Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
Authors: Michael Brauer, Gregory A Roth, Aleksandr Y Aravkin, Peng Zheng, Kalkidan Hassen Abate, Yohannes Habtegiorgis Abate, Cristiana Abbafati, Rouzbeh Abbasgholizadeh, Madineh Akram Abbasi, Mohammadreza Abbasian, Mitra Abbasifard, Mohsen Abbasi-Kangevari, Samar Abd ElHafeez, Sherief Abd-Elsalam, Parsa Abdi, Mohammad Abdollahi, Meriem Abdoun, Deldar Morad Abdulah, Auwal Abdullahi, Mesfin Abebe, Aidin Abedi, Armita Abedi, Tadesse M Abegaz, Roberto Ariel Abeldaño Zuñiga, Olumide Abiodun, Temesgen Lera Abiso, Richard Gyan Aboagye, Hassan Abolhassani, Mohamed Abouzid, Girma Beressa Aboye, Lucas Guimarães Abreu, Hasan Abualruz, Bilyaminu Abubakar, Eman Abu-Gharbieh, Hana Jihad Jihad Abukhadijah, Salahdein Aburuz, Ahmed Abu-Zaid, Mesafint Molla Adane, Isaac Yeboah Addo, Giovanni Addolorato, Rufus Adesoji Adedoyin, Victor Adekanmbi, Bashir Aden, Juliana Bunmi Adetunji, Temitayo Esther Adeyeoluwa, Rishan Adha, Amin Adibi, Qorinah Estiningtyas Sakilah Adnani, Leticia Akua Adzigbli, Aanuoluwapo Adeyimika Afolabi, Rotimi Felix Afolabi, Ashkan Afshin, Shadi Afyouni, Muhammad Sohail Afzal, Saira Afzal, Suneth Buddhika Agampodi, Faith Agbozo, Shahin Aghamiri, Antonella Agodi, Anurag Agrawal, Williams Agyemang-Duah, Bright Opoku Ahinkorah, Aqeel Ahmad, Danish Ahmad, Firdos Ahmad, Noah Ahmad, Shahzaib Ahmad, Tauseef Ahmad, Ali Ahmed, Anisuddin Ahmed, Ayman Ahmed, Luai A Ahmed, Muktar Beshir Ahmed, Safoora Ahmed, Syed Anees Ahmed, Marjan Ajami, Gizachew Taddesse Akalu, Essona Matatom Akara, Hossein Akbarialiabad, Shiva Akhlaghi, Karolina Akinosoglou, Tomi Akinyemiju, Mohammed Ahmed Akkaif, Sreelatha Akkala, Blessing Akombi-Inyang, Salah Al Awaidy, Syed Mahfuz Al Hasan, Fares Alahdab, Tareq Mohammed Ali AL-Ahdal, Samer O Alalalmeh, Tariq A Alalwan, Ziyad Al-Aly, Khurshid Alam, Nazmul Alam, Fahad Mashhour Alanezi, Turki M Alanzi, Almaza Albakri, Mohammad T AlBataineh, Wafa A Aldhaleei, Robert W Aldridge, Mulubirhan Assefa Alemayohu, Yihun Mulugeta Alemu, Bassam Al-Fatly, Adel Ali Saeed Al-Gheethi, Khairat Al-Habbal, Khalid F Alhabib, Robert Kaba Alhassan, Abid Ali, Amjad Ali, Beriwan Abdulqadir Ali, Iman Ali, Liaqat Ali, Mohammed Usman Ali, Rafat Ali, Syed Shujait Shujait Ali, Waad Ali, Gianfranco Alicandro, Sheikh Mohammad Alif, Syed Mohamed Aljunid, François Alla, Sabah Al-Marwani, Hesham M Al-Mekhlafi, Sami Almustanyir, Mahmoud A Alomari, Jordi Alonso, Jaber S Alqahtani, Ahmed Yaseen Alqutaibi, Rajaa M Al-Raddadi, Ahmad Alrawashdeh, Rami Hani Al-Rifai, Sahel Majed Alrousan, Salman Khalifah Al-Sabah, Najim Z Alshahrani, Zaid Altaany, Awais Altaf, Jaffar A Al-Tawfiq, Khalid A Altirkawi, Deborah Oyine Aluh, Nelson Alvis-Guzman, Nelson J Alvis-Zakzuk, Hassan Alwafi, Mohammad Sami Al-Wardat, Yaser Mohammed Al-Worafi, Hany Aly, Safwat Aly, Karem H Alzoubi, Walid Al-Zyoud, Uchenna Anderson Amaechi, Masous Aman Mohammadi, Reza Amani, Sohrab Amiri, Mohammad Hosein Amirzade-Iranaq, Enrico Ammirati, Hubert Amu, Dickson A Amugsi, Ganiyu Adeniyi Amusa, Robert Ancuceanu, Deanna Anderlini, Jason A Anderson, Pedro Prata Andrade, Catalina Liliana Andrei, Tudorel Andrei, Susan C Anenberg, Dhanalakshmi Angappan, Colin Angus, Abhishek Anil, Sneha Anil, Afifa Anjum, Amir Anoushiravani, Ippazio Cosimo Antonazzo, Catherine M Antony, Ernoiz Antriyandarti, Boluwatife Stephen Anuoluwa, Davood Anvari, Saeid Anvari, Saleha Anwar, Sumadi Lukman Anwar, Razique Anwer, Ekenedilichukwu Emmanuel Anyabolo, Anayochukwu Edward Anyasodor, Geminn Louis Carace Apostol, Jalal Arabloo, Razman Arabzadeh Bahri, Mosab Arafat, Demelash Areda, Brhane Berhe Aregawi, Abdulfatai Aremu, Benedetta Armocida, Michael Benjamin Arndt, Johan Ärnlöv, Mahwish Arooj, Anton A Artamonov, Kurnia Dwi Artanti, Idowu Thomas Aruleba, Ashokan Arumugam, Akram M Asbeutah, Saeed Asgary, Akeza Awealom Asgedom, Charlie Ashbaugh, Mubarek Yesse Ashemo, Tahira Ashraf, Amir Askarinejad, Michael Assmus, Thomas Astell-Burt, Mohammad Athar, Seyyed Shamsadin Athari, Prince Atorkey, Alok Atreya, Avinash Aujayeb, Marcel Ausloos, Leticia Avila-Burgos, Andargie Abate Awoke, Beatriz Paulina Ayala Quintanilla, Haleh Ayatollahi, Carlos Ayestas Portugal, Jose L Ayuso-Mateos, Sina Azadnajafabad, Rui M S Azevedo, Gulrez Shah Azhar, Hosein Azizi, Ahmed Y Azzam, Insa Linnea Backhaus, Muhammad Badar, Ashish D Badiye, Arvind Bagga, Soroush Baghdadi, Nasser Bagheri, Sara Bagherieh, Pegah Bahrami Taghanaki, Ruhai Bai, Atif Amin Baig, Jennifer L Baker, Shankar M Bakkannavar, Madhan Balasubramanian, Ovidiu Constantin Baltatu, Kiran Bam, Soham Bandyopadhyay, Biswajit Banik, Palash Chandra Banik, Aduragbemi Banke-Thomas, Hansi Bansal, Martina Barchitta, Mainak Bardhan, Erfan Bardideh, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Francesco Barone-Adesi, Hiba Jawdat Barqawi, Lope H Barrero, Amadou Barrow, Sandra Barteit, Zarrin Basharat, Afisu Basiru, João Diogo Basso, Mohammad-Mahdi Bastan, Sanjay Basu, Sai Batchu, Kavita Batra, Ravi Batra, Bernhard T Baune, Mohsen Bayati, Nebiyou Simegnew Bayileyegn, Thomas Beaney, Amir Hossein Behnoush, Maryam Beiranvand, Yannick Béjot, Alehegn Bekele, Uzma Iqbal Belgaumi, Arielle Wilder Bell, Michelle L Bell, Muhammad Bashir Bello, Olorunjuwon Omolaja Bello, Luis Belo, Apostolos Beloukas, Salaheddine Bendak, Derrick A Bennett, Fiona B Bennitt, Isabela M Bensenor, Habib Benzian, Azizullah Beran, Zombor Berezvai, Eduardo Bernabe, Robert S Bernstein, Paulo J G Bettencourt, Akshaya Srikanth Bhagavathula, Neeraj Bhala, Dinesh Bhandari, Nikha Bhardwaj, Pankaj Bhardwaj, Sonu Bhaskar, Ajay Nagesh Bhat, Vivek Bhat, Gurjit Kaur Bhatti, Jasvinder Singh Bhatti, Manpreet S Bhatti, Rajbir Bhatti, Mohiuddin Ahmed Bhuiyan, Zulfiqar A Bhutta, Boris Bikbov, Jessica Devin Bishai, Catherine Bisignano, Atanu Biswas, Bijit Biswas, Raaj Kishore Biswas, Tone Bjørge, Micheal Kofi Boachie, Hosea Boakye, Moses John Bockarie, Virginia Bodolica, Aadam Olalekan Bodunrin, Eyob Ketema Bogale, Srinivasa Rao Bolla, Archith Boloor, Milad Bonakdar Hashemi, Sri Harsha Boppana, Berrak Bora Basara, Hamed Borhany, Alejandro Botero Carvajal, Souad Bouaoud, Soufiane Boufous, Rupert Bourne, Christopher Boxe, Dejana Braithwaite, Luisa C Brant, Amanpreet Brar, Nicholas J K Breitborde, Susanne Breitner, Hermann Brenner, Andrey Nikolaevich Briko, Gabrielle Britton, Colin Stewart Brown, Annie J Browne, Andre R Brunoni, Dana Bryazka, Norma B Bulamu, Lemma N Bulto, Danilo Buonsenso, Katrin Burkart, Richard A Burns, Reinhard Busse, Yasser Bustanji, Nadeem Shafique Butt, Zahid A Butt, Florentino Luciano Caetano dos Santos, Jack Cagney, Lucero Cahuana-Hurtado, Daniela Calina, Luis Alberto Cámera, Luciana Aparecida Campos, Ismael R Campos-Nonato, Chao Cao, Fan Cao, Yubin Cao, Angelo Capodici, Rosario Cárdenas, Sinclair Carr, Giulia Carreras, Juan J Carrero, Andrea Carugno, Felix Carvalho, Márcia Carvalho, Joao Mauricio Castaldelli-Maia, Carlos A Castañeda-Orjuela, Giulio Castelpietra, Ferrán Catalá-López, Alberico L Catapano, Maria Sofia Cattaruzza, Arthur Caye, Christopher R Cederroth, Luca Cegolon, Muthia Cenderadewi, Kelly M Cercy, Ester Cerin, Joshua Chadwick, Chiranjib Chakraborty, Promit Ananyo Chakraborty, Sandip Chakraborty, Jeffrey Shi Kai Chan, Raymond N C Chan, Joht Singh Chandan, Rama Mohan Chandika, Pankaj Chaturvedi, An-Tian Chen, Catherine S Chen, Haowei Chen, Meng Xuan Chen, Mingling Chen, Simiao Chen, Ching-Yu Cheng, Esther T W Cheng, Nicolas Cherbuin, Gerald Chi, Fatemeh Chichagi, Odgerel Chimed-Ochir, Ritesh Chimoriya, Patrick R Ching, Jesus Lorenzo Chirinos-Caceres, Abdulaal Chitheer, William C S Cho, Bryan Chong, Hitesh Chopra, Rajiv Chowdhury, Devasahayam J Christopher, Dinh-Toi Chu, Isaac Sunday Chukwu, Eric Chung, Sheng-Chia Chung, Muhammad Chutiyami, Iolanda Cioffi, Rebecca M Cogen, Aaron J Cohen, Alyssa Columbus, Joao Conde, Alexandru Corlateanu, Samuele Cortese, Paolo Angelo Cortesi, Vera Marisa Costa, Simona Costanzo, Michael H Criqui, Jessica A Cruz, Natália Cruz-Martins, Garland T Culbreth, Alanna Gomes da Silva, Omid Dadras, Xiaochen Dai, Zhaoli Dai, Patience Unekwuojo Daikwo, Lachlan L Dalli, Giovanni Damiani, Emanuele D'Amico, Lucio D'Anna, Aso Mohammad Darwesh, Jai K Das, Subasish Das, Nihar Ranjan Dash, Mohsen Dashti, Claudio Alberto Dávila-Cervantes, Nicole Davis Weaver, Dragos Virgil Davitoiu, Fernando Pio De la Hoz, Alejandro de la Torre-Luque, Diego De Leo, Shayom Debopadhaya, Louisa Degenhardt, Cristian Del Bo', Ivan Delgado-Enciso, Juana Maria Delgado-Saborit, Chalachew Kassaw Demoze, Edgar Denova-Gutiérrez, Nikolaos Dervenis, Emina Dervišević, Hardik Dineshbhai Desai, Rupak Desai, Vinoth Gnana Chellaiyan Devanbu, Syed Masudur Rahman Dewan, Arkadeep Dhali, Kuldeep Dhama, Amol S Dhane, Mandira Lamichhane Dhimal, Meghnath Dhimal, Sameer Dhingra, Vishal R Dhulipala, Raja Ram Dhungana, Diana Dias da Silva, Daniel Diaz, Luis Antonio Diaz, Michael J Diaz, Adriana Dima, Delaney D Ding, Monica Dinu, Shirin Djalalinia, Thanh Chi Do, Thao Huynh Phuong Do, Camila Bruneli do Prado, Masoud Dodangeh, Sushil Dohare, Klara Georgieva Dokova, Wanyue Dong, Deepa Dongarwar, Mario D'Oria, Fariba Dorostkar, E Ray Dorsey, Rajkumar Doshi, Leila Doshmangir, Robert Kokou Dowou, Tim Robert Driscoll, Ashel Chelsea Dsouza, Haneil Larson Dsouza, Samuel C Dumith, Bruce B Duncan, Andre Rodrigues Duraes, Senbagam Duraisamy, Anar Dushpanova, Paulina Agnieszka Dzianach, Arkadiusz Marian Dziedzic, Alireza Ebrahimi, Chidiebere Peter Echieh, Abdelaziz Ed-Dra, Hisham Atan Edinur, David Edvardsson, Kristina Edvardsson, Ferry Efendi, Aziz Eftekharimehrabad, Ebrahim Eini, Michael Ekholuenetale, Temitope Cyrus Ekundayo, Rabie Adel El Arab, Maysaa El Sayed Zaki, Faris El-Dahiyat, Noha Mousaad Elemam, Frank J Elgar, Ghada Metwally Tawfik ElGohary, Hala Rashad Elhabashy, Muhammed Elhadi, Ahmed O Elmehrath, Omar Abdelsadek Abdou Elmeligy, Mohammed Elshaer, Ibrahim Elsohaby, Theophilus I Emeto, Negin Esfandiari, Babak Eshrati, Majid Eslami, Sayed Vahid Esmaeili, Kara Estep, Farshid Etaee, Natalia Fabin, Adeniyi Francis Fagbamigbe, Omotayo Francis Fagbule, Saman Fahimi, Luca Falzone, Mohammad Fareed, Carla Sofia e Sá Farinha, MoezAlIslam Ezzat Mahmoud Faris, Pawan Sirwan Faris, Andre Faro, Folorunso Oludayo Fasina, Ali Fatehizadeh, Nelsensius Klau Fauk, Timur Fazylov, Valery L Feigin, Xiaoqi Feng, Seyed-Mohammad Fereshtehnejad, Abdullah Hamid Feroze, Pietro Ferrara, Alize J Ferrari, Nuno Ferreira, Getahun Fetensa, Bikila Regassa Feyisa, Irina Filip, Florian Fischer, Ida Fitriana, Joanne Flavel, Carsten Flohr, David Flood, Luisa S Flor, Nataliya A Foigt, Morenike Oluwatoyin Folayan, Lisa M Force, Daniela Fortuna, Matteo Foschi, Richard Charles Franklin, Alberto Freitas, Sara D Friedman, Blima Fux, Sridevi G, Peter Andras Gaal, Santosh Gaihre, Márió Gajdács, Yaseen Galali, Silvano Gallus, Aravind P Gandhi, Balasankar Ganesan, Mohammad Arfat Ganiyani, Vanessa Garcia, William M Gardner, Ravindra K Garg, Rupesh K Gautam, Tilaye Gebru Gebi, Miglas W Gebregergis, Mesfin Gebrehiwot, Tesfay B B Gebremariam, Teferi Gebru Gebremeskel, Urge Gerema, Lemma Getacher, Genanew K a Getahun, Molla Getie, Fataneh Ghadirian, Sadegh Ghafarian, Amir Ghaffari Jolfayi, Khalid Yaser Ghailan, Alireza Ghajar, MohammadReza Ghasemi, Ghazal Ghasempour Dabaghi, Afsaneh Ghasemzadeh, Fariba Ghassemi, Ramy Mohamed Ghazy, Ali Gholami, Ali Gholamrezanezhad, Nasim Gholizadeh, Mahsa Ghorbani, Artyom Urievich Gil, Gabriela Fernanda Gil, Nora M Gilbertson, Paramjit Singh Gill, Tiffany K Gill, Ebisa Zerihun Gindaba, Alem Girmay, James C Glasbey, Elena V Gnedovskaya, Laszlo Göbölös, Myron Anthony Godinho, Amit Goel, Mahaveer Golechha, Pouya Goleij, Davide Golinelli, Nelson G M Gomes, Sameer Vali Gopalani, Giuseppe Gorini, Houman Goudarzi, Alessandra C Goulart, Mahdi Gouravani, Anmol Goyal, Simon Matthew Graham, Michal Grivna, Giuseppe Grosso, Shi-Yang Guan, Giovanni Guarducci, Mohammed Ibrahim Mohialdeen Gubari, Avirup Guha, Stefano Guicciardi, Snigdha Gulati, David Gulisashvili, Damitha Asanga Gunawardane, Cui Guo, Anish Kumar Gupta, Bhawna Gupta, Mohak Gupta, Rahul Gupta, Rajat Das Gupta, Rajeev Gupta, Sapna Gupta, Veer Bala Gupta, Vijai Kumar Gupta, Vivek Kumar Gupta, Farrokh Habibzadeh, Parham Habibzadeh, Tesfahun Simon Hadaro, Zahra Hadian, Nils Haep, Hamed Haghi-Aminjan, Dariush Haghmorad, Hailey Hagins, Demewoz Haile, Alemayehu Hailu, Adel Hajj Ali, Esam S Halboub, Aram Halimi, Brian J Hall, Sebastian Haller, Rabih Halwani, Randah R Hamadeh, Nadia M Hamdy, Sajid Hameed, Samer Hamidi, Ahmad Hammoud, Asif Hanif, Nasrin Hanifi, Zaim Anan Haq, Md Rabiul Haque, Harapan Harapan, Arief Hargono, Josep Maria Haro, Ahmed I Hasaballah, Ikramul Hasan, Mohammad Jahid Hasan, S M Mahmudul Hasan, Hamidreza Hasani, Mohammad Hasanian, Nadim Hashmeh, Md Saquib Hasnain, Amr Hassan, Ikrama Hassan, Mahgol Sadat Hassan Zadeh Tabatabaei, Shokoufeh Hassani, Soheil Hassanipour, Hadi Hassankhani, Johannes Haubold, Rasmus J Havmoeller, Simon I Hay, Jeffrey J Hebert, Omar E Hegazi, Tadele Yohannes Hegena, Golnaz Heidari, Mohammad Heidari, Bartosz Helfer, Mehdi Hemmati, Claire A Henson, Molly E Herbert, Claudiu Herteliu, Austin Heuer, Kamal Hezam, Thomas Kwadwo Hinneh, Yuta Hiraike, Nguyen Quoc Hoan, Ramesh Holla, Julia Hon, Mohammad Enamul Hoque, Nobuyuki Horita, Sahadat Hossain, Seyed Ehsan Hosseini, Hassan Hosseinzadeh, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Hanno Hoven, Mohamed Hsairi, Johnathan M Hsu, Chengxi Hu, Junjie Huang, Md Nazmul Huda, Erin N Hulland, Michael Hultström, Kiavash Hushmandi, Javid Hussain, Nawfal R Hussein, Chantal K Huynh, Hong-Han Huynh, Segun Emmanuel Ibitoye, Oluwatope Olaniyi Idowu, Audrey L Ihler, Nayu Ikeda, Kevin S Ikuta, Olayinka Stephen Ilesanmi, Irena M Ilic, Milena D Ilic, Mohammad Tarique Imam, Mustapha Immurana, Leeberk Raja Inbaraj, Lalu Muhammad Irham, Mustafa Alhaji Isa, Md Rabiul Islam, Faisal Ismail, Nahlah Elkudssiah Ismail, Hiroyasu Iso, Gaetano Isola, Masao Iwagami, Chidozie C D Iwu, Chinwe Juliana Iwu-Jaja, Vinothini J, Jalil Jaafari, Louis Jacob, Kathryn H Jacobsen, Farhad Jadidi-Niaragh, Kasra Jahankhani, Nader Jahanmehr, Haitham Jahrami, Akhil Jain, Nityanand Jain, Ammar Abdulrahman Jairoun, Abhishek Jaiswal, Mihajlo Jakovljevic, Reza Jalilzadeh Yengejeh, Roland Dominic G Jamora, Abubakar Ibrahim Jatau, Sabzali Javadov, Tahereh Javaheri, Shubha Jayaram, Jayakumar Jeganathan, Bijay Mukesh Jeswani, Heng Jiang, Catherine O Johnson, Mohammad Jokar, Nabi Jomehzadeh, Jost B Jonas, Tamas Joo, Abel Joseph, Nitin Joseph, Vivek Joshi, Charity Ehimwenma Joshua, Jacek Jerzy Jozwiak, Mikk Jürisson, Billingsley Kaambwa, Ali Kabir, Zubair Kabir, Vidya Kadashetti, Ethan M Kahn, Rizwan Kalani, Feroze Kaliyadan, Sanjay Kalra, Rajesh Kamath, Thanigaivelan Kanagasabai, Tanuj Kanchan, Himal Kandel, Edmund Wedam Kanmiki, Kehinde Kazeem Kanmodi, Sushil Kumar Kansal, Daniel John Kapner, Neeti Kapoor, Efstratios Karagiannidis, Mehrdad Karajizadeh, Paschalis Karakasis, Shama D Karanth, Ibraheem M Karaye, André Karch, Asima Karim, Hanie Karimi, Shilpi Karmakar, Faizan Zaffar Kashoo, Hengameh Kasraei, Woldeteklehaymanot Dagne Kassahun, Nicholas J Kassebaum, Molly B Kassel, Srinivasa Vittal Katikireddi, Joonas H Kauppila, Norito Kawakami, Neda Kaydi, Gbenga A Kayode, Foad Kazemi, Peter Njenga Keiyoro, Laura Kemmer, John H Kempen, Jessica A Kerr, Emmanuelle Kesse-Guyot, Yousef Saleh Khader, Morteza Abdullatif Khafaie, Himanshu Khajuria, Amirmohammad Khalaji, Mariam Khalil, Alireza Khalilian, Faham Khamesipour, Asaduzzaman Khan, M Nuruzzaman Khan, Maseer Khan, Mohammad Jobair Khan, Moien AB Khan, Shaghayegh Khanmohammadi, Khaled Khatab, Haitham Khatatbeh, Moawiah Mohammad Khatatbeh, Mahalaqua Nazli Khatib, Armin Khavandegar, Hamid Reza Khayat Kashani, Feriha Fatima Khidri, Elaheh Khodadoust, Moein Khormali, Zahra Khorrami, Atulya Aman Khosla, Mahmood Khosrowjerdi, Haneen Khreis, Helda Khusun, Zemene Demelash Kifle, Kwanghyun Kim, Min Seo Kim, Yun Jin Kim, Ruth W Kimokoti, Adnan Kisa, Sezer Kisa, Luke D Knibbs, Ann Kristin Skrindo Knudsen, David S Q Koh, Ali-Asghar Kolahi, Farzad Kompani, Jianqiu Kong, Gerbrand Koren, Miikka Korja, Vladimir Andreevich Korshunov, Oleksii Korzh, Soewarta Kosen, Nikhil Kothari, Parvaiz A Koul, Sindhura Lakshmi Koulmane Laxminarayana, Kewal Krishan, Vijay Krishnamoorthy, Yuvaraj Krishnamoorthy, Bindu Krishnan, Kris J Krohn, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Md Abdul Kuddus, Mohammed Kuddus, Nuworza Kugbey, Ilari Kuitunen, Mukhtar Kulimbet, Vishnutheertha Kulkarni, Ashish Kumar, Nithin Kumar, Vijay Kumar, Satyajit Kundu, Om P Kurmi, Asep Kusnali, Dian Kusuma, Tezer Kutluk, Carlo La Vecchia, Muhammad Awwal Ladan, Lucie Laflamme, Chandrakant Lahariya, Daphne Teck Ching Lai, Dharmesh Kumar Lal, Tea Lallukka, Judit Lám, Qing Lan, Tuo Lan, Iván Landires, Francesco Lanfranchi, Berthold Langguth, Van Charles Lansingh, Ariane Laplante-Lévesque, Bagher Larijani, Anders O Larsson, Savita Lasrado, Paolo Lauriola, Huu-Hoai Le, Long Khanh Dao Le, Nhi Huu Hanh Le, Thao Thi Thu Le, Janet L Leasher, Caterina Ledda, Munjae Lee, Paul H Lee, Seung Won Lee, Shaun Wen Huey Lee, Yo Han Lee, Kate E LeGrand, James Leigh, Elvynna Leong, Temesgen L Lerango, Haley Lescinsky, Janni Leung, Ming-Chieh Li, Wang-Zhong Li, Wei Li, Yichong Li, Zhihui Li, Virendra S Ligade, Lee-Ling Lim, Stephen S Lim, Ro-Ting Lin, Shuzhi Lin, Chaojie Liu, Gang Liu, Jinli Liu, Jue Liu, Richard T Liu, Shiwei Liu, Wei Liu, Xiaofeng Liu, Xuefeng Liu, Katherine M Livingstone, Erand Llanaj, Ayush Lohiya, Rubén López-Bueno, Platon D Lopukhov, Stefan Lorkowski, Paulo A Lotufo, Rafael Lozano, Jailos Lubinda, Giancarlo Lucchetti, Lisha Luo, Hengliang lv, Hawraz Ibrahim M Amin, Zheng Feei Ma, Kelsey Lynn Maass, Mahmoud Mabrok, Nikolaos Machairas, Monika Machoy, Asma Mafhoumi, Mohammed Magdy Abd El Razek, Azzam A Maghazachi, D R Mahadeshwara Prasad, Sandeep B Maharaj, Mansour Adam Mahmoud, Elham Mahmoudi, Azeem Majeed, Omar Mohamed Makram, Konstantinos Christos Makris, Satyaveni Malasala, Venkatesh Maled, Kashish Malhotra, Ahmad Azam Malik, Iram Malik, Lesibana Anthony Malinga, Deborah Carvalho Malta, Abdullah A Mamun, Ana Laura Manda, Yosef Manla, Ali Mansour, Borhan Mansouri, Pejman Mansouri, Marjan Mansourian, Mohammad Ali Mansournia, Lorenzo Giovanni Mantovani, Emmanuel Manu, Hamid Reza Marateb, Joemer C Maravilla, Elizabeth Marsh, Gabriel Martinez, Ramon Martinez-Piedra, Santi Martini, Francisco Rogerlândio Martins-Melo, Miquel Martorell, Wolfgang Marx, Sharmeen Maryam, Yasith Mathangasinghe, Alexander G Mathioudakis, Fernanda Penido Matozinhos, Jishanth Mattumpuram, Andrea Maugeri, Pallab K Maulik, Mahsa Mayeli, Mohsen Mazidi, Antonio Mazzotti, John J McGrath, Martin McKee, Anna Laura W McKowen, Susan A McLaughlin, Michael A McPhail, Steven M McPhail, Enkeleint A Mechili, Asim Mehmood, Khalid Mehmood, Kamran Mehrabani-Zeinabad, Entezar Mehrabi Nasab, Toni Meier, Fabiola Mejia-Rodriguez, Tesfahun Mekene Meto, Birye Dessalegn Mekonnen, Ritesh G Menezes, Belayneh Mengist, 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Shadrach Wilson, Yen Jun Wong, Utoomporn Wongsin, Sarah Wozniak, Chenkai Wu, Dongze Wu, Felicia Wu, Zenghong Wu, Juan Xia, Hong Xiao, Suowen Xu, Xiaoyue Xu, Yvonne Yiru Xu, Mukesh Kumar Yadav, Sajad Yaghoubi, Kazumasa Yamagishi, Lin Yang, Yuichiro Yano, Habib Yaribeygi, Yuichi Yasufuku, Pengpeng Ye, Renjulal Yesodharan, Subah Abderehim Yesuf, Saber Yezli, Siyan Yi, Arzu Yiğit, Zeamanuel Anteneh Yigzaw, Dehui Yin, Paul Yip, Malede Berihun Yismaw, Dong Keon Yon, Naohiro Yonemoto, Yuyi You, Mustafa Z Younis, Zabihollah Yousefi, Chuanhua Yu, Yong Yu, Siddhesh Zadey, Vesna Zadnik, Fathiah Zakham, Nazar Zaki, Josefina Zakzuk, Giulia Zamagni, Sojib Bin Zaman, Ghazal G Z Zandieh, Aurora Zanghì, Heather J Zar, Iman Zare, Fatemeh Zarimeidani, Mikhail Sergeevich Zastrozhin, Youjie Zeng, Chunxia Zhai, Anthony Lin Zhang, Haijun Zhang, Liqun Zhang, Meixin Zhang, Yunquan Zhang, Zhenyu Zhang, Zhi-Jiang Zhang, Hanqing Zhao, Jeff T Zhao, Xiu-Ju George Zhao, Yang Zhao, Yong Zhao, Chenwen Zhong, Jingjing Zhou, Juexiao Zhou, Shangcheng Zhou, Bin Zhu, Lei Zhu, Zhaohua Zhu, Boback Ziaeian, Makan Ziafati, Magdalena Zielińska, Stephanie R M Zimsen, Ghazal Zoghi, Thomas Zoller, Alimuddin Zumla, Sa'ed H Zyoud, Samer H Zyoud, Christopher J L Murray, Emmanuela Gakidou
Journal: The Lancet (2024)

<h2>Summary</h2><h3>Background</h3> Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. <h3>Methods</h3> The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. <h3>Findings</h3> Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). <h3>Interpretation</h3> Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. <h3>Funding</h3> Bill & Melinda Gates Foundation.