Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic…

GBD 2013 Risk Factors Collaborators, Mohammad H Forouzanfar, Lily Alexander, H Ross Anderson, Victoria F Bachman, Stan Biryukov, Michael Brauer, Richard Burnett, Daniel Casey, Matthew M Coates, Aaron Cohen, Kristen Delwiche, Kara Estep, Joseph J Frostad, KC Astha, Hmwe H Kyu, Maziar Moradi-Lakeh, Marie Ng, Erica Leigh Slepak, Bernadette A Thomas, Joseph Wagner, Gunn Marit Aasvang, Cristiana Abbafati, Ayse Abbasoglu Ozgoren, Foad Abd-Allah, Semaw F Abera, Victor Aboyans, Biju Abraham, Jerry Puthenpurakal Abraham, Ibrahim Abubakar, Niveen M E Abu-Rmeileh, Tania C Aburto, Tom Achoki, Ademola Adelekan, Koranteng Adofo, Arsène K Adou, José C Adsuar, Ashkan Afshin, Emilie E Agardh, Mazin J Al Khabouri, Faris H Al Lami, Sayed Saidul Alam, Deena Alasfoor, Mohammed I Albittar, Miguel A Alegretti, Alicia V Aleman, Zewdie A Alemu, Rafael Alfonso-Cristancho, Samia Alhabib, Raghib Ali, Mohammed K Ali, François Alla, Peter Allebeck, Peter J Allen, Ubai Alsharif, Elena Alvarez, Nelson Alvis-Guzman, Adansi A Amankwaa, Azmeraw T Amare, Emmanuel A Ameh, Omid Ameli, Heresh Amini, Walid Ammar, Benjamin O Anderson, Carl Abelardo T Antonio, Palwasha Anwari, Solveig Argeseanu Cunningham, Johan Arnlöv, Valentina S Arsic Arsenijevic, Al Artaman, Rana J Asghar, Reza Assadi, Lydia S Atkins, Charles Atkinson, Marco A Avila, Baffour Awuah, Alaa Badawi, Maria C Bahit, Talal Bakfalouni, Kalpana Balakrishnan, Shivanthi Balalla, Ravi Kumar Balu, Amitava Banerjee, Ryan M Barber, Suzanne L Barker-Collo, Simon Barquera, Lars Barregard, Lope H Barrero, Tonatiuh Barrientos-Gutierrez, Ana C Basto-Abreu, Arindam Basu, Sanjay Basu, Mohammed O Basulaiman, Carolina Batis Ruvalcaba, Justin Beardsley, Neeraj Bedi, Tolesa Bekele, Michelle L Bell, Corina Benjet, Derrick A Bennett, Habib Benzian, Eduardo Bernabé, Tariku J Beyene, Neeraj Bhala, Ashish Bhalla, Zulfiqar A Bhutta, Boris Bikbov, Aref A Bin Abdulhak, Jed D Blore, Fiona M Blyth, Megan A Bohensky, Berrak Bora Başara, Guilherme Borges, Natan M Bornstein, Dipan Bose, Soufiane Boufous, Rupert R Bourne, Michael Brainin, Alexandra Brazinova, Nicholas J Breitborde, Hermann Brenner, Adam D M Briggs, David M Broday, Peter M Brooks, Nigel G Bruce, Traolach S Brugha, Bert Brunekreef, Rachelle Buchbinder, Linh N Bui, Gene Bukhman, Andrew G Bulloch, Michael Burch, Peter G J Burney, Ismael R Campos-Nonato, Julio C Campuzano, Alejandra J Cantoral, Jack Caravanos, Rosario Cárdenas, Elisabeth Cardis, David O Carpenter, Valeria Caso, Carlos A Castañeda-Orjuela, Ruben E Castro, Ferrán Catalá-López, Fiorella Cavalleri, Alanur Çavlin, Vineet K Chadha, Jung-chen Chang, Fiona J Charlson, Honglei Chen, Wanqing Chen, Zhengming Chen, Peggy P Chiang, Odgerel Chimed-Ochir, Rajiv Chowdhury, Costas A Christophi, Ting-Wu Chuang, Sumeet S Chugh, Massimo Cirillo, Thomas KD Claßen, Valentina Colistro, Mercedes Colomar, Samantha M Colquhoun, Alejandra G Contreras, Cyrus Cooper, Kimberly Cooperrider, Leslie T Cooper, Josef Coresh, Karen J Courville, Michael H Criqui, Lucia Cuevas-Nasu, James Damsere-Derry, Hadi Danawi, Lalit Dandona, Rakhi Dandona, Paul I Dargan, Adrian Davis, Dragos V Davitoiu, Anand Dayama, E Filipa de Castro, Vanessa De la Cruz-Góngora, Diego De Leo, Graça de Lima, Louisa Degenhardt, Borja del Pozo-Cruz, Robert P Dellavalle, Kebede Deribe, Sarah Derrett, Don C Des Jarlais, Muluken Dessalegn, Gabrielle A deVeber, Karen M Devries, Samath D Dharmaratne, Mukesh K Dherani, Daniel Dicker, Eric L Ding, Klara Dokova, E Ray Dorsey, Tim R Driscoll, Leilei Duan, Adnan M Durrani, Beth E Ebel, Richard G Ellenbogen, Yousef M Elshrek, Matthias Endres, Sergey P Ermakov, Holly E Erskine, Babak Eshrati, Alireza Esteghamati, Saman Fahimi, Emerito Jose A Faraon, Farshad Farzadfar, Derek F J Fay, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Alize J Ferrari, Cleusa P Ferri, Abraham D Flaxman, Thomas D Fleming, Nataliya Foigt, Kyle J Foreman, Urbano Fra Paleo, Richard C Franklin, Belinda Gabbe, Lynne Gaffikin, Emmanuela Gakidou, Amiran Gamkrelidze, Fortuné G Gankpé, Ron T Gansevoort, Francisco A García-Guerra, Evariste Gasana, Johanna M Geleijnse, Bradford D Gessner, Pete Gething, Katherine B Gibney, Richard F Gillum, Ibrahim A M Ginawi, Maurice Giroud, Giorgia Giussani, Shifalika Goenka, Ketevan Goginashvili, Hector Gomez Dantes, Philimon Gona, Teresita Gonzalez de Cosio, Dinorah González-Castell, Carolyn C Gotay, Atsushi Goto, Hebe N Gouda, Richard L Guerrant, Harish C Gugnani, Francis Guillemin, David Gunnell, Rahul Gupta, Rajeev Gupta, Reyna A Gutiérrez, Nima Hafezi-Nejad, Holly Hagan, Maria Hagstromer, Yara A Halasa, Randah R Hamadeh, Mouhanad Hammami, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Tilahun Nigatu Haregu, Josep Maria Haro, Rasmus Havmoeller, Simon I Hay, Mohammad T Hedayati, Ileana B Heredia-Pi, Lucia Hernandez, Kyle R Heuton, Pouria Heydarpour, Martha Hijar, Hans W Hoek, Howard J Hoffman, John C Hornberger, H Dean Hosgood, Damian G Hoy, Mohamed Hsairi, Guoqing Hu, Howard Hu, Cheng Huang, John J Huang, Bryan J Hubbell, Laetitia Huiart, Abdullatif Husseini, Marissa L Iannarone, Kim M Iburg, Bulat T Idrisov, Nayu Ikeda, Kaire Innos, Manami Inoue, Farhad Islami, Samaya Ismayilova, Kathryn H Jacobsen, Henrica A Jansen, Deborah L Jarvis, Simerjot K Jassal, Alejandra Jauregui, Sudha Jayaraman, Panniyammakal Jeemon, Paul N Jensen, Vivekanand Jha, Fan Jiang, Guohong Jiang, Ying Jiang, Jost B Jonas, Knud Juel, Haidong Kan, Sidibe S Kany Roseline, Nadim E Karam, André Karch, Corine K Karema, Ganesan Karthikeyan, Anil Kaul, Norito Kawakami, Dhruv S Kazi, Andrew H Kemp, Andre P Kengne, Andre Keren, Yousef S Khader, Shams Eldin Ali Hassan Khalifa, Ejaz A Khan, Young-Ho Khang, Shahab Khatibzadeh, Irma Khonelidze, Christian Kieling, Daniel Kim, Sungroul Kim, Yunjin Kim, Ruth W Kimokoti, Yohannes Kinfu, Jonas M Kinge, Brett M Kissela, Miia Kivipelto, Luke D Knibbs, Ann Kristin Knudsen, Yoshihiro Kokubo, M Rifat Kose, Soewarta Kosen, Alexander Kraemer, Michael Kravchenko, Sanjay Krishnaswami, Hans Kromhout, Tiffany Ku, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Chanda Kulkarni, Veena S Kulkarni, G Anil Kumar, Gene F Kwan, Taavi Lai, Arjun Lakshmana Balaji, Ratilal Lalloo, Tea Lallukka, Hilton Lam, Qing Lan, Van C Lansingh, Heidi J Larson, Anders Larsson, Dennis O Laryea, Pablo M Lavados, Alicia E Lawrynowicz, Janet L Leasher, Jong-Tae Lee, James Leigh, Ricky Leung, Miriam Levi, Yichong Li, Yongmei Li, Juan Liang, Xiaofeng Liang, Stephen S Lim, M Patrice Lindsay, Steven E Lipshultz, Shiwei Liu, Yang Liu, Belinda K Lloyd, Giancarlo Logroscino, Stephanie J London, Nancy Lopez, Joannie Lortet-Tieulent, Paulo A Lotufo, Rafael Lozano, Raimundas Lunevicius, Jixiang Ma, Stefan Ma, Vasco M P Machado, Michael F MacIntyre, Carlos Magis-Rodriguez, Abbas A Mahdi, Marek Majdan, Reza Malekzadeh, Srikanth Mangalam, Christopher C Mapoma, Marape Marape, Wagner Marcenes, David J Margolis, Christopher Margono, Guy B Marks, Randall V Martin, Melvin B Marzan, Mohammad T Mashal, Felix Masiye, Amanda J Mason-Jones, Kunihiro Matsushita, Richard Matzopoulos, Bongani M Mayosi, Tasara T Mazorodze, Abigail C McKay, Martin McKee, Abigail McLain, Peter A Meaney, Catalina Medina, Man Mohan Mehndiratta, Fabiola Mejia-Rodriguez, Wubegzier Mekonnen, Yohannes A Melaku, Michele Meltzer, Ziad A Memish, Walter Mendoza, George A Mensah, Atte Meretoja, Francis Apolinary Mhimbira, Renata Micha, Ted R Miller, Edward J Mills, Awoke Misganaw, Santosh Mishra, Norlinah Mohamed Ibrahim, Karzan A Mohammad, Ali H Mokdad, Glen L Mola, Lorenzo Monasta, Julio C Montañez Hernandez, Marcella Montico, Ami R Moore, Lidia Morawska, Rintaro Mori, Joanna Moschandreas, Wilkister N Moturi, Dariush Mozaffarian, Ulrich O Mueller, Mitsuru Mukaigawara, Erin C Mullany, Kinnari S Murthy, Mohsen Naghavi, Ziad Nahas, Aliya Naheed, Kovin S Naidoo, Luigi Naldi, Devina Nand, Vinay Nangia, KM Venkat Narayan, Denis Nash, Bruce Neal, Chakib Nejjari, Sudan P Neupane, Charles R Newton, Frida N Ngalesoni, Jean de Dieu Ngirabega, Grant Nguyen, Nhung T Nguyen, Mark J Nieuwenhuijsen, Muhammad I Nisar, José R Nogueira, Joan M Nolla, Sandra Nolte, Ole F Norheim, Rosana E Norman, Bo Norrving, Luke Nyakarahuka, In-Hwan Oh, Takayoshi Ohkubo, Bolajoko O Olusanya, Saad B Omer, John Nelson Opio, Ricardo Orozco, Rodolfo S Pagcatipunan, Amanda W Pain, Jeyaraj D Pandian, Carlo Irwin A Panelo, Christina Papachristou, Eun-Kee Park, Charles D Parry, Angel J Paternina Caicedo, Scott B Patten, Vinod K Paul, Boris I Pavlin, Neil Pearce, Lilia S Pedraza, Andrea Pedroza, Ljiljana Pejin Stokic, Ayfer Pekericli, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz, Norberto Perico, Samuel A L Perry, Aslam Pervaiz, Konrad Pesudovs, Carrie B Peterson, Max Petzold, Michael R Phillips, Hwee Pin Phua, Dietrich Plass, Dan Poenaru, Guilherme V Polanczyk, Suzanne Polinder, Constance D Pond, C Arden Pope, Daniel Pope, Svetlana Popova, Farshad Pourmalek, John Powles, Dorairaj Prabhakaran, Noela M Prasad, Dima M Qato, Amado D Quezada, D Alex A Quistberg, Lionel Racapé, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Sajjad Ur Rahman, Murugesan Raju, Ivo Rakovac, Saleem M Rana, Mayuree Rao, Homie Razavi, K Srinath Reddy, Amany H Refaat, Jürgen Rehm, Giuseppe Remuzzi, Antonio L Ribeiro, Patricia M Riccio, Lee Richardson, Anne Riederer, Margaret Robinson, Anna Roca, Alina Rodriguez, David Rojas-Rueda, Isabelle Romieu, Luca Ronfani, Robin Room, Nobhojit Roy, George M Ruhago, Lesley Rushton, Nsanzimana Sabin, Ralph L Sacco, Sukanta Saha, Ramesh Sahathevan, Mohammad Ali Sahraian, Joshua A Salomon, Deborah Salvo, Uchechukwu K Sampson, Juan R Sanabria, Luz Maria Sanchez, Tania G Sánchez-Pimienta, Lidia Sanchez-Riera, Logan Sandar, Itamar S Santos, Amir Sapkota, Maheswar Satpathy, James E Saunders, Monika Sawhney, Mete I Saylan, Peter Scarborough, Jürgen C Schmidt, Ione J C Schneider, Ben Schöttker, David C Schwebel, James G Scott, Soraya Seedat, Sadaf G Sepanlou, Berrin Serdar, Edson E Servan-Mori, Gavin Shaddick, Saeid Shahraz, Teresa Shamah Levy, Siyi Shangguan, Jun She, Sara Sheikhbahaei, Kenji Shibuya, Hwashin H Shin, Yukito Shinohara, Rahman Shiri, Kawkab Shishani, Ivy Shiue, Inga D Sigfusdottir, Donald H Silberberg, Edgar P Simard, Shireen Sindi, Abhishek Singh, Gitanjali M Singh, Jasvinder A Singh, Vegard Skirbekk, Karen Sliwa, Michael Soljak, Samir Soneji, Kjetil Søreide, Sergey Soshnikov, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Nicolas J C Stapelberg, Vasiliki Stathopoulou, Nadine Steckling, Dan J Stein, Murray B Stein, Natalie Stephens, Heidi Stöckl, Kurt Straif, Konstantinos Stroumpoulis, Lela Sturua, Bruno F Sunguya, Soumya Swaminathan, Mamta Swaroop, Bryan L Sykes, Karen M Tabb, Ken Takahashi, Roberto T Talongwa, Nikhil Tandon, David Tanne, Marcel Tanner, Mohammad Tavakkoli, Braden J Te Ao, Carolina M Teixeira, Martha M Téllez Rojo, Abdullah S Terkawi, José Luis Texcalac-Sangrador, Sarah V Thackway, Blake Thomson, Andrew L Thorne-Lyman, Amanda G Thrift, George D Thurston, Taavi Tillmann, Myriam Tobollik, Marcello Tonelli, Fotis Topouzis, Jeffrey A Towbin, Hideaki Toyoshima, Jefferson Traebert, Bach X Tran, Leonardo Trasande, Matias Trillini, Ulises Trujillo, Zacharie Tsala Dimbuene, Miltiadis Tsilimbaris, Emin Murat Tuzcu, Uche S Uchendu, Kingsley N Ukwaja, Selen B Uzun, Steven van de Vijver, Rita Van Dingenen, Coen H van Gool, Jim van Os, Yuri Y Varakin, Tommi J Vasankari, Ana Maria N Vasconcelos, Monica S Vavilala, Lennert J Veerman, Gustavo Velasquez-Melendez, N Venketasubramanian, Lakshmi Vijayakumar, Salvador Villalpando, Francesco S Violante, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Gregory R Wagner, Stephen G Waller, Mitchell T Wallin, Xia Wan, Haidong Wang, JianLi Wang, Linhong Wang, Wenzhi Wang, Yanping Wang, Tati S Warouw, Charlotte H Watts, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Andrea Werdecker, K Ryan Wessells, Ronny Westerman, Harvey A Whiteford, James D Wilkinson, Hywel C Williams, Thomas N Williams, Solomon M Woldeyohannes, Charles D A Wolfe, John Q Wong, Anthony D Woolf, Jonathan L Wright, Brittany Wurtz, Gelin Xu, Lijing L Yan, Gonghuan Yang, Yuichiro Yano, Pengpeng Ye, Muluken Yenesew, Gökalp K Yentür, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Zourkaleini Younoussi, Chuanhua Yu, Maysaa E Zaki, Yong Zhao, Yingfeng Zheng, Maigeng Zhou, Jun Zhu, Shankuan Zhu, Xiaonong Zou, Joseph R Zunt, Alan D Lopez, Theo Vos, Christopher J Murray

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Bill & Melinda Gates Foundation.