TY  - JOUR
TI  - Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
AU  - Mohammad H. Forouzanfar
AU  - Ashkan Afshin
AU  - Lily Alexander
AU  - H Ross Anderson
AU  - Zulfiqar A Bhutta
AU  - Stan Biryukov
AU  - Michael Bräuer
AU  - Richard Burnett
AU  - Kelly Cercy
AU  - Fiona Charlson
AU  - Aaron J. Cohen
AU  - Lalit Dandona
AU  - Kara Estep
AU  - Alize J Ferrari
AU  - Joseph Frostad
AU  - Nancy Fullman
AU  - Peter W Gething
AU  - William W Godwin
AU  - Max Griswold
AU  - Simon I Hay
AU  - Yohannes Kinfu
AU  - Hmwe Hmwe Kyu
AU  - Heidi J. Larson
AU  - Xiaofeng Liang
AU  - Stephen S Lim
AU  - Patrick Y Liu
AU  - Alan D López
AU  - Rafael Lozano
AU  - Laurie Marczak
AU  - George A. Mensah
AU  - Ali H. Mokdad
AU  - Maziar Moradi‐Lakeh
AU  - Mohsen Naghavi
AU  - Bruce Neal
AU  - Marissa B Reitsma
AU  - Gregory A Roth
AU  - Joshua A. Salomon
AU  - Patrick J Sur
AU  - Theo Vos
AU  - Joseph A. Wagner
AU  - Haidong Wang
AU  - Yi Zhao
AU  - Maigeng Zhou
AU  - Gunn Marit Aasvang
AU  - Amanuel Alemu Abajobir
AU  - Kalkidan Hassen Abate
AU  - Cristiana Abbafati
AU  - Kaja M Abbas
AU  - Foad Abd-Allah
AU  - Abdishakur M Abdulle
AU  - Semaw Ferede Abera
AU  - Biju Abraham
AU  - Laith J Abu-Raddad
AU  - Gebre Yitayih Abyu
AU  - Akindele Olupelumi Adebiyi
AU  - Isaac Akinkunmi Adedeji
AU  - Zanfina Ademi
AU  - Arsène Kouablan Adou
AU  - José Carmelo Adsuar
AU  - Emilie Agardh
AU  - Arnav Agarwal
AU  - Anurag Agrawal
AU  - Aliasghar Ahmad Kiadaliri
AU  - Oluremi N Ajala
AU  - Tomi F Akinyemiju
AU  - Ziyad Al-Aly
AU  - Khurshid Alam
AU  - Noore K M Alam
AU  - Saleh Fahed Aldhahri
AU  - Robert William Aldridge
AU  - Zewdie Aderaw Alemu
AU  - Raghib Ali
AU  - Ala'a Alkerwi
AU  - François Alla
AU  - Peter Allebeck
AU  - Ubai Alsharif
AU  - Khalid A Altirkawi
AU  - Elena Alvarez Martin
AU  - Nelson Alvis‐Guzmán
AU  - Azmeraw T. Amare
AU  - Alemayehu Amberbir
AU  - Adeladza Kofi Amegah
AU  - Heresh Amini
AU  - Walid Ammar
AU  - Stephen Marc Amrock
AU  - Hjalte H Andersen
AU  - Benjamin O. Anderson
AU  - Carl Abelardo T. Antonio
AU  - Palwasha Anwari
AU  - Johan Ärnlöv
AU  - Al Artaman
AU  - Hamid Asayesh
AU  - Rana J Asghar
AU  - Reza Assadi
AU  - Suleman Atique
AU  - Euripide Frinel G Arthur Avokpaho
AU  - Ashish Awasthi
AU  - Beatriz Paulina Ayala Quintanilla
AU  - Peter Azzopardi
AU  - Umar Bacha
PY  - 2016
JO  - The Lancet
DO  - 10.1016/s0140-6736(16)31679-8
UR  - https://doi.org/10.1016/s0140-6736(16)31679-8
AB  - BACKGROUND: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. METHODS: We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors-the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). FINDINGS: Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6-58·8) of global deaths and 41·2% (39·8-42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. INTERPRETATION: Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. FUNDING: Bill & Melinda Gates Foundation.
ER  -