Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017
Authors: Jeffrey D Stanaway, Ashkan Afshin, Emmanuela Gakidou, Stephen S Lim, Degu Abate, Kalkidan Hassen Abate, Cristiana Abbafati, Nooshin Abbasi, Hedayat Abbastabar, Foad Abd-Allah, Jemal Abdela, Ahmed Abdelalim, Ibrahim Abdollahpour, Rizwan Suliankatchi Abdulkader, Molla Abebe, Zegeye Abebe, Semaw F Abera, Olifan Zewdie Abil, Haftom Niguse Abraha, Aklilu Roba Abrham, Laith Jamal Abu-Raddad, Niveen ME Abu-Rmeileh, Manfred Mario Kokou Accrombessi, Dilaram Acharya, Pawan Acharya, Abdu A Adamu, Akilew Awoke Adane, Oladimeji M Adebayo, Rufus Adesoji Adedoyin, Victor Adekanmbi, Zanfina Ademi, Olatunji O Adetokunboh, Mina G Adib, Amha Admasie, Jose C Adsuar, Kossivi Agbelenko Afanvi, Mohsen Afarideh, Gina Agarwal, Anju Aggarwal, Sargis Aghasi Aghayan, Anurag Agrawal, Sutapa Agrawal, Alireza Ahmadi, Mehdi Ahmadi, Hamid Ahmadieh, Muktar Beshir Ahmed, Amani Nidhal Aichour, Ibtihel Aichour, Miloud Taki Eddine Aichour, Mohammad Esmaeil Akbari, Tomi Akinyemiju, Nadia Akseer, Ziyad Al-Aly, Ayman Al-Eyadhy, Hesham M Al-Mekhlafi, Fares Alahdab, Khurshid Alam, Samiah Alam, Tahiya Alam, Alaa Alashi, Seyed Moayed Alavian, Kefyalew Addis Alene, Komal Ali, Syed Mustafa Ali, Mehran Alijanzadeh, Reza Alizadeh-Navaei, Syed Mohamed Aljunid, Ala'a Alkerwi, François Alla, Ubai Alsharif, Khalid Altirkawi, Nelson Alvis-Guzman, Azmeraw T Amare, Walid Ammar, Nahla Hamed Anber, Jason A Anderson, Catalina Liliana Andrei, Sofia Androudi, Megbaru Debalkie Animut, Mina Anjomshoa, Mustafa Geleto Ansha, Josep M Antó, Carl Abelardo T Antonio, Palwasha Anwari, Lambert Tetteh Appiah, Seth Christopher Yaw Appiah, Jalal Arabloo, Olatunde Aremu, Johan Ärnlöv, Al Artaman, Krishna K Aryal, Hamid Asayesh, Zerihun Ataro, Marcel Ausloos, Euripide F G A Avokpaho, Ashish Awasthi, Beatriz Paulina Ayala Quintanilla, Rakesh Ayer, Tambe B Ayuk, Peter S Azzopardi, Arefeh Babazadeh, Hamid Badali, Alaa Badawi, Kalpana Balakrishnan, Ayele Geleto Bali, Kylie Ball, Shoshana H Ballew, Maciej Banach, Joseph Adel Mattar Banoub, Aleksandra Barac, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Lope H Barrero, Sanjay Basu, Bernhard T Baune, Shahrzad Bazargan-Hejazi, Neeraj Bedi, Ettore Beghi, Masoud Behzadifar, Meysam Behzadifar, Yannick Béjot, Bayu Begashaw Bekele, Eyasu Tamru Bekru, Ezra Belay, Yihalem Abebe Belay, Michelle L Bell, Aminu K Bello, Derrick A Bennett, Isabela M Bensenor, Gilles Bergeron, Adugnaw Berhane, Eduardo Bernabe, Robert S Bernstein, Mircea Beuran, Tina Beyranvand, Neeraj Bhala, Ashish Bhalla, Suraj Bhattarai, Zulfiqar A Bhutta, Belete Biadgo, Ali Bijani, Boris Bikbov, Ver Bilano, Nigus Bililign, Muhammad Shahdaat Bin Sayeed, Donal Bisanzio, Tuhin Biswas, Tone Bjørge, Brigette F Blacker, Archie Bleyer, Rohan Borschmann, Ibrahim R Bou-Orm, Soufiane Boufous, Rupert Bourne, Oliver J Brady, Michael Brauer, Alexandra Brazinova, Nicholas J K Breitborde, Hermann Brenner, Andrey Nikolaevich Briko, Gabrielle Britton, Traolach Brugha, Rachelle Buchbinder, Richard T Burnett, Reinhard Busse, Zahid A Butt, Leah E Cahill, Lucero Cahuana-Hurtado, Ismael R Campos-Nonato, Rosario Cárdenas, Giulia Carreras, Juan J Carrero, Félix Carvalho, Carlos A Castañeda-Orjuela, Jacqueline Castillo Rivas, Franz Castro, Ferrán Catalá-López, Kate Causey, Kelly M Cercy, Ester Cerin, Yazan Chaiah, Hsing-Yi Chang, Jung-Chen Chang, Kai-Lan Chang, Fiona J Charlson, Aparajita Chattopadhyay, Vijay Kumar Chattu, Miao Li Chee, Ching-Yu Cheng, Adrienne Chew, Peggy Pei-Chia Chiang, Odgerel Chimed-Ochir, Ken Lee Chin, Abdulaal Chitheer, Jee-Young J Choi, Rajiv Chowdhury, Hanne Christensen, Devasahayam J Christopher, Sheng-Chia Chung, Flavia M Cicuttini, Massimo Cirillo, Aaron J Cohen, Daniel Collado-Mateo, Cyrus Cooper, Owen R Cooper, Josef Coresh, Leslie Cornaby, Paolo Angelo Cortesi, Monica Cortinovis, Megan Costa, Ewerton Cousin, Michael H Criqui, Elizabeth A Cromwell, David K Cundiff, Alemneh Kabeta Daba, Berihun Assefa Dachew, Abel Fekadu Dadi, Albertino Antonio Moura Damasceno, Lalit Dandona, Rakhi Dandona, Sarah C Darby, Paul I Dargan, Ahmad Daryani, Rajat Das Gupta, José Das Neves, Tamirat Tesfaye Dasa, Aditya Prasad Dash, Dragos Virgil Davitoiu, Kairat Davletov, Vanessa De la Cruz-Góngora, Fernando Pio De La Hoz, Diego De Leo, Jan-Walter De Neve, Louisa Degenhardt, Selina Deiparine, Robert P Dellavalle, Gebre Teklemariam Demoz, Edgar Denova-Gutiérrez, Kebede Deribe, Nikolaos Dervenis, Aniruddha Deshpande, Don C Des Jarlais, Getenet Ayalew Dessie, Gabrielle Aline Deveber, Subhojit Dey, Samath Dhamminda Dharmaratne, Meghnath Dhimal, Mesfin Tadese Dinberu, Eric L Ding, Helen Derara Diro, Shirin Djalalinia, Huyen Phuc Do, Klara Dokova, David Teye Doku, Kerrie E Doyle, Tim R Driscoll, Manisha Dubey, Eleonora Dubljanin, Eyasu Ejeta Duken, Bruce B Duncan, Andre R Duraes, Natalie Ebert, Hedyeh Ebrahimi, Soheil Ebrahimpour, David Edvardsson, Andem Effiong, Anne Elise Eggen, Charbel El Bcheraoui, Ziad El-Khatib, Iqbal Rf Elyazar, Ahmadali Enayati, Aman Yesuf Endries, Benjamin Er, Holly E Erskine, Sharareh Eskandarieh, Alireza Esteghamati, Kara Estep, Hamed Fakhim, Mahbobeh Faramarzi, Mohammad Fareed, Talha A Farid, Carla Sofia E sá Farinha, Andrea Farioli, Andre Faro, Maryam S Farvid, Mohammad Hosein Farzaei, Batool Fatima, Kairsten A Fay, Ali Akbar Fazaeli, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Eduarda Fernandes, Joao C Fernandes, Giannina Ferrara, Alize J Ferrari, Manuela L Ferreira, Irina Filip, Jonas David Finger, Florian Fischer, Nataliya A Foigt, Kyle J Foreman, Takeshi Fukumoto, Nancy Fullman, Thomas Fürst, João M Furtado, Neal D Futran, Seana Gall, Silvano Gallus, Amiran Gamkrelidze, Morsaleh Ganji, Alberto L Garcia-Basteiro, William M Gardner, Abadi Kahsu Gebre, Amanuel Tesfay Gebremedhin, Teklu Gebrehiwo Gebremichael, Tilayie Feto Gelano, Johanna M Geleijnse, Yilma Chisha Dea Geramo, Peter W Gething, Kebede Embaye Gezae, Reza Ghadimi, Keyghobad Ghadiri, Khalil Ghasemi Falavarjani, Maryam Ghasemi-Kasman, Mamata Ghimire, Rakesh Ghosh, Aloke Gopal Ghoshal, Simona Giampaoli, Paramjit Singh Gill, Tiffany K Gill, Richard F Gillum, Ibrahim Abdelmageed Ginawi, Giorgia Giussani, Elena V Gnedovskaya, William W Godwin, Srinivas Goli, Hector Gómez-Dantés, Philimon N Gona, Sameer Vali Gopalani, Alessandra C Goulart, Ayman Grada, Morgan E Grams, Giuseppe Grosso, Harish Chander Gugnani, Yuming Guo, Rahul Gupta, Rajeev Gupta, Tanush Gupta, Reyna Alma Gutiérrez, Daniela S Gutiérrez-Torres, Juanita A Haagsma, Tesfa Dejenie Habtewold, Vladimir Hachinski, Nima Hafezi-Nejad, Tekleberhan B Hagos, Tewodros Tesfa Hailegiyorgis, Gessessew Bugssa Hailu, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Randah R Hamadeh, Samer Hamidi, Alexis J Handal, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Sivadasanpillai Harikrishnan, Josep Maria Haro, Hadi Hassankhani, Hamid Yimam Hassen, Rasmus Havmoeller, Caitlin N Hawley, Simon I Hay, Akbar Hedayatizadeh-Omran, Behzad Heibati, Behnam Heidari, Mohsen Heidari, Delia Hendrie, Andualem Henok, Ileana Heredia-Pi, Claudiu Herteliu, Fatemeh Heydarpour, Sousan Heydarpour, Desalegn T Hibstu, Tarig B Higazi, Esayas Haregot Hilawe, Hans W Hoek, Howard J Hoffman, Michael K Hole, Enayatollah Homaie Rad, Praveen Hoogar, H Dean Hosgood, Seyed Mostafa Hosseini, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Damian G Hoy, Mohamed Hsairi, Thomas Hsiao, Guoqing Hu, Howard Hu, John J Huang, Mamusha Aman Hussen, Chantal K Huynh, Kim Moesgaard Iburg, Nayu Ikeda, Olayinka Stephen Ilesanmi, Usman Iqbal, Seyed Sina Naghibi Irvani, Caleb Mackay Salpeter Irvine, Sheikh Mohammed Shariful Islam, Farhad Islami, Maria D Jackson, Kathryn H Jacobsen, Leila Jahangiry, Nader Jahanmehr, Sudhir Kumar Jain, Mihajlo Jakovljevic, Spencer L James, Simerjot K Jassal, Achala Upendra Jayatilleke, Panniyammakal Jeemon, Ravi Prakash Jha, Vivekanand Jha, John S Ji, Jost B Jonas, Jitendra Jonnagaddala, Zahra Jorjoran Shushtari, Ankur Joshi, Jacek Jerzy Jozwiak, Mikk Jürisson, Zubair Kabir, Amaha Kahsay, Rizwan Kalani, Tanuj Kanchan, Surya Kant, Chittaranjan Kar, Manoochehr Karami, Behzad Karami Matin, André Karch, Corine Karema, Narges Karimi, Seyed M Karimi, Amir Kasaeian, Dessalegn H Kassa, Getachew Mullu Kassa, Tesfaye Dessale Kassa, Nicholas J Kassebaum, Srinivasa Vittal Katikireddi, Anil Kaul, Norito Kawakami, Zhila Kazemi, Ali Kazemi Karyani, Adane Teshome Kefale, Peter Njenga Keiyoro, Grant Rodgers Kemp, Andre Pascal Kengne, Andre Keren, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Behzad Khafaei, Morteza Abdullatif Khafaie, Alireza Khajavi, Nauman Khalid, Ibrahim A Khalil, Gulfaraz Khan, Muhammad Shahzeb Khan, Muhammad Ali Khan, Young-Ho Khang, Mona M Khater, Mohammad Khazaei, Habibolah Khazaie, Abdullah T Khoja, Ardeshir Khosravi, Mohammad Hossein Khosravi, Aliasghar A Kiadaliri, Daniel N Kiirithio, Cho-Il Kim, Daniel Kim, Young-Eun Kim, Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna Kissimova-Skarbek, Mika Kivimäki, Luke D Knibbs, Ann Kristin Skrindo Knudsen, Sonali Kochhar, Yoshihiro Kokubo, Tufa Kolola, Jacek A Kopec, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Michael A Kravchenko, Kewal Krishan, Kristopher J Krohn, Hans Kromhout, Barthelemy Kuate Defo, Burcu Kucuk Bicer, G Anil Kumar, Manasi Kumar, Igor Kuzin, Hmwe Hmwe Kyu, Carl Lachat, Deepesh P Lad, Sheetal D Lad, Alessandra Lafranconi, Ratilal Lalloo, Tea Lallukka, Faris Hasan Lami, Justin J Lang, Van C Lansingh, Samantha Leigh Larson, Arman Latifi, Jeffrey V Lazarus, Paul H Lee, James Leigh, Mostafa Leili, Cheru Tesema Leshargie, Janni Leung, Miriam Levi, Sonia Lewycka, Shanshan Li, Yichong Li, Juan Liang, Xiaofeng Liang, Yu Liao, Misgan Legesse Liben, Lee-Ling Lim, Shai Linn, Shiwei Liu, Rakesh Lodha, Giancarlo Logroscino, Alan D Lopez, Stefan Lorkowski, Paulo A Lotufo, Rafael Lozano, Tim C D Lucas, Raimundas Lunevicius, Stefan Ma, Erlyn Rachelle King Macarayan, Ísis Eloah Machado, Fabiana Madotto, Hue Thi Mai, Marek Majdan, Reza Majdzadeh, Azeem Majeed, Reza Malekzadeh, Deborah Carvalho Malta, Abdullah A Mamun, Ana-Laura Manda, Helena Manguerra, Mohammad Ali Mansournia, Lorenzo Giovanni Mantovani, Joemer C Maravilla, Wagner Marcenes, Ashley Marks, Randall V Martin, Sheila C O Martins, Francisco Rogerlândio Martins-Melo, Winfried März, Melvin B Marzan, Benjamin Ballard Massenburg, Manu Raj Mathur, Prashant Mathur, Kunihiro Matsushita, Pallab K Maulik, Mohsen Mazidi, Colm McAlinden, John J McGrath, Martin McKee, Ravi Mehrotra, Kala M Mehta, Varshil Mehta, Toni Meier, Fantahun Ayenew Mekonnen, Yohannes A Melaku, Addisu Melese, Mulugeta Melku, Peter T N Memiah, Ziad A Memish, Walter Mendoza, Desalegn Tadese Mengistu, George A Mensah, Gert B M Mensink, Seid Tiku Mereta, Atte Meretoja, Tuomo J Meretoja, Tomislav Mestrovic, Haftay Berhane Mezgebe, Bartosz Miazgowski, Tomasz Miazgowski, Anoushka I Millear, Ted R Miller, Molly Katherine Miller-Petrie, G K Mini, Mojde Mirarefin, Andreea Mirica, Erkin M Mirrakhimov, Awoke Temesgen Misganaw, Habtamu Mitiku, Babak Moazen, Bahram Mohajer, Karzan Abdulmuhsin Mohammad, Moslem Mohammadi, Noushin Mohammadifard, Mousa Mohammadnia-Afrouzi, Shafiu Mohammed, Farnam Mohebi, Ali H Mokdad, Mariam Molokhia, Fatemeh Momeniha, Lorenzo Monasta, Yoshan Moodley, Ghobad Moradi, Maziar Moradi-Lakeh, Mehdi Moradinazar, Paula Moraga, Lidia Morawska, Joana Morgado-Da-Costa, Shane Douglas Morrison, Marilita M Moschos, Simin Mouodi, Seyyed Meysam Mousavi, Dariush Mozaffarian, Kalayu Brhane Mruts, Achenef Asmamaw Muche, Kindie Fentahun Muchie, Ulrich Otto Mueller, Oumer Sada Muhammed, Satinath Mukhopadhyay, Kate Muller, Kamarul Imran Musa, Ghulam Mustafa, Ashraf F Nabhan, Mohsen Naghavi, Aliya Naheed, Azin Nahvijou, Gurudatta Naik, Nitish Naik, Farid Najafi, Vinay Nangia, Jobert Richie Nansseu, Bruno Ramos Nascimento, Bruce Neal, Nahid Neamati, Ionut Negoi, Ruxandra Irina Negoi, Subas Neupane, Charles Richard James Newton, Josephine W Ngunjiri, Anh Quynh Nguyen, Grant Nguyen, Ha Thu Nguyen, Huong Lan Thi Nguyen, Huong Thanh Nguyen, Minh Nguyen, Nam Ba Nguyen, Emma Nichols, Jing Nie, Dina Nur Anggraini Ningrum, Yirga Legesse Nirayo, Nobuo Nishi, Molly R Nixon, Marzieh Nojomi, Shuhei Nomura, Ole F Norheim, Mehdi Noroozi, Bo Norrving, Jean Jacques Noubiap, Hamid Reza Nouri, Malihe Nourollahpour Shiadeh, Mohammad Reza Nowroozi, Elaine O Nsoesie, Peter S Nyasulu, Carla M Obermeyer, Christopher M Odell, Richard Ofori-Asenso, Felix Akpojene Ogbo, In-Hwan Oh, Olanrewaju Oladimeji, Andrew T Olagunju, Tinuke O Olagunju, Pedro R Olivares, Helen Elizabeth Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, Kanyin L Ong, Sok King Ong, Eyal Oren, Heather M Orpana, Alberto Ortiz, Erika Ota, Stanislav S Otstavnov, Simon Øverland, Mayowa Ojo Owolabi, Mahesh P A, Rosana Pacella, Abhijit P Pakhare, Amir H Pakpour, Adrian Pana, Songhomitra Panda-Jonas, Eun-Kee Park, Charles D H Parry, Hadi Parsian, Shanti Patel, Sanghamitra Pati, Snehal T Patil, Ajay Patle, George C Patton, Deepak Paudel, Katherine R Paulson, Wayra Citlali Paz Ballesteros, Neil Pearce, Alexandre Pereira, David M Pereira, Norberto Perico, Konrad Pesudovs, Max Petzold, Hai Quang Pham, Michael R Phillips, Julian David Pillay, Michael A Piradov, Meghdad Pirsaheb, Tobias Pischon, Farhad Pishgar, Oleguer Plana-Ripoll, Dietrich Plass, Suzanne Polinder, Kevan R Polkinghorne, Maarten J Postma, Richie Poulton, Akram Pourshams, Hossein Poustchi, Dorairaj Prabhakaran, Swayam Prakash, Narayan Prasad, Caroline A Purcell, Manorama B Purwar, Mostafa Qorbani, Amir Radfar, Anwar Rafay, Alireza Rafiei, Fakher Rahim, Zohreh Rahimi, Afarin Rahimi-Movaghar, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz ur Rahman, Muhammad Aziz Rahman, Rajesh Kumar Rai, Fatemeh Rajati, Sasa Rajsic, Sree Bhushan Raju, Usha Ram, Chhabi Lal Ranabhat, Prabhat Ranjan, Goura Kishor Rath, David Laith Rawaf, Salman Rawaf, K Srinath Reddy, Colin D Rehm, Jürgen Rehm, Robert C Reiner, Marissa B Reitsma, Giuseppe Remuzzi, Andre M N Renzaho, Serge Resnikoff, Luz Myriam Reynales-Shigematsu, Satar Rezaei, Antonio Luiz P Ribeiro, Juan A Rivera, Kedir Teji Roba, Sonia Rodríguez-Ramírez, Leonardo Roever, Yesenia Román, Luca Ronfani, Gholamreza Roshandel, Ali Rostami, Gregory A Roth, Dietrich Rothenbacher, Ambuj Roy, Enrico Rubagotti, Lesley Rushton, Charumathi Sabanayagam, Perminder S Sachdev, Basema Saddik, Ehsan Sadeghi, Sahar Saeedi Moghaddam, Hosein Safari, Yahya Safari, Roya Safari-Faramani, Mahdi Safdarian, Sare Safi, Saeid Safiri, Rajesh Sagar, Amirhossein Sahebkar, Mohammad Ali Sahraian, Haniye Sadat Sajadi, Nasir Salam, Payman Salamati, Zikria Saleem, Yahya Salimi, Hamideh Salimzadeh, Joshua A Salomon, Devashri Digvijay Salvi, Inbal Salz, Abdallah M Samy, Juan Sanabria, Maria Dolores Sanchez-Niño, Tania G Sánchez-Pimienta, Taren Sanders, Yingying Sang, Damian Francesco Santomauro, Itamar S Santos, João Vasco Santos, Milena M Santric Milicevic, Bruno Piassi Sao Jose, Mayank Sardana, Abdur Razzaque Sarker, Rodrigo Sarmiento-Suárez, Nizal Sarrafzadegan, Benn Sartorius, Shahabeddin Sarvi, Brijesh Sathian, Maheswar Satpathy, Arundhati R Sawant, Monika Sawhney, Mete Saylan, Mehdi Sayyah, Elke Schaeffner, Maria Inês Schmidt, Ione J C Schneider, Ben Schöttker, Aletta Elisabeth Schutte, David C Schwebel, Falk Schwendicke, James G Scott, Soraya Seedat, Mario Sekerija, Sadaf G Sepanlou, Marc L Serre, Edson Serván-Mori, Seyedmojtaba Seyedmousavi, Hosein Shabaninejad, Gavin Shaddick, Azadeh Shafieesabet, Mehdi Shahbazi, Amira A Shaheen, Masood Ali Shaikh, Teresa Shamah Levy, Mehran Shams-Beyranvand, Mohammadbagher Shamsi, Heidar Sharafi, Kiomars Sharafi, Mehdi Sharif, Mahdi Sharif-Alhoseini, Hamid Sharifi, Jayendra Sharma, Meenakshi Sharma, Rajesh Sharma, Jun She, Aziz Sheikh, Peilin Shi, Kenji Shibuya, Mekonnen Sisay Shiferaw, Mika Shigematsu, Min-Jeong Shin, Rahman Shiri, Reza Shirkoohi, Ivy Shiue, Farhad Shokraneh, Haitham Shoman, Mark G Shrime, Matthew S Shupler, Si Si, Soraya Siabani, Abla Mehio Sibai, Tariq J Siddiqi, Inga Dora Sigfusdottir, Rannveig Sigurvinsdottir, Diego Augusto Santos Silva, João Pedro Silva, Dayane Gabriele Alves Silveira, Jasvinder A Singh, Narinder Pal Singh, Virendra Singh, Dhirendra Narain Sinha, Eirini Skiadaresi, Vegard Skirbekk, David L Smith, Mari Smith, Badr Hasan Sobaih, Soheila Sobhani, Ranjani Somayaji, Moslem Soofi, Reed J D Sorensen, Joan B Soriano, Ireneous N Soyiri, Angela Spinelli, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vinay Srinivasan, Vladimir I Starodubov, Nadine Steckling, Dan J Stein, Murray B Stein, Goran Stevanovic, Leo Stockfelt, Mark A Stokes, Lela Sturua, Michelle L Subart, Agus Sudaryanto, Mu'awiyyah Babale Sufiyan, Gerhard Sulo, Bruno F Sunguya, Patrick John Sur, Bryan L Sykes, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Takahiro Tabuchi, Santosh Kumar Tadakamadla, Ken Takahashi, Nikhil Tandon, Segen Gebremeskel Tassew, Mohammad Tavakkoli, Nuno Taveira, Arash Tehrani-Banihashemi, Tigist Gashaw Tekalign, Shishay Wahdey Tekelemedhin, Merhawi Gebremedhin Tekle, Habtamu Temesgen, Mohamad-Hani Temsah, Omar Temsah, Abdullah Sulieman Terkawi, Belay Tessema, Mebrahtu Teweldemedhin, Kavumpurathu Raman Thankappan, Andrew Theis, Sathish Thirunavukkarasu, Hannah J Thomas, Matthew Lloyd Thomas, Nihal Thomas, George D Thurston, Binyam Tilahun, Taavi Tillmann, Quyen G To, Myriam Tobollik, Marcello Tonelli, Roman Topor-Madry, Anna E Torre, Miguel Tortajada-Girbés, Mathilde Touvier, Marcos Roberto Tovani-Palone, Jeffrey A Towbin, Bach Xuan Tran, Khanh Bao Tran, Thomas Clement Truelsen, Nu Thi Truong, Afewerki Gebremeskel Tsadik, Lorainne Tudor Car, E Murat Tuzcu, Hayley D Tymeson, Stefanos Tyrovolas, Kingsley N Ukwaja, Irfan Ullah, Rachel L Updike, Muhammad Shariq Usman, Olalekan A Uthman, Muthiah Vaduganathan, Afsane Vaezi, Pascual R Valdez, Aaron Van Donkelaar, Elena Varavikova, Santosh Varughese, Tommi Juhani Vasankari, Vidhya Venkateswaran, Narayanaswamy Venketasubramanian, Santos Villafaina, Francesco S Violante, Sergey Konstantinovitch Vladimirov, Vasily Vlassov, Stein Emil Vollset, Theo Vos, Kia Vosoughi, Giang Thu Vu, Isidora S Vujcic, Fasil Shiferaw Wagnew, Yasir Waheed, Stephen G Waller, Judd L Walson, Yafeng Wang, Yanping Wang, Yuan-Pang Wang, Elisabete Weiderpass, Robert G Weintraub, Fitsum Weldegebreal, Andrea Werdecker, Adhena Ayaliew Werkneh, J Jason West, Ronny Westerman, Harvey A Whiteford, Justyna Widecka, Tissa Wijeratne, Andrea Sylvia Winkler, Alison B Wiyeh, Charles Shey Wiysonge, Charles D A Wolfe, Tien Yin Wong, Shouling Wu, Denis Xavier, Gelin Xu, Simon Yadgir, Ali Yadollahpour, Seyed Hossein Yahyazadeh Jabbari, Tomohide Yamada, Lijing L Yan, Yuichiro Yano, Mehdi Yaseri, Yasin Jemal Yasin, Alex Yeshaneh, Ebrahim M Yimer, Paul Yip, Engida Yisma, Naohiro Yonemoto, Seok-Jun Yoon, Marcel Yotebieng, Mustafa Z Younis, Mahmoud Yousefifard, Chuanhua Yu, Zoubida Zaidi, Sojib Bin Zaman, Mohammad Zamani, Luis Zavala-Arciniega, Anthony Lin Zhang, Hao Zhang, Kai Zhang, Maigeng Zhou, Stephanie R M Zimsen, Sanjay Zodpey, Christopher J L Murray
Journal: The Lancet (2018)

BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations.MethodsWe used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017.FindingsIn 2017, 34·1 million (95% uncertainty interval [UI] 33·3–35·0) deaths and 1·21 billion (1·14–1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6–62·4) of deaths and 48·3% (46·3–50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39–11·5) deaths and 218 million (198–237) DALYs, followed by smoking (7·10 million [6·83–7·37] deaths and 182 million [173–193] DALYs), high fasting plasma glucose (6·53 million [5·23–8·23] deaths and 171 million [144–201] DALYs), high body-mass index (BMI; 4·72 million [2·99–6·70] deaths and 148 million [98·6–202] DALYs), and short gestation for birthweight (1·43 million [1·36–1·51] deaths and 139 million [131–147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3–6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low.InterpretationBy quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning.FundingBill & Melinda Gates Foundation and Bloomberg Philanthropies.