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2017•The LancetOpen access

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

Emmanuela E. Gakidou, Ashkan Afshin, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Cristiana Abbafati, Kaja Abbas, Foad Abd-Allah, Abdishakur M Abdulle, Semaw Ferede Abera, Victor Aboyans, Laith Jamal 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 Akinyemi, Nadia Akseer, Fares Alahdab, Ziyad Al‐Aly, Khurshid Alam, Noore Alam, Shazia Alam, Deena Alasfoor, Kefyalew Addis Alene, Komal Ali, Reza Alizadeh‐Navaei, Ala’a Alkerwi, François Alla, Peter Allebeck, Rajaa Mohammad Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi, Nelson Alvis‐Guzmán, 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 Ávila‐Burgos, Euripide Avokpaho, Ashish Awasthi, Peter S. Azzopardi, Umar Bacha, Alaa Badawi, Kalpana Balakrishnan, Shoshana H. Ballew, Aleksandra M. Barac, Ryan M Barber, Suzanne Lyn Barker-Collo, Till Bärnighausen, Sı́món Barquera, Lars Barregård, Lope H. Barrero, Carolina Batis, Katherine E. Battle, Blair R Baumgarner, Bernhard Theodor Baune, Justin Beardsley, Neeraj Bedi, Ettore Beghi, Michelle Lee Bell, Derrick Bennett, James Risdon Bennett, Isabela M. Benseñor, Adugnaw Berhane, Derbew Fikadu Berhe, Eduardo Bernabé, Balem Demtsu Betsu, Mircea Beuran, Addisu Shunu Beyene, Anil Kumar Bhansali, Zulfiqar Ahmed Bhutta, Burcu Küçük Biçer, Boris T. Bikbov, Charles Birungi, Stan Biryukov, Christopher D. Blosser, Dube Jara Boneya, Ibrahim R. Bou-Orm, Michael D Brauer, Nicholas J. K. Breitborde, Hermann Brenner, Traolach Sean Brugha, Lemma N Bulto, Zahid A Butt, Lucero Cahuana-Hurtado, Rosario Cárdenas, Juan Jesús Carrero, Carlos Andrés Castañeda-Orjuela, Ferrán Catalá-López, Kelly M. Cercy, Hsing‐Yi Chang, Fiona Charlson, Odgerel Chimed‐Ochir, Vesper Hichilombwe Chisumpa, Abdulaal Chitheer, Hanne Christensen, Devasahayam Jesudas Christopher, Massimo Círillo, 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, Dragoş Virgil Daviţoiu, Kairat Davletov, Barbora Vozarova de Courten, Barthélémy Kuate Defo, Louisa J Degenhardt, Selina Deiparine, Robert Paul Dellavalle, Kebede Deribe, Aniruddha Deshpande, Samath Dhamminda Dharmaratne, Eric L. Ding, Shirin Djalalinia, Huyen Phuc Do, Klara Georgieva Dokova, David Teye Doku, Aaron van Donkelaar, E. Ray Dorsey, Tim Driscoll, Manisha Dubey, Bruce Bartholow Duncan, Sarah Duncan, Hedyeh Ebrahimi, Ziad El‐Khatib, Ahmadali Enayati, Aman Yesuf Endries, Sergey Petrovich Ermakov, Holly E Erskine, Babak Eshrati, Sharareh Eskandarieh, Alireza Esteghamati, Kara Estep, Emerito Jose A Faraon, Carla Sofia e Sá Farinha, André Faro, Farshad Farzadfar, Kairsten A. Fay, Valery L. Feigin, Seyed‐Mohammad Fereshtehnejad, João Carlos Fernandes, Alize J Ferrari, Tesfaye Regassa Feyissa, Irina Filip, Florian Fischer, Christina Fitzmaurice, Abraham D Flaxman, Nataliya A Foigt, Kyle J Foreman, Joseph Jon Frostad, Nancy Fullman, Thomas Fürst, João M. Furtado, Morsaleh Ganji, Alberto L. García‐Basteiro, Tsegaye Tewelde Gebrehiwot, Johanna Marianne Geleijnse, Ayele Bali Geleto, Bikila Lencha, 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 Godwin, Philimon Nyakauru Gona, Amador Goodridge, Sameer Vali Gopalani, Yevgeniy Goryakin, Alessandra Carvalho Goulart, Nicholas Graetz, Harish Chander C Gugnani, Jingwen Guo, Rajeev Gupta, Tanush Gupta, Vipin Gupta, Reyna Alma Gutiérrez, Vladimir Hachinski, Nima Hafezi‐Nejad, Gessessew Bugssa Hailu, Randah R Hamadeh, Samer Hamidi, Mouhanad Hammami, Alexis Jeannine Handal, Graeme J. Hankey, Sarah Wulf Hanson, Hilda L Harb, Habtamu Abera Hareri, Mohammad Sadegh Hassanvand, Rasmus J. Havmoeller, Caitlin N. Hawley, Simon Iain Hay, Mohammad Taghi Hedayati, Delia V. Hendrie, Ileana Heredia-Pi, Julio Cesar Montañez Hernandez, Hans Wijbrand Hoek, Nobuyuki Horita, Hung Chak Ho, Sorin Hostiuc, Damian G Hoy, Mohamed Hsaïri, Guoqing Hu, John J. Huang, Hsiang Yu Huang, Norlinah Mohamed Ibrahim, Kim Moesgaard Iburg, Chad Thomas Ikeda, Manami Inoue, Caleb Mackay Salpeter Irvine, Maria D. Jackson, Kathryn H. Jacobsen, Nader Jahanmehr, Mihajlo Jakovljević, Alejandra Jáuregui, Mehdi Javanbakht, Panniyammakal Jeemon, Lars Johansson, Catherine Owens Johnson, Jost Bruno Jonas, Mikk Jürisson, Zubair Kabir, Rajendra Kadel, Amaha Kahsay, Ritul Kamal, André Karch, Corine Karema, Amir Kasaeian, Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Norito Kawakami, Peter Njenga Keiyoro, Sefonias Getachew Kelbore, Laura Kemmer, André Pascal Kengne, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim A Khalil, Ejaz Ahmad Khan, Young‐Ho Khang, Ardeshir Khosravi, Jagdish Khubchandani, Ali Kiadaliri, Christian Kieling, Jun Yup Kim, Yun Jin Kim, Daniel J Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kısa, Katarzyna Kissimova‐Skarbek, Mika Kivimäki, Luke D. Knibbs, Ann Kristin Knudsen, Jacek A Kopec, Soewarta Kosen, Parvaiz Ahmad Koul, Ai Koyanagi, Michael A Kravchenko, Kristopher J Krohn, Hans Kromhout, G Anil Kumar, Michael Kutz, Hmwe Hmwe Kyu, Dharmesh Kumar Lal, Ratilal Lalloo, Tea M. Lallukka, Qing Lan, Van Charles Lansingh, Anders Larsson, Paul Hong Lee, Alexander Lee, James Leigh, Janni Leung, Miriam Levi, Teresa Shamah‐Levy, Li Yichong, 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 Lunevičius, Erlyn Rachelle King Macarayan, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Marek Majdán, Reza Majdzadeh, Azeem Majeed, Reza Malekzadeh, Rajesh Malhotra, Déborah Carvalho Malta, Abdullah Al Mamun, Helena Manguerra, Lorenzo Giovanni Mantovani, Chabila Christopher Mapoma, Randall V. Martin, José Martı́nez-Raga, Francisco Rogerlândio Martins‐Melo, Manu Raj Mathur, Kunihiro Matsushita, Richard Matzopoulos, Mohsen Mazidi, Colm McAlinden, John Joseph McGrath, Suresh Mehata, Man Mohan Mehndiratta, Toni Meier, Yohannes Adama Melaku, Peter T. N. Memiah, Ziad Ahmed Memish, Walter Mendoza, Melkamu Merid Mengesha, George A. Mensah, Gert Mensink, Seid Tiku Mereta, Tuomo J Meretoja, Atte Meretoja, Haftay Berhane Mezgebe, Renata Micha, Anoushka Millear, Ted R. Miller, Shawn Minnig, Mojde Mirarefin, Erkin Mirsaidovich 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, Lídia Morawska, Shane Douglas Morrison, Cliff Mountjoy-Venning, Ulrich Otto Mueller, Erin C Mullany, Kate Muller, Gudlavalleti Venkata Satyanarayana Murthy, Kamarul Imran Musa, Mohsen Naghavi, Aliya Naheed, Vinay B. Nangia, Gopalakrishnan Natarajan, Ruxandra Irina Negoi, Ionuţ Negoi, Cuong Tat Nguyen, Quyen Le Nguyen, Trang Huyen Nguyen, Grant Nguyen, Minh Nguyen, Emma L. Nichols, Dina Nur Anggraini Ningrum, Marika Nomura, Vuong Minh Nong, Ole Frithjof Norheim, Bo Norrving, Jean Jacques Noubiap, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In‐Hwan Oh, Olanrewaju Oladimeji, Andrew T Olagunju, Tinuke O Olagunju, Pedro Rufino Olivares, Helen Elizabeth Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Alberto Ortíz, Erika Ota, Mayowa Ojo Owolabi, Padukudru Anand Mahesh, Rosana Pacella, Adrian Pană, Basant Kumar Panda, Songhomitra Panda‐Jonas, Jeyaraj Durai Pandian, Christina Papachristou, Eun‐Kee Park, Charles D. H. Parry, Scott Burton Patten, George Patton, David M. Pereira, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Phillips, Julian David Pillay, М. А. Пирадов, Farhad Pishgar, Dietrich Plaß, Martin A Pletcher, Suzanne Polinder, Svetlana Popova, Richie 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, Saša Rajšić, Usha Ram, Salman Rawaf, Colin D. Rehm, Jürgen Rehm, Robert C. Reiner, Marissa Bettay Reitsma, Giuseppe Remuzzi, André M. N. Renzaho, Serge Resnikoff, Luz Myriam Reynales-Shigematsu, Satar Rezaei, Antônio Luiz Pinho Ribeiro, Juan Á. Rivera, Kedir Teji Roba, David Rojas Rueda, Yesenia Román, Robin Room, Gholamreza Roshandel, Gregory A. Roth, Dietrich Rothenbacher, Enrico Rubagotti, Lesley Rushton, Nafis Sadat, Mahdi Safdarian, Sare Safi, Saeid Safiri, Ramesh Sahathevan, Joseph S Salama, Joshua A. Salomon, Abdallah M Samy, Juan Ramon Sanabria, María Dolores Sánchez-Niño, Tania G Sánchez-Pimienta, Damian Francesco Santomauro, Itamar S Santos, Milena M Santric-Milicevic, Benn K. D. Sartorius, Maheswar Satpathy, Monika S. Sawhney, Sonia K Saxena, María Inês Schmidt, Ione Jayce Ceola Schneider, Aletta Elisabeth Schutte, David C. Schwebel, Falk Schwendicke, Soraya Seedat, Sadaf Ghajarieh Sepanlou, Berrin Serdar, Edson E Servan-Mori, Gavin Shaddick, Amira A Shaheen, Saeid Shahraz, Masood Ali Shaikh, Mansour Shamsipour, Morteza Shamsizadeh, Sheikh Mohammed Shariful Islam, Jayendra R. 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 Dóra Sigfúsdóttir, Diego Augusto Santos Silva, João Pedro Silva, Dayane Gabriele Alves Silveira, Jasvinder A. Singh, Virendra B. Singh, Dhirendra Narain Sinha, Eirini Skiadaresi, Erica Leigh Slepak, David L. Smith, Mari Smith, Badr Hasan Sobaih, Eugène Sobngwi, Samir Soneji, Reed J D Sorensen, Luciano Alberto Sposato, Chandrashekhar T Sreeramareddy, Vinay Srinivasan, Nicholas Steel, Dan J. Stein, Caitlyn Steiner, S. Steinke, Mark Andrew Stokes, Bryan Strub, Michelle L. Subart, Mu’awiyyah Babale Sufiyan, Rizwan Abdulkader Suliankatchi, Patrick John Sur, Soumya Swaminathan, Bryan L. Sykes, Cassandra E. I. Szoeke, Rafael Tabarés‐Seisdedos, Santosh Kumar Tadakamadla, Ken Takahashi, Jukka Takala, Nikhil Tandon, Marcel Tanner, Yihunie L. Tarekegn, Mohammad Ali Tavakkoli, Teketo Kassaw Tegegne, Arash Tehrani‐Banihashemi, Abdullah Sulieman Terkawi, Belay Tesssema, Jarnail Singh Thakur, Ornwipa Thamsuwan, Kavumpurathu Raman Thankappan, Andrew Theis, Matthew Lloyd Thomas, Alan J Thomson, Amanda Gay Thrift, Taavi Tillmann, Ruoyan Tobe-Gai, Myriam Tobollik, Mette Christophersen Tollånes, Marcello A. Tonelli, Roman Topór-Mądry, Anna E 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 L Updike, Olalekan Abdulrahman Uthman, Job F. M. van Boven, Santosh Varughese, Tommi Juhani Vasankari, Lennert J Veerman, Vidhya Venkateswaran, Narayanaswamy Venketasubramanian, Francesco Saverio Violante, Sergey Konstantinovitch Vladimirov, Vasily Vlassov, Stein Emil Vollset, Theo Vos, Fiseha Wadilo, Tolassa Wakayo, Mitchell Taylor Wallin, Yuan‐Pang Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Daniel J. Weiss, Andrea Werdecker, Ronny Westerman, Harvey 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 S. F. YIP, Naohiro Yonemoto, Seok‐Jun Yoon, Marcel Yotebieng, Mustafa Z Younis, Zoubida Zaidi, Maysaa El Sayed Zaki, Luis Zavala‐Arciniega, Xueying Zhang, Stephanie R M Zimsen, Ben Zipkin, SANJAY P. ZODPEY, Stephen S Lim, Christopher J L Murray

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Abstract

BACKGROUND: The 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. METHODS: We 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. FINDINGS: Since 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. INTERPRETATION: Increasingly 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. FUNDING: The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

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BACKGROUND: The 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. METHODS: We 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. FINDINGS: Since 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. INTERPRETATION: Increasingly 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. FUNDING: The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

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Available abstract

BACKGROUND: The 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. METHODS: We 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. FINDINGS: Since 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. INTERPRETATION: Increasingly 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. FUNDING: The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

Key concepts: Environmental health, Risk assessment, Burden of disease, Medicine, Economics, Population, Management

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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 — Research Paper | ScholarLens