devries, M. McKee, N. Pearce, H. Stöckl, T. Tillmann, C. H. Watts, S. D. Dharmaratne, K. Dokova, E. R. Dorsey, T. R. Driscoll, G. B. Marks, J. Leigh, L. Duan, Y. Li, S. Liu, J. Ma, L. Wang, P. Ye, M. Zhou, X. Liang, A. M. Durrani, Y. M. Elshrek, S. P. Ermakov, S. Soshnikov, B. Eshrati, F. Farzadfar, A. Esteghamati, N. Hafezi-Nejad, S. Sheikhbahaei, S. G. Sepanlou, P. Heydarpour, M. Sahraian, V. Rahimi-Movaghar, C. P. Ferri, N. Foigt, R. C. Franklin, A. Gamkrelidze, I. Khonelidze, L. Sturua, F. G. Gankpé, E. Gasana, N. Sabin, J. M. Geleijnse, B. D. Gessner, R. F. Gillum, I. A.M. Ginawi, M. Giroud, G. Giussani, K. Goginashvili, P. Gona, A. Goto, R. L. Guerrant, A. S. Terkawi, H. C. Gugnani, D. Gunnell, R. Gupta, M. Hagstromer, Y. A. Halasa, B. T. Idrisov, R. R. Hamadeh, M. Hammami, G. J. Hankey, Y. Hao, Y. Zheng, T. Haregu, S. van de Vijver, J. Haro, M. T. Hedayati, M. Hijar, H. J. Hoffman, G. A. Mensah, U. K. Sampson, J. C. Hornberger, H. Hosgood, M. Hsairi, G. Hu, C. Huang, B. J. Hubbell, L. Huiart, L. Racapé, A. Husseini, K. M. Iburg, N. Ikeda, K. Innos, M. Inoue, N. Kawakami, K. Shibuya, F. Islami, S. Ismayilova, K. H. Jacobsen, H. A. Jansen, S. K. Jassal, Sudha Jayaraman, P. Jeemon, D. Prabhakaran, F. Jiang, G. Jiang, M. R. Phillips, J. B. Jonas, K. Juel, J. She, H. Kan, S. S. Kany Roseline, N. E. Karam, A. Karch, C. K. Karema, G. Karthikeyan, V. K. Paul, M. Satpathy, N. Tandon, A. Kaul, D. S. Kazi, A. H. Kemp, P. A. Lotufo, G. V. Polanczyk, I. S. Santos, A. P. Kengne, R. Matzopoulos, C. D. Parry, K. Sliwa, B. M. Mayosi, D. J. Stein, A. Keren, Y. S. Khader, S. E. Ali Hassan Khalifa, E. A. Khan, Y. Khang, C. Kieling, D. Kim, S. Kim, Y. Kim, R. W. Kimokoti, Y. Kinfu, B. M. Kissela, Y. Kokubo, S. Kosen, T. S. Warouw, M. Kravchenko, Y. Y. Varakin, S. Krishnaswami, B. Kuate Defo, E. J. Kuipers, S. Polinder, C. Kulkarni, V. S. Kulkarni, G. F. Kwan, T. Lai, R. Lalloo, T. Lallukka, R. Shiri, H. Lam, Q. Lan, V. C. Lansingh, P. M. Lavados, A. E. Lawrynowicz, J. L. Leasher, J. Lee, S. Yoon, M. Levi, J. Liang, Y. Wang, J. Zhu, S. E. Lipshultz, B. K. Lloyd, R. Room, G. Logroscino, J. Lortet-Tieulent, S. Ma, H. P. Phua, C. Magis-Rodriguez, A. A. Mahdi, R. Malekzadeh, S. Mangalam, C. C. Mapoma, F. Masiye, M. Marape, W. Marcenes, P. A. Meaney, D. J. Margolis, D. H. Silberberg, R. V. Martin, M. B. Marzan, M. T. Mashal, A. J. Mason-Jones, T. T. Mazorodze, A. C. McKay, M. Mehndiratta, M. Meltzer, W. Mendoza, F. Apolinary Mhimbira, T. R. Miller, E. J. Mills, S. Mishra, N. Mohamed Ibrahim, K. A. Mohammad, G. L. Mola, L. Monasta, M. Montico, L. Ronfani, A. R. Moore, L. Morawska, R. E. Norman, R. Mori, M. Tsilimbaris, J. Moschandreas, W. N. Moturi, A. Werdecker, U. O. Mueller, R. Westerman, M. Mukaigawara, Z. Nahas, K. S. Naidoo, L. Naldi, D. Nand, V. Nangia, B. Neal, C. Nejjari, S. P. Neupane, C. R. Newton, F. N. Ngalesoni, J. D. Ngirabega, J. M. Nolla, S. E. Vollset, O. F. Norheim, B. Norrving, L. Nyakarahuka, I. Oh, T. Ohkubo, B. O. Olusanya, J. N. Opio, R. S. Pagcatipunan, J. D. Pandian, E. Park, S. Seedat, B. I. Pavlin, L. Pejin Stokic, D. M. Pereira, R. Perez-Padilla, F. Perez-Ruiz, N. Perico, G. Remuzzi, M. Trillini, S. A.L. Perry, A. Pervaiz, K. Pesudovs, C. B. Peterson, M. Petzold, D. Plass, D. Poenaru, C. D. Pond, C. Pope, S. Popova, J. Rehm, N. M. Prasad, D. M. Qato, A. Rafay, S. M. Rana, S. Ur Rahman, M. Raju, I. Rakovac, M. Rao, H. Razavi, A. L. Ribeiro, G. Velasquez-Melendez, P. M. Riccio, L. A. Sposato, A. Roca, I. Romieu, K. Straif, G. M. Ruhago, B. F. Sunguya, R. L. Sacco, S. Saha, R. Sahathevan, J. R. Sanabria, L. Sanchez-Riera, A. Sapkota, J. E. Saunders, S. Soneji, M. Sawhney, M. I. Saylan, I. J.C. Schneider, D. C. Schwebel, J. A. Singh, B. Serdar, G. Shaddick, Y. Shinohara, K. Shishani, I. Shiue, I. D. Sigfusdottir, A. Singh, K. Søreide, C. T. Sreeramareddy, N. J.C. Stapelberg, V. Stathopoulou, N. Steckling, K. Stroumpoulis, S. Swaminathan, M. Swaroop, Y. Yano, B. L. Sykes, K. M. Tabb, R. T. Talongwa, D. Tanne, M. Tavakkoli, S. V. Thackway, G. D. Thurston, F. Topouzis, J. A. Towbin, H. Toyoshima, J. Traebert, U. Trujillo, Z. Tsala Dimbuene, E. Tuzcu, U. S. Uchendu, K. N. Ukwaja, R. Van Dingenen, C. H. van Gool, J. van Os, T. J. Vasankari, A. N. Vasconcelos, F. S. Violante, V. Victorovich Vlassov, S. G. Waller, M. T. Wallin, W. Wang, K. Wessells, J. D. Wilkinson, H. C. Williams, S. M. Woldeyohannes, J. Q. Wong, A. D. Woolf, G. Xu, L. L. Yan, G. Yang, P. Yip, N. Yonemoto, M. Z. Younis, Z. Younoussi, C. Yu, M. E. Zaki, Y. Zhao, S. Zhu

Research output: Contribution to journalArticle

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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 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.

Original languageEnglish
Pages (from-to)2287-2323
Number of pages37
JournalThe Lancet
Volume386
Issue number10010
DOIs
StatePublished - 5 Dec 2015

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Quality-Adjusted Life Years
Global Burden of Disease
Unsafe Sex
Body Mass Index
Child Nutrition Disorders
Blood Pressure
Hypertension
Northern Africa
Hand Disinfection
Middle East
Far East
Mothers
Growth Disorders
Neglected Diseases
Behavioral Sciences
Trichloroethylene
Eastern Europe
Sanitation
Bayes Theorem
Social Sciences

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Forouzanfar, M. H. ; Alexander, L. ; Bachman, V. F. ; Biryukov, S. ; Brauer, M. ; Casey, D. ; Coates, M. M. ; Delwiche, K. ; Estep, K. ; Frostad, J. J. ; Astha, K. C. ; Kyu, H. H. ; Moradi-Lakeh, M. ; Ng, M. ; Slepak, E. ; Thomas, B. A. ; Wagner, J. ; Achoki, T. ; Atkinson, C. ; Barber, R. M. ; Cooperrider, K. ; Dandona, L. ; Dicker, D. ; Flaxman, A. D. ; Fleming, T. D. ; Foreman, K. J. ; Gakidou, E. ; Hay, S. I. ; Heuton, K. R. ; Iannarone, M. L. ; Ku, T. ; Larson, H. J. ; Lim, S. S. ; Lopez, A. D. ; Lozano, R. ; MacIntyre, M. F. ; Margono, C. ; McLain, A. ; Mokdad, A. H. ; Mullany, E. C. ; Murray, C. J.L. ; Naghavi, M. ; Nguyen, G. ; Pain, A. W. ; Richardson, L. ; Robinson, M. ; Sandar, L. ; Stephens, N. ; Temesgen, A. M. ; Thomson, B. ; Vos, T. ; Wan, X. ; Wang, H. ; Wurtz, B. ; Ebel, B. E. ; Ellenbogen, R. G. ; Wright, J. L. ; Alfonso-Cristancho, R. ; Anderson, B. O. ; Jensen, P. N. ; Quistberg, D. A. ; Riederer, A. ; Vavilala, M. S. ; Zunt, J. R. ; Anderson, H. R. ; Pourmalek, F. ; Gotay, C. C. ; Burnett, R. ; Shin, H. H. ; Weichenthal, S. ; Cohen, A. ; Knudsen, A. ; Aasvang, G. ; Kinge, J. M. ; Skirbekk, V. ; Vollset, S. ; Abbafati, C. ; Abbasoglu Ozgoren, A. ; Çavlin, A. ; Kucuk Bicer, B. ; Abd-Allah, F. ; Abera, S. F. ; Melaku, Y. A. ; Aboyans, V. ; Abraham, B. ; Puthenpurakal Abraham, J. ; Abraham, J. Puthenpurakal ; Thorne-Lyman, A. L. ; Ding, E. L. ; Fahimi, S. ; Khatibzadeh, S. ; Wagner, G. R. ; Bukhman, G. ; Campos-Nonato, I. R. ; Feigl, A. B. ; Salomon, J. A. ; Benzian, H. ; Abubakar, I. ; Abu-Rmeileh, N. M.E. ; Aburto, T. C. ; Avila, M. A. ; Barquera, S. ; Barrientos-Gutierrez, T. ; Campuzano, J. C. ; Cantoral, A. J. ; Contreras, A. G. ; Cuevas-Nasu, L. ; De, V. ; García-Guerra, F. A. ; Gomez Dantes, H. ; Gonzalez de Cosio, T. ; González-Castell, D. ; Heredia-Pi, I. B. ; Hernandez, L. ; Jauregui, A. ; Medina, C. ; Mejia-Rodriguez, F. ; Montañez Hernandez, J. C. ; Pedraza, L. S. ; Pedroza, A. ; Quezada, A. D. ; Salvo, D. ; Sanchez, L. M. ; Sánchez-Pimienta, T. G. ; Servan-Mori, E. E. ; Shamah Levy, T. ; Téllez Rojo, M. M. ; Villalpando, S. ; Adelekan, A. ; Adofo, K. ; Adou, A. K. ; Adsuar, J. C. ; Fra Paleo, U. ; Afshin, A. ; Micha, R. ; Mozaffarian, D. ; Shahraz, S. ; Shangguan, S. ; Singh, G. M. ; Agardh, E. E. ; Al Khabouri, M. J. ; Al Lami, F. H. ; Alam, S. ; Naheed, A. ; Alasfoor, D. ; Albittar, M. I. ; Alegretti, M. A. ; Cavalleri, F. ; Aleman, A. V. ; Colistro, V. ; Alemu, Z. A. ; Alhabib, S. ; Chen, Z. ; Gething, P. ; Ali, R. ; Bennett, D. A. ; Briggs, A. D.M. ; Rahimi, K. ; Scarborough, P. ; Simard, E. P. ; Ali, M. K. ; Argeseanu Cunningham, S. ; Liu, Y. ; Narayan, K. M.V. ; Omer, S. B. ; Alla, F. ; Guillemin, F. ; Allebeck, P. ; Roy, N. ; Kivipelto, M. ; Weiderpass, E. ; Fereshtehnejad, S. ; Havmoeller, R. ; Sindi, S. ; Allen, P. J. ; Alsharif, U. ; Endres, M. ; Nolte, S. ; Papachristou, C. ; Alvarez, E. ; Alvis-Guzman, N. ; Paternina Caicedo, A. J. ; Amankwaa, A. A. ; Amare, A. T. ; Hoek, H. W. ; Gansevoort, R. T. ; Yenesew, M. ; Ameh, E. A. ; Ameli, O. ; Amini, H. ; Tanner, M. ; Ammar, W. ; Harb, H. L. ; Antonio, C. A.T. ; Faraon, E. A. ; Panelo, C. A. ; Anwari, P. ; Arnlöv, J. ; Larsson, A. ; Arsic Arsenijevic, V. S. ; Artaman, A. ; Asghar, R. J. ; Assadi, R. ; Atkins, L. S. ; Awuah, B. ; Laryea, D. O. ; Badawi, A. ; Bahit, M. C. ; Bakfalouni, T. ; Balakrishnan, K. ; Balalla, S. ; Feigin, V. L. ; Te Ao, B. J. ; Balu, R. ; Dandona, R. ; Goenka, S. ; Kumar, G. ; Murthy, K. S. ; Reddy, K. ; Banerjee, A. ; Barker-Collo, S. L. ; del Pozo-Cruz, B. ; Barregard, L. ; Barrero, L. H. ; Basto-Abreu, A. C. ; Batis Ruvalcaba, C. ; de Castro, E. F. ; Lopez, N. ; Texcalac, J. L. ; Basu, A. ; Gaffikin, L. ; Basu, S. ; Basulaiman, M. O. ; Memish, Z. A. ; Beardsley, J. ; Bedi, N. ; Bekele, T. ; Bell, M. L. ; Huang, J. J. ; Benjet, C. ; Borges, G. ; Gutiérrez, R. A. ; Orozco, R. ; Trasande, L. ; Hagan, H. ; Bernabé, E. ; Wolfe, C. D.A. ; Beyene, T. 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@article{c3aa9318b1184ed3a1e83bdf5cc33660,
title = "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",
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 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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K.} and J. Chang and Scott, {J. G.} and Hoy, {D. G.} and Knibbs, {L. D.} and Charlson, {F. J.} and Erskine, {H. E.} and Ferrari, {A. J.} and Gouda, {H. N.} and Veerman, {L. J.} and Whiteford, {H. A.} and W. Chen and X. Zou and H. Chen and London, {S. J.} and Y. Jiang and K. Takahashi and O. Chimed-Ochir and R. Chowdhury and J. Powles and Christophi, {C. A.} and T. Chuang and Chugh, {S. S.} and M. Cirillo and Cla{\ss}en, {T. K.D.} and A. Kraemer and M. Tobollik and M. Colomar and C. Cooper and Cooper, {L. T.} and J. Coresh and K. Matsushita and Tran, {B. X.} and Courville, {K. J.} and Criqui, {M. H.} and Stein, {M. B.} and J. Damsere-Derry and H. Danawi and Refaat, {A. H.} and Dargan, {P. I.} and A. Davis and Fay, {D. F.J.} and Schmidt, {J. C.} and Davitoiu, {D. V.} and A. Dayama and D. DeLeo and {de Lima}, G. and Machado, {V. M.P.} and Nogueira, {J. R.} and Teixeira, {C. M.} and Dellavalle, {R. P.} and K. Deribe and W. Mekonnen and {Des Jarlais}, {D. C.} and M. Dessalegn and deVeber, {G. A.} and Lindsay, {M. P.} and H. Hu and Devries, {K. M.} and M. McKee and N. Pearce and H. St{\"o}ckl and T. Tillmann and Watts, {C. H.} and Dharmaratne, {S. D.} and K. Dokova and Dorsey, {E. R.} and Driscoll, {T. R.} and Marks, {G. B.} and J. Leigh and L. Duan and Y. Li and S. Liu and J. Ma and L. Wang and P. Ye and M. Zhou and X. Liang and Durrani, {A. M.} and Elshrek, {Y. M.} and Ermakov, {S. P.} and S. Soshnikov and B. Eshrati and F. Farzadfar and A. Esteghamati and N. Hafezi-Nejad and S. Sheikhbahaei and Sepanlou, {S. G.} and P. Heydarpour and M. Sahraian and V. Rahimi-Movaghar and Ferri, {C. P.} and N. Foigt and Franklin, {R. C.} and A. Gamkrelidze and I. Khonelidze and L. Sturua and Gankp{\'e}, {F. G.} and E. Gasana and N. Sabin and Geleijnse, {J. M.} and Gessner, {B. D.} and Gillum, {R. F.} and Ginawi, {I. A.M.} and M. Giroud and G. Giussani and K. Goginashvili and P. Gona and A. Goto and Guerrant, {R. L.} and Terkawi, {A. S.} and Gugnani, {H. 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J.C.} and Schwebel, {D. C.} and Singh, {J. A.} and B. Serdar and G. Shaddick and Y. Shinohara and K. Shishani and I. Shiue and Sigfusdottir, {I. D.} and A. Singh and K. S{\o}reide and Sreeramareddy, {C. T.} and Stapelberg, {N. J.C.} and V. Stathopoulou and N. Steckling and K. Stroumpoulis and S. Swaminathan and M. Swaroop and Y. Yano and Sykes, {B. L.} and Tabb, {K. M.} and Talongwa, {R. T.} and D. Tanne and M. Tavakkoli and Thackway, {S. V.} and Thurston, {G. D.} and F. Topouzis and Towbin, {J. A.} and H. Toyoshima and J. Traebert and U. Trujillo and {Tsala Dimbuene}, Z. and E. Tuzcu and Uchendu, {U. S.} and Ukwaja, {K. N.} and {Van Dingenen}, R. and {van Gool}, {C. H.} and {van Os}, J. and Vasankari, {T. J.} and Vasconcelos, {A. N.} and Violante, {F. S.} and {Victorovich Vlassov}, V. and Waller, {S. G.} and Wallin, {M. T.} and W. Wang and K. Wessells and Wilkinson, {J. D.} and Williams, {H. C.} and Woldeyohannes, {S. M.} and Wong, {J. Q.} and Woolf, {A. D.} and G. Xu and Yan, {L. L.} and G. Yang and P. Yip and N. Yonemoto and Younis, {M. Z.} and Z. Younoussi and C. Yu and Zaki, {M. E.} and Y. Zhao and S. Zhu",
year = "2015",
month = "12",
day = "5",
doi = "10.1016/S0140-6736(15)00128-2",
language = "English",
volume = "386",
pages = "2287--2323",
journal = "The Lancet",
issn = "0140-6736",
publisher = "Elsevier Ltd",
number = "10010",

}

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Martin, RV, Marzan, MB, Mashal, MT, Mason-Jones, AJ, Mazorodze, TT, McKay, AC, Mehndiratta, M, Meltzer, M, Mendoza, W, Apolinary Mhimbira, F, Miller, TR, Mills, EJ, Mishra, S, Mohamed Ibrahim, N, Mohammad, KA, Mola, GL, Monasta, L, Montico, M, Ronfani, L, Moore, AR, Morawska, L, Norman, RE, Mori, R, Tsilimbaris, M, Moschandreas, J, Moturi, WN, Werdecker, A, Mueller, UO, Westerman, R, Mukaigawara, M, Nahas, Z, Naidoo, KS, Naldi, L, Nand, D, Nangia, V, Neal, B, Nejjari, C, Neupane, SP, Newton, CR, Ngalesoni, FN, Ngirabega, JD, Nolla, JM, Vollset, SE, Norheim, OF, Norrving, B, Nyakarahuka, L, Oh, I, Ohkubo, T, Olusanya, BO, Opio, JN, Pagcatipunan, RS, Pandian, JD, Park, E, Seedat, S, Pavlin, BI, Pejin Stokic, L, Pereira, DM, Perez-Padilla, R, Perez-Ruiz, F, Perico, N, Remuzzi, G, Trillini, M, Perry, SAL, Pervaiz, A, Pesudovs, K, Peterson, CB, Petzold, M, Plass, D, Poenaru, D, Pond, CD, Pope, C, Popova, S, Rehm, J, Prasad, NM, Qato, DM, Rafay, A, Rana, SM, Ur Rahman, S, Raju, M, Rakovac, 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Yonemoto, N, Younis, MZ, Younoussi, Z, Yu, C, Zaki, ME, Zhao, Y & Zhu, S 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, vol. 386, no. 10010, pp. 2287-2323. https://doi.org/10.1016/S0140-6736(15)00128-2

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, M. H.; Alexander, L.; Bachman, V. F.; Biryukov, S.; Brauer, M.; Casey, D.; Coates, M. M.; Delwiche, K.; Estep, K.; Frostad, J. J.; Astha, K. C.; Kyu, H. H.; Moradi-Lakeh, M.; Ng, M.; Slepak, E.; Thomas, B. A.; Wagner, J.; Achoki, T.; Atkinson, C.; Barber, R. M.; Cooperrider, K.; Dandona, L.; Dicker, D.; Flaxman, A. D.; Fleming, T. D.; Foreman, K. J.; Gakidou, E.; Hay, S. I.; Heuton, K. R.; Iannarone, M. L.; Ku, T.; Larson, H. J.; Lim, S. S.; Lopez, A. D.; Lozano, R.; MacIntyre, M. F.; Margono, C.; McLain, A.; Mokdad, A. H.; Mullany, E. C.; Murray, C. J.L.; Naghavi, M.; Nguyen, G.; Pain, A. W.; Richardson, L.; Robinson, M.; Sandar, L.; Stephens, N.; Temesgen, A. M.; Thomson, B.; Vos, T.; Wan, X.; Wang, H.; Wurtz, B.; Ebel, B. E.; Ellenbogen, R. G.; Wright, J. L.; Alfonso-Cristancho, R.; Anderson, B. O.; Jensen, P. N.; Quistberg, D. A.; Riederer, A.; Vavilala, M. S.; Zunt, J. R.; Anderson, H. R.; Pourmalek, F.; Gotay, C. C.; Burnett, R.; Shin, H. H.; Weichenthal, S.; Cohen, A.; Knudsen, A.; Aasvang, G.; Kinge, J. M.; Skirbekk, V.; Vollset, S.; Abbafati, C.; Abbasoglu Ozgoren, A.; Çavlin, A.; Kucuk Bicer, B.; Abd-Allah, F.; Abera, S. F.; Melaku, Y. A.; Aboyans, V.; Abraham, B.; Puthenpurakal Abraham, J.; Abraham, J. Puthenpurakal; Thorne-Lyman, A. L.; Ding, E. L.; Fahimi, S.; Khatibzadeh, S.; Wagner, G. R.; Bukhman, G.; Campos-Nonato, I. R.; Feigl, A. B.; Salomon, J. A.; Benzian, H.; Abubakar, I.; Abu-Rmeileh, N. M.E.; Aburto, T. C.; Avila, M. A.; Barquera, S.; Barrientos-Gutierrez, T.; Campuzano, J. C.; Cantoral, A. J.; Contreras, A. G.; Cuevas-Nasu, L.; De, V.; García-Guerra, F. A.; Gomez Dantes, H.; Gonzalez de Cosio, T.; González-Castell, D.; Heredia-Pi, I. B.; Hernandez, L.; Jauregui, A.; Medina, C.; Mejia-Rodriguez, F.; Montañez Hernandez, J. C.; Pedraza, L. S.; Pedroza, A.; Quezada, A. D.; Salvo, D.; Sanchez, L. M.; Sánchez-Pimienta, T. G.; Servan-Mori, E. E.; Shamah Levy, T.; Téllez Rojo, M. M.; Villalpando, S.; Adelekan, A.; Adofo, K.; Adou, A. K.; Adsuar, J. C.; Fra Paleo, U.; Afshin, A.; Micha, R.; Mozaffarian, D.; Shahraz, S.; Shangguan, S.; Singh, G. M.; Agardh, E. E.; Al Khabouri, M. J.; Al Lami, F. H.; Alam, S.; Naheed, A.; Alasfoor, D.; Albittar, M. I.; Alegretti, M. A.; Cavalleri, F.; Aleman, A. V.; Colistro, V.; Alemu, Z. A.; Alhabib, S.; Chen, Z.; Gething, P.; Ali, R.; Bennett, D. A.; Briggs, A. D.M.; Rahimi, K.; Scarborough, P.; Simard, E. P.; Ali, M. K.; Argeseanu Cunningham, S.; Liu, Y.; Narayan, K. M.V.; Omer, S. B.; Alla, F.; Guillemin, F.; Allebeck, P.; Roy, N.; Kivipelto, M.; Weiderpass, E.; Fereshtehnejad, S.; Havmoeller, R.; Sindi, S.; Allen, P. J.; Alsharif, U.; Endres, M.; Nolte, S.; Papachristou, C.; Alvarez, E.; Alvis-Guzman, N.; Paternina Caicedo, A. J.; Amankwaa, A. A.; Amare, A. T.; Hoek, H. W.; Gansevoort, R. T.; Yenesew, M.; Ameh, E. A.; Ameli, O.; Amini, H.; Tanner, M.; Ammar, W.; Harb, H. L.; Antonio, C. A.T.; Faraon, E. A.; Panelo, C. A.; Anwari, P.; Arnlöv, J.; Larsson, A.; Arsic Arsenijevic, V. S.; Artaman, A.; Asghar, R. J.; Assadi, R.; Atkins, L. S.; Awuah, B.; Laryea, D. O.; Badawi, A.; Bahit, M. C.; Bakfalouni, T.; Balakrishnan, K.; Balalla, S.; Feigin, V. L.; Te Ao, B. J.; Balu, R.; Dandona, R.; Goenka, S.; Kumar, G.; Murthy, K. S.; Reddy, K.; Banerjee, A.; Barker-Collo, S. L.; del Pozo-Cruz, B.; Barregard, L.; Barrero, L. H.; Basto-Abreu, A. C.; Batis Ruvalcaba, C.; de Castro, E. F.; Lopez, N.; Texcalac, J. L.; Basu, A.; Gaffikin, L.; Basu, S.; Basulaiman, M. O.; Memish, Z. A.; Beardsley, J.; Bedi, N.; Bekele, T.; Bell, M. L.; Huang, J. J.; Benjet, C.; Borges, G.; Gutiérrez, R. A.; Orozco, R.; Trasande, L.; Hagan, H.; Bernabé, E.; Wolfe, C. D.A.; Beyene, T. J.; Bhala, N.; Derrett, S.; Bhalla, A.; Jha, V.; Bhutta, Z. A.; Nisar, M. I.; Bikbov, B.; Bin Abdulhak, A. A.; Vijayakumar, L.; Chiang, P. P.; Blore, J. D.; Brooks, P. M.; Lakshmana Balaji, A.; Colquhoun, S. M.; Weintraub, R. G.; Blyth, F. M.; Meretoja, A.; Bohensky, M. A.; Bora Basara, B.; Yentür, G. K.; Kose, M. R.; Pekericli, A.; Uzun, S. B.; Bornstein, N. M.; Bose, D.; Boufous, S.; Degenhardt, L.; Bourne, R. R.; Brainin, M.; Brazinova, A.; Majdan, M.; Breitborde, N. J.; Schöttker, B.; Brenner, H.; Broday, D. M.; Lunevicius, R.; Bruce, N. G.; Dherani, M. K.; Pope, D.; Brugha, T. S.; Brunekreef, B.; Kromhout, H.; Buchbinder, R.; Gabbe, B.; Gibney, K. B.; Thrift, A. G.; Bui, L. N.; Nguyen, N. T.; Bulloch, A. G.; Patten, S. B.; Tonelli, M.; Wang, J.; Burch, M.; Burney, P. G.J.; Jarvis, D. L.; Rodriguez, A.; Rushton, L.; Soljak, M.; Williams, T. N.; Caravanos, J.; Nash, D.; Cárdenas, R.; Cardis, E.; Nieuwenhuijsen, M. J.; Rojas-Rueda, D.; Carpenter, D. O.; Leung, R.; Caso, V.; Castañeda-Orjuela, C. A.; Castro, R. E.; Catalá-López, F.; Chadha, V. K.; Chang, J.; Scott, J. G.; Hoy, D. G.; Knibbs, L. D.; Charlson, F. J.; Erskine, H. E.; Ferrari, A. J.; Gouda, H. N.; Veerman, L. J.; Whiteford, H. A.; Chen, W.; Zou, X.; Chen, H.; London, S. J.; Jiang, Y.; Takahashi, K.; Chimed-Ochir, O.; Chowdhury, R.; Powles, J.; Christophi, C. A.; Chuang, T.; Chugh, S. S.; Cirillo, M.; Claßen, T. K.D.; Kraemer, A.; Tobollik, M.; Colomar, M.; Cooper, C.; Cooper, L. T.; Coresh, J.; Matsushita, K.; Tran, B. X.; Courville, K. J.; Criqui, M. H.; Stein, M. B.; Damsere-Derry, J.; Danawi, H.; Refaat, A. H.; Dargan, P. I.; Davis, A.; Fay, D. F.J.; Schmidt, J. C.; Davitoiu, D. V.; Dayama, A.; DeLeo, D.; de Lima, G.; Machado, V. M.P.; Nogueira, J. R.; Teixeira, C. M.; Dellavalle, R. P.; Deribe, K.; Mekonnen, W.; Des Jarlais, D. C.; Dessalegn, M.; deVeber, G. A.; Lindsay, M. P.; Hu, H.; Devries, K. M.; McKee, M.; Pearce, N.; Stöckl, H.; Tillmann, T.; Watts, C. H.; Dharmaratne, S. D.; Dokova, K.; Dorsey, E. R.; Driscoll, T. R.; Marks, G. B.; Leigh, J.; Duan, L.; Li, Y.; Liu, S.; Ma, J.; Wang, L.; Ye, P.; Zhou, M.; Liang, X.; Durrani, A. M.; Elshrek, Y. M.; Ermakov, S. P.; Soshnikov, S.; Eshrati, B.; Farzadfar, F.; Esteghamati, A.; Hafezi-Nejad, N.; Sheikhbahaei, S.; Sepanlou, S. G.; Heydarpour, P.; Sahraian, M.; Rahimi-Movaghar, V.; Ferri, C. P.; Foigt, N.; Franklin, R. C.; Gamkrelidze, A.; Khonelidze, I.; Sturua, L.; Gankpé, F. G.; Gasana, E.; Sabin, N.; Geleijnse, J. M.; Gessner, B. D.; Gillum, R. F.; Ginawi, I. A.M.; Giroud, M.; Giussani, G.; Goginashvili, K.; Gona, P.; Goto, A.; Guerrant, R. L.; Terkawi, A. S.; Gugnani, H. C.; Gunnell, D.; Gupta, R.; Hagstromer, M.; Halasa, Y. A.; Idrisov, B. T.; Hamadeh, R. R.; Hammami, M.; Hankey, G. J.; Hao, Y.; Zheng, Y.; Haregu, T.; van de Vijver, S.; Haro, J.; Hedayati, M. T.; Hijar, M.; Hoffman, H. J.; Mensah, G. A.; Sampson, U. K.; Hornberger, J. C.; Hosgood, H.; Hsairi, M.; Hu, G.; Huang, C.; Hubbell, B. J.; Huiart, L.; Racapé, L.; Husseini, A.; Iburg, K. M.; Ikeda, N.; Innos, K.; Inoue, M.; Kawakami, N.; Shibuya, K.; Islami, F.; Ismayilova, S.; Jacobsen, K. H.; Jansen, H. A.; Jassal, S. K.; Jayaraman, Sudha; Jeemon, P.; Prabhakaran, D.; Jiang, F.; Jiang, G.; Phillips, M. R.; Jonas, J. B.; Juel, K.; She, J.; Kan, H.; Kany Roseline, S. S.; Karam, N. E.; Karch, A.; Karema, C. K.; Karthikeyan, G.; Paul, V. K.; Satpathy, M.; Tandon, N.; Kaul, A.; Kazi, D. S.; Kemp, A. H.; Lotufo, P. A.; Polanczyk, G. V.; Santos, I. S.; Kengne, A. P.; Matzopoulos, R.; Parry, C. D.; Sliwa, K.; Mayosi, B. M.; Stein, D. J.; Keren, A.; Khader, Y. S.; Ali Hassan Khalifa, S. E.; Khan, E. A.; Khang, Y.; Kieling, C.; Kim, D.; Kim, S.; Kim, Y.; Kimokoti, R. W.; Kinfu, Y.; Kissela, B. M.; Kokubo, Y.; Kosen, S.; Warouw, T. S.; Kravchenko, M.; Varakin, Y. Y.; Krishnaswami, S.; Kuate Defo, B.; Kuipers, E. J.; Polinder, S.; Kulkarni, C.; Kulkarni, V. S.; Kwan, G. F.; Lai, T.; Lalloo, R.; Lallukka, T.; Shiri, R.; Lam, H.; Lan, Q.; Lansingh, V. C.; Lavados, P. M.; Lawrynowicz, A. E.; Leasher, J. L.; Lee, J.; Yoon, S.; Levi, M.; Liang, J.; Wang, Y.; Zhu, J.; Lipshultz, S. E.; Lloyd, B. K.; Room, R.; Logroscino, G.; Lortet-Tieulent, J.; Ma, S.; Phua, H. P.; Magis-Rodriguez, C.; Mahdi, A. A.; Malekzadeh, R.; Mangalam, S.; Mapoma, C. C.; Masiye, F.; Marape, M.; Marcenes, W.; Meaney, P. A.; Margolis, D. J.; Silberberg, D. H.; Martin, R. V.; Marzan, M. B.; Mashal, M. T.; Mason-Jones, A. J.; Mazorodze, T. T.; McKay, A. C.; Mehndiratta, M.; Meltzer, M.; Mendoza, W.; Apolinary Mhimbira, F.; Miller, T. R.; Mills, E. J.; Mishra, S.; Mohamed Ibrahim, N.; Mohammad, K. A.; Mola, G. L.; Monasta, L.; Montico, M.; Ronfani, L.; Moore, A. R.; Morawska, L.; Norman, R. E.; Mori, R.; Tsilimbaris, M.; Moschandreas, J.; Moturi, W. N.; Werdecker, A.; Mueller, U. O.; Westerman, R.; Mukaigawara, M.; Nahas, Z.; Naidoo, K. S.; Naldi, L.; Nand, D.; Nangia, V.; Neal, B.; Nejjari, C.; Neupane, S. P.; Newton, C. R.; Ngalesoni, F. N.; Ngirabega, J. D.; Nolla, J. M.; Vollset, S. E.; Norheim, O. F.; Norrving, B.; Nyakarahuka, L.; Oh, I.; Ohkubo, T.; Olusanya, B. O.; Opio, J. N.; Pagcatipunan, R. S.; Pandian, J. D.; Park, E.; Seedat, S.; Pavlin, B. I.; Pejin Stokic, L.; Pereira, D. M.; Perez-Padilla, R.; Perez-Ruiz, F.; Perico, N.; Remuzzi, G.; Trillini, M.; Perry, S. A.L.; Pervaiz, A.; Pesudovs, K.; Peterson, C. B.; Petzold, M.; Plass, D.; Poenaru, D.; Pond, C. D.; Pope, C.; Popova, S.; Rehm, J.; Prasad, N. M.; Qato, D. M.; Rafay, A.; Rana, S. M.; Ur Rahman, S.; Raju, M.; Rakovac, I.; Rao, M.; Razavi, H.; Ribeiro, A. L.; Velasquez-Melendez, G.; Riccio, P. M.; Sposato, L. A.; Roca, A.; Romieu, I.; Straif, K.; Ruhago, G. M.; Sunguya, B. F.; Sacco, R. L.; Saha, S.; Sahathevan, R.; Sanabria, J. R.; Sanchez-Riera, L.; Sapkota, A.; Saunders, J. E.; Soneji, S.; Sawhney, M.; Saylan, M. I.; Schneider, I. J.C.; Schwebel, D. C.; Singh, J. A.; Serdar, B.; Shaddick, G.; Shinohara, Y.; Shishani, K.; Shiue, I.; Sigfusdottir, I. D.; Singh, A.; Søreide, K.; Sreeramareddy, C. T.; Stapelberg, N. J.C.; Stathopoulou, V.; Steckling, N.; Stroumpoulis, K.; Swaminathan, S.; Swaroop, M.; Yano, Y.; Sykes, B. L.; Tabb, K. M.; Talongwa, R. T.; Tanne, D.; Tavakkoli, M.; Thackway, S. V.; Thurston, G. D.; Topouzis, F.; Towbin, J. A.; Toyoshima, H.; Traebert, J.; Trujillo, U.; Tsala Dimbuene, Z.; Tuzcu, E.; Uchendu, U. S.; Ukwaja, K. N.; Van Dingenen, R.; van Gool, C. H.; van Os, J.; Vasankari, T. J.; Vasconcelos, A. N.; Violante, F. S.; Victorovich Vlassov, V.; Waller, S. G.; Wallin, M. T.; Wang, W.; Wessells, K.; Wilkinson, J. D.; Williams, H. C.; Woldeyohannes, S. M.; Wong, J. Q.; Woolf, A. D.; Xu, G.; Yan, L. L.; Yang, G.; Yip, P.; Yonemoto, N.; Younis, M. Z.; Younoussi, Z.; Yu, C.; Zaki, M. E.; Zhao, Y.; Zhu, S.

In: The Lancet, Vol. 386, No. 10010, 05.12.2015, p. 2287-2323.

Research output: Contribution to journalArticle

TY - JOUR

T1 - 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

T2 - A systematic analysis for the Global Burden of Disease Study 2013

AU - Forouzanfar, M. H.

AU - Alexander, L.

AU - Bachman, V. F.

AU - Biryukov, S.

AU - Brauer, M.

AU - Casey, D.

AU - Coates, M. M.

AU - Delwiche, K.

AU - Estep, K.

AU - Frostad, J. J.

AU - Astha, K. C.

AU - Kyu, H. H.

AU - Moradi-Lakeh, M.

AU - Ng, M.

AU - Slepak, E.

AU - Thomas, B. A.

AU - Wagner, J.

AU - Achoki, T.

AU - Atkinson, C.

AU - Barber, R. M.

AU - Cooperrider, K.

AU - Dandona, L.

AU - Dicker, D.

AU - Flaxman, A. D.

AU - Fleming, T. D.

AU - Foreman, K. J.

AU - Gakidou, E.

AU - Hay, S. I.

AU - Heuton, K. R.

AU - Iannarone, M. L.

AU - Ku, T.

AU - Larson, H. J.

AU - Lim, S. S.

AU - Lopez, A. D.

AU - Lozano, R.

AU - MacIntyre, M. F.

AU - Margono, C.

AU - McLain, A.

AU - Mokdad, A. H.

AU - Mullany, E. C.

AU - Murray, C. J.L.

AU - Naghavi, M.

AU - Nguyen, G.

AU - Pain, A. W.

AU - Richardson, L.

AU - Robinson, M.

AU - Sandar, L.

AU - Stephens, N.

AU - Temesgen, A. M.

AU - Thomson, B.

AU - Vos, T.

AU - Wan, X.

AU - Wang, H.

AU - Wurtz, B.

AU - Ebel, B. E.

AU - Ellenbogen, R. G.

AU - Wright, J. L.

AU - Alfonso-Cristancho, R.

AU - Anderson, B. O.

AU - Jensen, P. N.

AU - Quistberg, D. A.

AU - Riederer, A.

AU - Vavilala, M. S.

AU - Zunt, J. R.

AU - Anderson, H. R.

AU - Pourmalek, F.

AU - Gotay, C. C.

AU - Burnett, R.

AU - Shin, H. H.

AU - Weichenthal, S.

AU - Cohen, A.

AU - Knudsen, A.

AU - Aasvang, G.

AU - Kinge, J. M.

AU - Skirbekk, V.

AU - Vollset, S.

AU - Abbafati, C.

AU - Abbasoglu Ozgoren, A.

AU - Çavlin, A.

AU - Kucuk Bicer, B.

AU - Abd-Allah, F.

AU - Abera, S. F.

AU - Melaku, Y. A.

AU - Aboyans, V.

AU - Abraham, B.

AU - Puthenpurakal Abraham, J.

AU - Abraham, J. Puthenpurakal

AU - Thorne-Lyman, A. L.

AU - Ding, E. L.

AU - Fahimi, S.

AU - Khatibzadeh, S.

AU - Wagner, G. R.

AU - Bukhman, G.

AU - Campos-Nonato, I. R.

AU - Feigl, A. B.

AU - Salomon, J. A.

AU - Benzian, H.

AU - Abubakar, I.

AU - Abu-Rmeileh, N. M.E.

AU - Aburto, T. C.

AU - Avila, M. A.

AU - Barquera, S.

AU - Barrientos-Gutierrez, T.

AU - Campuzano, J. C.

AU - Cantoral, A. J.

AU - Contreras, A. G.

AU - Cuevas-Nasu, L.

AU - De, V.

AU - García-Guerra, F. A.

AU - Gomez Dantes, H.

AU - Gonzalez de Cosio, T.

AU - González-Castell, D.

AU - Heredia-Pi, I. B.

AU - Hernandez, L.

AU - Jauregui, A.

AU - Medina, C.

AU - Mejia-Rodriguez, F.

AU - Montañez Hernandez, J. C.

AU - Pedraza, L. S.

AU - Pedroza, A.

AU - Quezada, A. D.

AU - Salvo, D.

AU - Sanchez, L. M.

AU - Sánchez-Pimienta, T. G.

AU - Servan-Mori, E. E.

AU - Shamah Levy, T.

AU - Téllez Rojo, M. M.

AU - Villalpando, S.

AU - Adelekan, A.

AU - Adofo, K.

AU - Adou, A. K.

AU - Adsuar, J. C.

AU - Fra Paleo, U.

AU - Afshin, A.

AU - Micha, R.

AU - Mozaffarian, D.

AU - Shahraz, S.

AU - Shangguan, S.

AU - Singh, G. M.

AU - Agardh, E. E.

AU - Al Khabouri, M. J.

AU - Al Lami, F. H.

AU - Alam, S.

AU - Naheed, A.

AU - Alasfoor, D.

AU - Albittar, M. I.

AU - Alegretti, M. A.

AU - Cavalleri, F.

AU - Aleman, A. V.

AU - Colistro, V.

AU - Alemu, Z. A.

AU - Alhabib, S.

AU - Chen, Z.

AU - Gething, P.

AU - Ali, R.

AU - Bennett, D. A.

AU - Briggs, A. D.M.

AU - Rahimi, K.

AU - Scarborough, P.

AU - Simard, E. P.

AU - Ali, M. K.

AU - Argeseanu Cunningham, S.

AU - Liu, Y.

AU - Narayan, K. M.V.

AU - Omer, S. B.

AU - Alla, F.

AU - Guillemin, F.

AU - Allebeck, P.

AU - Roy, N.

AU - Kivipelto, M.

AU - Weiderpass, E.

AU - Fereshtehnejad, S.

AU - Havmoeller, R.

AU - Sindi, S.

AU - Allen, P. J.

AU - Alsharif, U.

AU - Endres, M.

AU - Nolte, S.

AU - Papachristou, C.

AU - Alvarez, E.

AU - Alvis-Guzman, N.

AU - Paternina Caicedo, A. J.

AU - Amankwaa, A. A.

AU - Amare, A. T.

AU - Hoek, H. W.

AU - Gansevoort, R. T.

AU - Yenesew, M.

AU - Ameh, E. A.

AU - Ameli, O.

AU - Amini, H.

AU - Tanner, M.

AU - Ammar, W.

AU - Harb, H. L.

AU - Antonio, C. A.T.

AU - Faraon, E. A.

AU - Panelo, C. A.

AU - Anwari, P.

AU - Arnlöv, J.

AU - Larsson, A.

AU - Arsic Arsenijevic, V. S.

AU - Artaman, A.

AU - Asghar, R. J.

AU - Assadi, R.

AU - Atkins, L. S.

AU - Awuah, B.

AU - Laryea, D. O.

AU - Badawi, A.

AU - Bahit, M. C.

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PY - 2015/12/5

Y1 - 2015/12/5

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=85049491557&partnerID=8YFLogxK

U2 - 10.1016/S0140-6736(15)00128-2

DO - 10.1016/S0140-6736(15)00128-2

M3 - Article

C2 - 26364544

AN - SCOPUS:85049491557

VL - 386

SP - 2287

EP - 2323

JO - The Lancet

JF - The Lancet

SN - 0140-6736

IS - 10010

ER -