Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
Authors: Mohammad H Forouzanfar, Lily Alexander, H Ross Anderson, Victoria F Bachman, Stan Biryukov, Michael Brauer, Richard Burnett, Daniel Casey, Matthew M Coates, Aaron Cohen, Kristen Delwiche, Kara Estep, Joseph J Frostad, K C Astha, Hmwe H Kyu, Maziar Moradi-Lakeh, Marie Ng, Erica Leigh Slepak, Bernadette A Thomas, Joseph Wagner, Gunn Marit Aasvang, Cristiana Abbafati, Ayse Abbasoglu Ozgoren, Foad Abd-Allah, Semaw F Abera, Victor Aboyans, Biju Abraham, Jerry Puthenpurakal Abraham, Ibrahim Abubakar, Niveen M E Abu-Rmeileh, Tania C Aburto, Tom Achoki, Ademola Adelekan, Koranteng Adofo, Arsène K Adou, José C Adsuar, Ashkan Afshin, Emilie E Agardh, Mazin J Al Khabouri, Faris H Al Lami, Sayed Saidul Alam, Deena Alasfoor, Mohammed I Albittar, Miguel A Alegretti, Alicia V Aleman, Zewdie A Alemu, Rafael Alfonso-Cristancho, Samia Alhabib, Raghib Ali, Mohammed K Ali, François Alla, Peter Allebeck, Peter J Allen, Ubai Alsharif, Elena Alvarez, Nelson Alvis-Guzman, Adansi A Amankwaa, Azmeraw T Amare, Emmanuel A Ameh, Omid Ameli, Heresh Amini, Walid Ammar, Benjamin O Anderson, Carl Abelardo T Antonio, Palwasha Anwari, Solveig Argeseanu Cunningham, Johan Arnlöv, Valentina S Arsic Arsenijevic, Al Artaman, Rana J Asghar, Reza Assadi, Lydia S Atkins, Charles Atkinson, Marco A Avila, Baffour Awuah, Alaa Badawi, Maria C Bahit, Talal Bakfalouni, Kalpana Balakrishnan, Shivanthi Balalla, Ravi Kumar Balu, Amitava Banerjee, Ryan M Barber, Suzanne L Barker-Collo, Simon Barquera, Lars Barregard, Lope H Barrero, Tonatiuh Barrientos-Gutierrez, Ana C Basto-Abreu, Arindam Basu, Sanjay Basu, Mohammed O Basulaiman, Carolina Batis Ruvalcaba, Justin Beardsley, Neeraj Bedi, Tolesa Bekele, Michelle L Bell, Corina Benjet, Derrick A Bennett, Habib Benzian, Eduardo Bernabé, Tariku J Beyene, Neeraj Bhala, Ashish Bhalla, Zulfiqar A Bhutta, Boris Bikbov, Aref A Bin Abdulhak, Jed D Blore, Fiona M Blyth, Megan A Bohensky, Berrak Bora Başara, Guilherme Borges, Natan M Bornstein, Dipan Bose, Soufiane Boufous, Rupert R Bourne, Michael Brainin, Alexandra Brazinova, Nicholas J Breitborde, Hermann Brenner, Adam D M Briggs, David M Broday, Peter M Brooks, Nigel G Bruce, Traolach S Brugha, Bert Brunekreef, Rachelle Buchbinder, Linh N Bui, Gene Bukhman, Andrew G Bulloch, Michael Burch, Peter G J Burney, Ismael R Campos-Nonato, Julio C Campuzano, Alejandra J Cantoral, Jack Caravanos, Rosario Cárdenas, Elisabeth Cardis, David O Carpenter, Valeria Caso, Carlos A Castañeda-Orjuela, Ruben E Castro, Ferrán Catalá-López, Fiorella Cavalleri, Alanur Çavlin, Vineet K Chadha, Jung-Chen Chang, Fiona J Charlson, Honglei Chen, Wanqing Chen, Zhengming Chen, Peggy P Chiang, Odgerel Chimed-Ochir, Rajiv Chowdhury, Costas A Christophi, Ting-Wu Chuang, Sumeet S Chugh, Massimo Cirillo, Thomas K D Claßen, Valentina Colistro, Mercedes Colomar, Samantha M Colquhoun, Alejandra G Contreras, Cyrus Cooper, Kimberly Cooperrider, Leslie T Cooper, Josef Coresh, Karen J Courville, Michael H Criqui, Lucia Cuevas-Nasu, James Damsere-Derry, Hadi Danawi, Lalit Dandona, Rakhi Dandona, Paul I Dargan, Adrian Davis, Dragos V Davitoiu, Anand Dayama, E Filipa De Castro, Vanessa De La Cruz-Góngora, Diego De Leo, Graça De Lima, Louisa Degenhardt, Borja Del Pozo-Cruz, Robert P Dellavalle, Kebede Deribe, Sarah Derrett, Don C Des Jarlais, Muluken Dessalegn, Gabrielle A Deveber, Karen M Devries, Samath D Dharmaratne, Mukesh K Dherani, Daniel Dicker, Eric L Ding, Klara Dokova, E Ray Dorsey, Tim R Driscoll, Leilei Duan, Adnan M Durrani, Beth E Ebel, Richard G Ellenbogen, Yousef M Elshrek, Matthias Endres, Sergey P Ermakov, Holly E Erskine, Babak Eshrati, Alireza Esteghamati, Saman Fahimi, Emerito Jose A Faraon, Farshad Farzadfar, Derek F J Fay, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Alize J Ferrari, Cleusa P Ferri, Abraham D Flaxman, Thomas D Fleming, Nataliya Foigt, Kyle J Foreman, Urbano Fra Paleo, Richard C Franklin, Belinda Gabbe, Lynne Gaffikin, Emmanuela Gakidou, Amiran Gamkrelidze, Fortuné G Gankpé, Ron T Gansevoort, Francisco A García-Guerra, Evariste Gasana, Johanna M Geleijnse, Bradford D Gessner, Pete Gething, Katherine B Gibney, Richard F Gillum, Ibrahim a M Ginawi, Maurice Giroud, Giorgia Giussani, Shifalika Goenka, Ketevan Goginashvili, Hector Gomez Dantes, Philimon Gona, Teresita Gonzalez de Cosio, Dinorah González-Castell, Carolyn C Gotay, Atsushi Goto, Hebe N Gouda, Richard L Guerrant, Harish C Gugnani, Francis Guillemin, David Gunnell, Rahul Gupta, Rajeev Gupta, Reyna A Gutiérrez, Nima Hafezi-Nejad, Holly Hagan, Maria Hagstromer, Yara A Halasa, Randah R Hamadeh, Mouhanad Hammami, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Tilahun Nigatu Haregu, Josep Maria Haro, Rasmus Havmoeller, Simon I Hay, Mohammad T Hedayati, Ileana B Heredia-Pi, Lucia Hernandez, Kyle R Heuton, Pouria Heydarpour, Martha Hijar, Hans W Hoek, Howard J Hoffman, John C Hornberger, H Dean Hosgood, Damian G Hoy, Mohamed Hsairi, Guoqing Hu, Howard Hu, Cheng Huang, John J Huang, Bryan J Hubbell, Laetitia Huiart, Abdullatif Husseini, Marissa L Iannarone, Kim M Iburg, Bulat T Idrisov, Nayu Ikeda, Kaire Innos, Manami Inoue, Farhad Islami, Samaya Ismayilova, Kathryn H Jacobsen, Henrica A Jansen, Deborah L Jarvis, Simerjot K Jassal, Alejandra Jauregui, Sudha Jayaraman, Panniyammakal Jeemon, Paul N Jensen, Vivekanand Jha, Fan Jiang, Guohong Jiang, Ying Jiang, Jost B Jonas, Knud Juel, Haidong Kan, Sidibe S Kany Roseline, Nadim E Karam, André Karch, Corine K Karema, Ganesan Karthikeyan, Anil Kaul, Norito Kawakami, Dhruv S Kazi, Andrew H Kemp, Andre P Kengne, Andre Keren, Yousef S Khader, Shams Eldin Ali Hassan Khalifa, Ejaz A Khan, Young-Ho Khang, Shahab Khatibzadeh, Irma Khonelidze, Christian Kieling, Daniel Kim, Sungroul Kim, Yunjin Kim, Ruth W Kimokoti, Yohannes Kinfu, Jonas M Kinge, Brett M Kissela, Miia Kivipelto, Luke D Knibbs, Ann Kristin Knudsen, Yoshihiro Kokubo, M Rifat Kose, Soewarta Kosen, Alexander Kraemer, Michael Kravchenko, Sanjay Krishnaswami, Hans Kromhout, Tiffany Ku, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Chanda Kulkarni, Veena S Kulkarni, G Anil Kumar, Gene F Kwan, Taavi Lai, Arjun Lakshmana Balaji, Ratilal Lalloo, Tea Lallukka, Hilton Lam, Qing Lan, Van C Lansingh, Heidi J Larson, Anders Larsson, Dennis O Laryea, Pablo M Lavados, Alicia E Lawrynowicz, Janet L Leasher, Jong-Tae Lee, James Leigh, Ricky Leung, Miriam Levi, Yichong Li, Yongmei Li, Juan Liang, Xiaofeng Liang, Stephen S Lim, M Patrice Lindsay, Steven E Lipshultz, Shiwei Liu, Yang Liu, Belinda K Lloyd, Giancarlo Logroscino, Stephanie J London, Nancy Lopez, Joannie Lortet-Tieulent, Paulo A Lotufo, Rafael Lozano, Raimundas Lunevicius, Jixiang Ma, Stefan Ma, Vasco M P Machado, Michael F Macintyre, Carlos Magis-Rodriguez, Abbas A Mahdi, Marek Majdan, Reza Malekzadeh, Srikanth Mangalam, Christopher C Mapoma, Marape Marape, Wagner Marcenes, David J Margolis, Christopher Margono, Guy B Marks, Randall V Martin, Melvin B Marzan, Mohammad T Mashal, Felix Masiye, Amanda J Mason-Jones, Kunihiro Matsushita, Richard Matzopoulos, Bongani M Mayosi, Tasara T Mazorodze, Abigail C Mckay, Martin Mckee, Abigail Mclain, Peter A Meaney, Catalina Medina, Man Mohan Mehndiratta, Fabiola Mejia-Rodriguez, Wubegzier Mekonnen, Yohannes A Melaku, Michele Meltzer, Ziad A Memish, Walter Mendoza, George A Mensah, Atte Meretoja, Francis Apolinary Mhimbira, Renata Micha, Ted R Miller, Edward J Mills, Awoke Misganaw, Santosh Mishra, Norlinah Mohamed Ibrahim, Karzan A Mohammad, Ali H Mokdad, Glen L Mola, Lorenzo Monasta, Julio C Montañez Hernandez, Marcella Montico, Ami R Moore, Lidia Morawska, Rintaro Mori, Joanna Moschandreas, Wilkister N Moturi, Dariush Mozaffarian, Ulrich O Mueller, Mitsuru Mukaigawara, Erin C Mullany, Kinnari S Murthy, Mohsen Naghavi, Ziad Nahas, Aliya Naheed, Kovin S Naidoo, Luigi Naldi, Devina Nand, Vinay Nangia, K M Venkat Narayan, Denis Nash, Bruce Neal, Chakib Nejjari, Sudan P Neupane, Charles R Newton, Frida N Ngalesoni, Jean de Dieu Ngirabega, Grant Nguyen, Nhung T Nguyen, Mark J Nieuwenhuijsen, Muhammad I Nisar, José R Nogueira, Joan M Nolla, Sandra Nolte, Ole F Norheim, Rosana E Norman, Bo Norrving, Luke Nyakarahuka, In-Hwan Oh, Takayoshi Ohkubo, Bolajoko O Olusanya, Saad B Omer, John Nelson Opio, Ricardo Orozco, Rodolfo S Pagcatipunan, Amanda W Pain, Jeyaraj D Pandian, Carlo Irwin A Panelo, Christina Papachristou, Eun-Kee Park, Charles D Parry, Angel J Paternina Caicedo, Scott B Patten, Vinod K Paul, Boris I Pavlin, Neil Pearce, Lilia S Pedraza, Andrea Pedroza, Ljiljana Pejin Stokic, Ayfer Pekericli, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz, Norberto Perico, Samuel a L Perry, Aslam Pervaiz, Konrad Pesudovs, Carrie B Peterson, Max Petzold, Michael R Phillips, Hwee Pin Phua, Dietrich Plass, Dan Poenaru, Guilherme V Polanczyk, Suzanne Polinder, Constance D Pond, C Arden Pope, Daniel Pope, Svetlana Popova, Farshad Pourmalek, John Powles, Dorairaj Prabhakaran, Noela M Prasad, Dima M Qato, Amado D Quezada, D Alex A Quistberg, Lionel Racapé, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Sajjad Ur Rahman, Murugesan Raju, Ivo Rakovac, Saleem M Rana, Mayuree Rao, Homie Razavi, K Srinath Reddy, Amany H Refaat, Jürgen Rehm, Giuseppe Remuzzi, Antonio L Ribeiro, Patricia M Riccio, Lee Richardson, Anne Riederer, Margaret Robinson, Anna Roca, Alina Rodriguez, David Rojas-Rueda, Isabelle Romieu, Luca Ronfani, Robin Room, Nobhojit Roy, George M Ruhago, Lesley Rushton, Nsanzimana Sabin, Ralph L Sacco, Sukanta Saha, Ramesh Sahathevan, Mohammad Ali Sahraian, Joshua A Salomon, Deborah Salvo, Uchechukwu K Sampson, Juan R Sanabria, Luz Maria Sanchez, Tania G Sánchez-Pimienta, Lidia Sanchez-Riera, Logan Sandar, Itamar S Santos, Amir Sapkota, Maheswar Satpathy, James E Saunders, Monika Sawhney, Mete I Saylan, Peter Scarborough, Jürgen C Schmidt, Ione J C Schneider, Ben Schöttker, David C Schwebel, James G Scott, Soraya Seedat, Sadaf G Sepanlou, Berrin Serdar, Edson E Servan-Mori, Gavin Shaddick, Saeid Shahraz, Teresa Shamah Levy, Siyi Shangguan, Jun She, Sara Sheikhbahaei, Kenji Shibuya, Hwashin H Shin, Yukito Shinohara, Rahman Shiri, Kawkab Shishani, Ivy Shiue, Inga D Sigfusdottir, Donald H Silberberg, Edgar P Simard, Shireen Sindi, Abhishek Singh, Gitanjali M Singh, Jasvinder A Singh, Vegard Skirbekk, Karen Sliwa, Michael Soljak, Samir Soneji, Kjetil Søreide, Sergey Soshnikov, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Nicolas J C Stapelberg, Vasiliki Stathopoulou, Nadine Steckling, Dan J Stein, Murray B Stein, Natalie Stephens, Heidi Stöckl, Kurt Straif, Konstantinos Stroumpoulis, Lela Sturua, Bruno F Sunguya, Soumya Swaminathan, Mamta Swaroop, Bryan L Sykes, Karen M Tabb, Ken Takahashi, Roberto T Talongwa, Nikhil Tandon, David Tanne, Marcel Tanner, Mohammad Tavakkoli, Braden J Te Ao, Carolina M Teixeira, Martha M Téllez Rojo, Abdullah S Terkawi, José Luis Texcalac-Sangrador, Sarah V Thackway, Blake Thomson, Andrew L Thorne-Lyman, Amanda G Thrift, George D Thurston, Taavi Tillmann, Myriam Tobollik, Marcello Tonelli, Fotis Topouzis, Jeffrey A Towbin, Hideaki Toyoshima, Jefferson Traebert, Bach X Tran, Leonardo Trasande, Matias Trillini, Ulises Trujillo, Zacharie Tsala Dimbuene, Miltiadis Tsilimbaris, Emin Murat Tuzcu, Uche S Uchendu, Kingsley N Ukwaja, Selen B Uzun, Steven Van de Vijver, Rita Van Dingenen, Coen H Van Gool, Jim Van Os, Yuri Y Varakin, Tommi J Vasankari, Ana Maria N Vasconcelos, Monica S Vavilala, Lennert J Veerman, Gustavo Velasquez-Melendez, N Venketasubramanian, Lakshmi Vijayakumar, Salvador Villalpando, Francesco S Violante, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Gregory R Wagner, Stephen G Waller, Mitchell T Wallin, Xia Wan, Haidong Wang, Jianli Wang, Linhong Wang, Wenzhi Wang, Yanping Wang, Tati S Warouw, Charlotte H Watts, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Andrea Werdecker, K Ryan Wessells, Ronny Westerman, Harvey A Whiteford, James D Wilkinson, Hywel C Williams, Thomas N Williams, Solomon M Woldeyohannes, Charles D A Wolfe, John Q Wong, Anthony D Woolf, Jonathan L Wright, Brittany Wurtz, Gelin Xu, Lijing L Yan, Gonghuan Yang, Yuichiro Yano, Pengpeng Ye, Muluken Yenesew, Gökalp K Yentür, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Zourkaleini Younoussi, Chuanhua Yu, Maysaa E Zaki, Yong Zhao, Yingfeng Zheng, Maigeng Zhou, Jun Zhu, Shankuan Zhu, Xiaonong Zou, Joseph R Zunt, Alan D Lopez, Theo Vos, Christopher J Murray
Journal: The Lancet (2016)

BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context.MethodsWe used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI).FindingsBetween 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa.InterpretationDeclines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden.FundingBill & Melinda Gates Foundation.