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

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Abstract

BACKGROUND: The 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. METHODS: We 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. FINDINGS: In 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. INTERPRETATION: By 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. FUNDING: Bill & Melinda Gates Foundation.

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The record

Venue

The Lancet

Topic

Health, Environment, Cognitive Aging

Field

Environmental Science

Canadian institutions

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Funders

Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institute on Deafness and Other Communication DisordersNational Institute of Mental HealthDipartimento di Medicina e Chirurgia, Università degli Studi di Milano-BicoccaCenter for International HealthSydney Medical SchoolNational Health and Medical Research CouncilHealth CanadaDepartment of Global Health and Population, Harvard T.H. Chan School of Public HealthUniversity of Colorado DenverJohns Hopkins Bloomberg School of Public HealthUniversity of California, Los AngelesCollege of Engineering, Michigan State UniversityNational Oceanic and Atmospheric AdministrationCenters for Disease Control and PreventionMedical Research CouncilRobert Koch InstitutUniwersytet OpolskiNational Institutes of Biomedical Innovation, Health and NutritionUniversitair Ziekenhuis AntwerpenAlfaisal UniversityLaboratório Associado para a Química VerdeWestern Sydney UniversityMinistry of Health of the Russian FederationLomonosov Moscow State UniversityBispebjerg HospitalUniversidade Federal de SergipeDuke Kunshan UniversityApplied Molecular Biosciences UnitKurdistan University Of Medical SciencesWageningen University and ResearchSamara UniversityH. Lundbeck A/SUniversity of NamibiaLorestan University of Medical SciencesAlborz University of Medical SciencesKwame Nkrumah University of Science and TechnologyHormozgan University of Medical SciencesServierUniversity of ThessalyMedizinische Universität GrazAlexandria UniversityHawassa UniversityMansoura UniversityKarl-Franzens-Universität GrazInternational Centre for Diarrhoeal Disease Research, BangladeshThe Wellcome Trust DBT India AllianceUniversity of Social Welfare and Rehabilitation SciencesGeorge Institute for Global HealthUniversity of PeradeniyaXiamen UniversityNSW Ministry of HealthTartu ÜlikoolUniversity of TabrizUniversitatea de Medicină şi Farmacie "Carol Davila" BucureştiUniversity of the PhilippinesUrmia UniversityNational Research University Higher School of EconomicsUniversity of Cape TownAddis Ababa UniversityUniversità degli Studi di SalernoUniversidade do PortoUniversity of TsukubaUniversity of DhakaNational Taiwan UniversityAristotle University of ThessalonikiQazvin University of Medical SciencesMedical University - VarnaUniversité de BordeauxUnited Arab Emirates UniversityUniversità di BolognaBahir Dar UniversityNIH Clinical CenterBaqiyatallah University of Medical SciencesGöteborgs UniversitetUniversidade de São PauloUniversitetet i OsloNational and Kapodistrian University of AthensKoch Institute for Integrative Cancer Research, Massachusetts Institute of TechnologyGuilan University of Medical SciencesUniversitair Medisch Centrum GroningenUmeå UniversitetNational Institute on AgingChinese University of Hong KongUniversité de BourgogneUniversity College LondonKorea Health Industry Development InstituteUniversiti Kebangsaan MalaysiaKuwait UniversityTampereen YliopistoTabriz University of Medical SciencesUniversidad Autónoma MetropolitanaSeoul National University HospitalHebrew University of JerusalemNovo NordiskUniversity of HailUniversitat de BarcelonaMax-Planck-GesellschaftKarolinska InstitutetGeorg-August-Universität GöttingenUniversity of CanberraLunds UniversitetAbbott DiagnosticsDirectorate for Biological SciencesDebre Markos UniversityPolitechnika CzestochowskaBundesministerium für GesundheitDalhousie UniversityUniversidad Nacional de ColombiaUniversity of HaifaNational Institutes of HealthNational University of SingaporeBanaras Hindu UniversityKyung Hee UniversityYonsei UniversityHacettepe ÜniversitesiU.S. Department of Veterans AffairsKosin UniversityUniversitat Pompeu FabraSun Yat-sen UniversityFakultet Medicinskih Nauka, Univerziteta U KragujevcuShiraz University of Medical SciencesAin Shams UniversityCochrane South AfricaImperial College LondonPublic Health EnglandUniversiti Sains MalaysiaCurtin University of TechnologyUniversity of MelbourneHelsingin YliopistoRMIT UniversityDeakin UniversityUniversity of New South WalesEli Lilly and CompanyCentral University of Tamil NaduPublic Health AgencyMichigan State UniversityAstellas PharmaSimmons CollegeSingapore Eye Research InstituteIndian Council of Medical ResearchUniversidad de ChileDepartment of Biotechnology, Ministry of Science and Technology, IndiaUniversity of TasmaniaStudent Research Committee, Tabriz University of Medical SciencesFrankfurt University of Applied SciencesLa Trobe UniversityUniversity of GlasgowCarolina Population Center, University of North Carolina at Chapel HillMenzies Health Institute QueenslandSanofiUniversity of OxfordUniversity of SouthamptonUniversity of LeicesterErasmus Universitair Medisch Centrum RotterdamBritish Heart FoundationUniversität BaselUniwersytet ŁódzkiMaragheh University of Medical SciencesBrien Holden Vision InstituteKrishna Institute Of Medical Sciences Deemed To Be UniversityUniwersytet Jagielloński Collegium MedicumChalmers Tekniska HögskolaBloomberg PhilanthropiesUniversity of EmbuNovavaxCooperative Institute for Research in Environmental SciencesUniversity of ChichesterUniversitas Negeri SemarangUniversity of North Carolina at Chapel HillEuropean CommissionAhmadu Bello UniversityNational Institute for Health and Care ResearchUniversità degli Studi di FirenzeDanoneUniversity of Occupational and Environmental HealthDebre Tabor UniversityUniversiteit UtrechtDuke-NUS Medical SchoolNational Heart Foundation of AustraliaIstituto di Ricerche Farmacologiche Mario Negri - IRCCSInyuvesi Yakwazulu-NataliAnglia Ruskin UniversityQueen Elizabeth Hospital Birmingham CharityUniversität BielefeldFlinders UniversityOklahoma State UniversityLawson Health Research InstituteScottish GovernmentValeant Pharmaceuticals InternationalAarhus UniversitetTeikyo University School of MedicineAksum UniversityTrường Đại học Duy TânUniversity of WarwickOhio State UniversityJohns Hopkins UniversityKorea UniversityWellcome TrustUniversity of OttawaNIHR Oxford Biomedical Research CentreHorizon PharmaceuticalsMinistry of Health and Medical EducationHaramaya UniversityArabian Gulf UniversityUniversita degli Studi di Bari Aldo MoroUniversity of California, San DiegoHamadan University of Medical SciencesSouth Australian Health and Medical Research InstituteJordan University of Science and TechnologyNational Cerebral and Cardiovascular CenterNational Health Research InstitutesUniversity of West FloridaAustralian Catholic UniversityShiraz UniversityCancer Research UKSeoul National UniversityBurnet InstituteUniversity of Massachusetts BostonUniversity of ColomboUniversidade Federal do Rio Grande do SulCentral South UniversitySeattle Children's Research InstituteNorwegian Institute of Public HealthUnited Nations Population FundRafsanjan University of Medical SciencesUniversity of South FloridaKing's College LondonSree Chitra Tirunal Institute for Medical Sciences and TechnologyYale UniversityJimma UniversityHarvard UniversityDeutsches KrebsforschungszentrumAuckland University of Technology, New ZealandPomorski Uniwersytet Medyczny W SzczecinieUniversità degli Studi di MilanoUniversity of OtagoMazandaran University of Medical SciencesKaiser PermanenteUniversity of AlbertaUniversitetet i TromsøSanjay Gandhi Postgraduate Institute of Medical SciencesDaiichi-SankyoUniversity of LouisvilleWest Virginia UniversityAmgenAmarin CorporationNational Center for Global Health and MedicineUniversiteit GentBill and Melinda Gates FoundationPfizerHögskolan DalarnaRijksuniversiteit GroningenUniversity of WashingtonBristol-Myers SquibbQueensland University of TechnologyUniversidad de Costa RicaAmerican University of BeirutUniverzita Komenského v BratislaveDurban University of TechnologySaint Paul's Hospital Millennium Medical CollegeFaculty of Medicine and Health, University of SydneyUniversiti Brunei DarussalamUmweltbundesamtAix-Marseille UniversitéIran University of Medical SciencesGriffith UniversityRede de Química e TecnologiaTulane UniversityArizona State UniversityTexas Tech UniversityNational Drug and Alcohol Research CentreFriedrich-Schiller-Universität JenaPublic Health Agency of CanadaBirmingham City UniversityUniversitetet i BergenMoscow Institute of Physics and TechnologyEmory UniversityUniversity of OklahomaUniversity of Southern CaliforniaBiomedical Research CouncilGilead SciencesUniversiti MalayaEngineering and Physical Sciences Research CouncilIsfahan University of Medical SciencesInstituto de Salud Carlos IIISan Diego State UniversityGlaxoSmithKlineChinese Center for Disease Control and PreventionGeorge Mason UniversityShanghai Jiao Tong UniversityUniversity of South AfricaTaipei Medical UniversityUniversity College CorkCleveland ClinicNational Heart, Lung, and Blood InstituteAstraZenecaMenzies Institute for Medical ResearchBabol University of Medical SciencesUniversidade Federal de Minas GeraisAlzheimer's AssociationDamon Runyon Cancer Research Foundation

Keywords

Risk assessmentMedicineRelative riskEnvironmental healthCohort studyEstimationCounterfactual thinkingDemographyConfidence intervalPsychologyEconomics

Has abstract in OpenAlex

yes

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