Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
Authors: Emmanuela Gakidou, Ashkan Afshin, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Cristiana Abbafati, Kaja M Abbas, Foad Abd-Allah, Abdishakur M Abdulle, Semaw Ferede Abera, Victor Aboyans, Laith J Abu-Raddad, Niveen M E Abu-Rmeileh, Gebre Yitayih Abyu, Isaac Akinkunmi Adedeji, Olatunji Adetokunboh, Mohsen Afarideh, Anurag Agrawal, Sutapa Agrawal, Hamid Ahmadieh, Muktar Beshir Ahmed, Miloud Taki Eddine Aichour, Amani Nidhal Aichour, Ibtihel Aichour, Rufus Olusola Akinyemi, Nadia Akseer, Fares Alahdab, Ziyad Al-Aly, Khurshid Alam, Noore Alam, Tahiya Alam, Deena Alasfoor, Kefyalew Addis Alene, Komal Ali, Reza Alizadeh-Navaei, Ala'a Alkerwi, François Alla, Peter Allebeck, Rajaa Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi, Nelson Alvis-Guzman, Azmeraw T Amare, Erfan Amini, Walid Ammar, Yaw Ampem Amoako, Hossein Ansari, Josep M Antó, Carl Abelardo T Antonio, Palwasha Anwari, Nicholas Arian, Johan Ärnlöv, Al Artaman, Krishna Kumar Aryal, Hamid Asayesh, Solomon Weldegebreal Asgedom, Tesfay Mehari Atey, Leticia Avila-Burgos, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Peter Azzopardi, Umar Bacha, Alaa Badawi, Kalpana Balakrishnan, Shoshana H Ballew, Aleksandra Barac, Ryan M Barber, Suzanne L Barker-Collo, Till Bärnighausen, Simon Barquera, Lars Barregard, Lope H Barrero, Carolina Batis, Katherine E Battle, Blair R Baumgarner, Bernhard T Baune, Justin Beardsley, Neeraj Bedi, Ettore Beghi, Michelle L Bell, Derrick A Bennett, James R Bennett, Isabela M Bensenor, Adugnaw Berhane, Derbew Fikadu Berhe, Eduardo Bernabé, Balem Demtsu Betsu, Mircea Beuran, Addisu Shunu Beyene, Anil Bhansali, Zulfiqar A Bhutta, Burcu Kucuk Bicer, Boris Bikbov, Charles Birungi, Stan Biryukov, Christopher D Blosser, Dube Jara Boneya, Ibrahim R Bou-Orm, Michael Brauer, Nicholas J K Breitborde, Hermann Brenner, Traolach S Brugha, Lemma Negesa Bulto Bulto, Zahid A Butt, Lucero Cahuana-Hurtado, Rosario Cárdenas, Juan Jesus Carrero, Carlos A Castañeda-Orjuela, Ferrán Catalá-López, Kelly Cercy, Hsing-Yi Chang, Fiona J Charlson, Odgerel Chimed-Ochir, Vesper Hichilombwe Chisumpa, Abdulaal A Chitheer, Hanne Christensen, Devasahayam Jesudas Christopher, Massimo Cirillo, Aaron J Cohen, Haley Comfort, Cyrus Cooper, Josef Coresh, Leslie Cornaby, Paolo Angelo Cortesi, Michael H Criqui, John A Crump, Lalit Dandona, Rakhi Dandona, José das Neves, Gail Davey, Dragos V Davitoiu, Kairat Davletov, Barbora de Courten, Barthelemy Kuate Defo, Louisa Degenhardt, Selina Deiparine, Robert P Dellavalle, Kebede Deribe, Aniruddha Deshpande, Samath D Dharmaratne, Eric L Ding, Shirin Djalalinia, Huyen Phuc Do, Klara Dokova, David Teye Doku, Aaron van Donkelaar, E Ray Dorsey, Tim R Driscoll, Manisha Dubey, Bruce Bartholow Duncan, Sarah Duncan, Hedyeh Ebrahimi, Ziad Ziad El-Khatib, Ahmadali Enayati, Aman Yesuf Endries, Sergey Petrovich Ermakov, Holly E Erskine, Babak Eshrati, Sharareh Eskandarieh, Alireza Esteghamati, Kara Estep, Emerito Jose Aquino Faraon, Carla Sofia e Sa Farinha, André Faro, Farshad Farzadfar, Kairsten Fay, Valery L Feigin, Seyed-Mohammad Fereshtehnejad, João C Fernandes, Alize J Ferrari, Tesfaye Regassa Feyissa, Irina Filip, Florian Fischer, Christina Fitzmaurice, Abraham D Flaxman, Nataliya Foigt, Kyle J Foreman, Joseph J Frostad, Nancy Fullman, Thomas Fürst, Joao M Furtado, Morsaleh Ganji, Alberto L Garcia-Basteiro, Tsegaye Tewelde Gebrehiwot, Johanna M Geleijnse, Ayele Geleto, Bikila Lencha Gemechu, Hailay Abrha Gesesew, Peter W Gething, Alireza Ghajar, Katherine B Gibney, Paramjit Singh Gill, Richard F Gillum, Ababi Zergaw Giref, Melkamu Dedefo Gishu, Giorgia Giussani, William W Godwin, Philimon N Gona, Amador Goodridge, Sameer Vali Gopalani, Yevgeniy Goryakin, Alessandra Carvalho Goulart, Nicholas Graetz, Harish Chander Gugnani, Jingwen Guo, Rajeev Gupta, Tanush Gupta, Vipin Gupta, Reyna A Gutiérrez, Vladimir Hachinski, Nima Hafezi-Nejad, Gessessew Bugssa Hailu, Randah Ribhi Hamadeh, Samer Hamidi, Mouhanad Hammami, Alexis J Handal, Graeme J Hankey, Sarah Wulf Hanson, Hilda L Harb, Habtamu Abera Hareri, Mohammad Sadegh Hassanvand, Rasmus Havmoeller, Caitlin Hawley, Simon I Hay, Mohammad T Hedayati, Delia Hendrie, Ileana Beatriz Heredia-Pi, Julio Cesar Montañez Hernandez, Hans W Hoek, Nobuyuki Horita, H Dean Hosgood, Sorin Hostiuc, Damian G Hoy, Mohamed Hsairi, Guoqing Hu, John J Huang, Hsiang Huang, Norlinah Mohamed Ibrahim, Kim Moesgaard Iburg, Chad Ikeda, Manami Inoue, Caleb Mackay Salpeter Irvine, Maria Delores Jackson, Kathryn H Jacobsen, Nader Jahanmehr, Mihajlo B Jakovljevic, Alejandra Jauregui, Mehdi Javanbakht, Panniyammakal Jeemon, Lars R K Johansson, Catherine O Johnson, Jost B Jonas, Mikk Jürisson, Zubair Kabir, Rajendra Kadel, Amaha Kahsay, Ritul Kamal, André Karch, Corine Kakizi Karema, Amir Kasaeian, Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Norito Kawakami, Peter Njenga Keiyoro, Sefonias Getachew Kelbore, Laura Kemmer, Andre Pascal Kengne, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim A Khalil, Ejaz Ahmad Khan, Young-Ho Khang, Ardeshir Khosravi, Jagdish Khubchandani, Aliasghar Ahmad Kiadaliri, Christian Kieling, Jun Y Kim, Yun Jin Kim, Daniel Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna A Kissimova-Skarbek, Mika Kivimaki, Luke D Knibbs, Ann Kristin Knudsen, Jacek A Kopec, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Michael Kravchenko, Kristopher J Krohn, Hans Kromhout, G Anil Kumar, Michael Kutz, Hmwe H Kyu, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Qing Lan, Van C Lansingh, Anders Larsson, Paul H Lee, Alexander Lee, James Leigh, Janni Leung, Miriam Levi, Teresa Shamah Levy, Yichong Li, Yongmei Li, Xiaofeng Liang, Misgan Legesse Liben, Shai Linn, Patrick Liu, Rakesh Lodha, Giancarlo Logroscino, Katherine J Looker, Alan D Lopez, Stefan Lorkowski, Paulo A Lotufo, Rafael Lozano, Raimundas Lunevicius, Erlyn Rachelle King Macarayan, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Marek Majdan, Reza Majdzadeh, Azeem Majeed, Reza Malekzadeh, Rajesh Malhotra, Deborah Carvalho Malta, Abdullah A Mamun, Helena Manguerra, Lorenzo G Mantovani, Chabila C Mapoma, Randall V Martin, Jose Martinez-Raga, Francisco Rogerlândio Martins-Melo, Manu Raj Mathur, Kunihiro Matsushita, Richard Matzopoulos, Mohsen Mazidi, Colm McAlinden, John J McGrath, Suresh Mehata, Man Mohan Mehndiratta, Toni Meier, Yohannes Adama Melaku, Peter Memiah, Ziad A Memish, Walter Mendoza, Melkamu Merid Mengesha, George A Mensah, Gert B M Mensink, Seid Tiku Mereta, Tuomo J Meretoja, Atte Meretoja, Haftay Berhane Mezgebe, Renata Micha, Anoushka Millear, Ted R Miller, Shawn Minnig, Mojde Mirarefin, Erkin M Mirrakhimov, Awoke Misganaw, Shiva Raj Mishra, Karzan Abdulmuhsin Mohammad, Kedir Endris Mohammed, Shafiu Mohammed, Murali B V Mohan, Ali H Mokdad, Lorenzo Monasta, Marcella Montico, Maziar Moradi-Lakeh, Paula Moraga, Lidia Morawska, Shane D Morrison, Cliff Mountjoy-Venning, Ulrich O Mueller, Erin C Mullany, Kate Muller, Gudlavalleti Venkata Satyanarayana Murthy, Kamarul Imran Musa, Mohsen Naghavi, Aliya Naheed, Vinay Nangia, Gopalakrishnan Natarajan, Ruxandra Irina Negoi, Ionut Negoi, Cuong Tat Nguyen, Quyen Le Nguyen, Trang Huyen Nguyen, Grant Nguyen, Minh Nguyen, Emma Nichols, Dina Nur Anggraini Ningrum, Marika Nomura, Vuong Minh Nong, Ole F Norheim, Bo Norrving, Jean Jacques N Noubiap, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In-Hwan Oh, Olanrewaju Oladimeji, Andrew Toyin Olagunju, Tinuke Oluwasefunmi Olagunju, Pedro R Olivares, Helen E Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Alberto Ortiz, Erika Ota, Mayowa O Owolabi, Mahesh PA, Rosana E Pacella, Adrian Pana, Basant Kumar Panda, Songhomitra Panda-Jonas, Jeyaraj D Pandian, Christina Papachristou, Eun-Kee Park, Charles D Parry, Scott B Patten, George C Patton, David M Pereira, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Robert Phillips, Julian David Pillay, Michael A Piradov, Farhad Pishgar, Dietrich Plass, Martin A Pletcher, Suzanne Polinder, Svetlana Popova, Richie G Poulton, Farshad Pourmalek, Narayan Prasad, Carrie Purcell, Mostafa Qorbani, Amir Radfar, Anwar Rafay, Afarin Rahimi-Movaghar, Vafa Rahimi-Movaghar, Mohammad Hifz Ur Rahman, Muhammad Aziz Rahman, Mahfuzar Rahman, Rajesh Kumar Rai, Sasa Rajsic, Usha Ram, Salman Rawaf, 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 L Ribeiro, Juan A Rivera, Kedir Teji Roba, David Rojas-Rueda, Yesenia Roman, Robin Room, Gholamreza Roshandel, Gregory A Roth, Dietrich Rothenbacher, Enrico Rubagotti, Lesley Rushton, Nafis Sadat, Mahdi Safdarian, Sare Safi, Saeid Safiri, Ramesh Sahathevan, Joseph Salama, Joshua A Salomon, Abdallah M Samy, Juan Ramon Sanabria, Maria Dolores Sanchez-Niño, Tania G Sánchez-Pimienta, Damian Santomauro, Itamar S Santos, Milena M Santric Milicevic, Benn Sartorius, Maheswar Satpathy, Monika Sawhney, Sonia Saxena, Maria Inês Schmidt, Ione J C Schneider, Aletta E Schutte, David C Schwebel, Falk Schwendicke, Soraya Seedat, Sadaf G Sepanlou, Berrin Serdar, Edson E Servan-Mori, Gavin Shaddick, Amira Shaheen, Saeid Shahraz, Masood Ali Shaikh, Mansour Shamsipour, Morteza Shamsizadeh, Sheikh Mohammed Shariful Islam, Jayendra Sharma, Rajesh Sharma, Jun She, Jiabin Shen, Peilin Shi, Kenji Shibuya, Chloe Shields, Mekonnen Sisay Shiferaw, Mika Shigematsu, Min-Jeong Shin, Rahman Shiri, Reza Shirkoohi, Kawkab Shishani, Haitham Shoman, Mark G Shrime, Inga Dora Sigfusdottir, Diego Augusto Santos Silva, João Pedro Silva, Dayane Gabriele Alves Silveira, Jasvinder A Singh, Virendra Singh, Dhirendra Narain Sinha, Eirini Skiadaresi, Erica Leigh Slepak, David L Smith, Mari Smith, Badr H A Sobaih, Eugene Sobngwi, Samir Soneji, Reed J D Sorensen, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vinay Srinivasan, Nicholas Steel, Dan J Stein, Caitlyn Steiner, Sabine Steinke, Mark Andrew Stokes, Bryan Strub, Michelle Subart, Muawiyyah Babale Sufiyan, Rizwan Abdulkader Suliankatchi, Patrick J Sur, Soumya Swaminathan, Bryan L Sykes, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Santosh Kumar Tadakamadla, Ken Takahashi, Jukka S Takala, Nikhil Tandon, Marcel Tanner, Yihunie L Tarekegn, Mohammad Tavakkoli, Teketo Kassaw Tegegne, Arash Tehrani-Banihashemi, Abdullah Sulieman Terkawi, Belay Tesssema, JS Thakur, Ornwipa Thamsuwan, Kavumpurathu Raman Thankappan, Andrew M Theis, Matthew Lloyd Thomas, Alan J Thomson, Amanda G Thrift, Taavi Tillmann, Ruoyan Tobe-Gai, Myriam Tobollik, Mette C Tollanes, Marcello Tonelli, Roman Topor-Madry, Anna Torre, Miguel Tortajada, Mathilde Touvier, Bach Xuan Tran, Thomas Truelsen, Kald Beshir Tuem, Emin Murat Tuzcu, Stefanos Tyrovolas, Kingsley Nnanna Ukwaja, Chigozie Jesse Uneke, Rachel Updike, Olalekan A Uthman, Job F M van Boven, Santosh Varughese, Tommi Vasankari, Lennert J Veerman, Vidhya Venkateswaran, Narayanaswamy Venketasubramanian, Francesco S Violante, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Theo Vos, Fiseha Wadilo, Tolassa Wakayo, Mitchell T Wallin, Yuan-Pang Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Daniel J Weiss, Andrea Werdecker, Ronny Westerman, Harvey A Whiteford, Charles Shey Wiysonge, Belete Getahun Woldeyes, Charles D A Wolfe, Rachel Woodbrook, Abdulhalik Workicho, Denis Xavier, Gelin Xu, Simon Yadgir, Bereket Yakob, Lijing L Yan, Mehdi Yaseri, Hassen Hamid Yimam, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Marcel Yotebieng, Mustafa Z Younis, Zoubida Zaidi, Maysaa El Sayed Zaki, Luis Zavala-Arciniega, Xueying Zhang, Stephanie Raman M Zimsen, Ben Zipkin, Sanjay Zodpey, Stephen S Lim, Christopher J L Murray
Journal: The Lancet (2017)

BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.MethodsWe used the comparative risk assessment 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 clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. 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. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.FindingsSince 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9–11·6) decline in deaths and a 10·8% (8·3–13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7–17·5) of deaths and 6·2% (3·9–8·7) of DALYs, and population growth for 12·4% (10·1–14·9) of deaths and 12·4% (10·1–14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9–29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.InterpretationIncreasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.FundingThe Bill & Melinda Gates Foundation, Bloomberg Philanthropies.