Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Christopher J.L. Murray, Aleksandr Y. Aravkin, Peng Zheng, Cristiana Abbafati, Kaja M. Abbas, Mohsen Abbasi-Kangevari, Foad Abd-Allah, Ahmed Abdelalim, Mohammad Abdollahi, Ibrahim Abdollahpour, Kedir Hussein Abegaz, Hassan Abolhassani, Victor Aboyans, Lucas Guimarães Abreu, Michael R.M. Abrigo, Ahmed Abualhasan, Laith Jamal Abu-Raddad, Abdelrahman I. Abushouk, Maryam Adabi, Victor AdekanmbiAbiodun Moshood Adeoye, Olatunji O. Adetokunboh, Davoud Adham, Shailesh M. Advani, Gina Agarwal, Seyed Mohammad Kazem Aghamir, Anurag Agrawal, Tauseef Ahmad, Keivan Ahmadi, Mehdi Ahmadi, Hamid Ahmadieh, Muktar Beshir Ahmed, Temesgen Yihunie Akalu, Rufus Olusola Akinyemi, Tomi Akinyemiju, Blessing Akombi, Chisom Joyqueenet Akunna, Fares Alahdab, Ziyad Al-Aly, Khurshid Alam, Samiah Alam, Tahiya Alam, Fahad Mashhour Alanezi, Turki M. Alanzi, Biresaw wassihun Alemu, Khalid F. Alhabib, Muhammad Ali, Saqib Ali, Gianfranco Alicandro, Cyrus Alinia, Vahid Alipour, Hesam Alizade, Syed Mohamed Aljunid, François Alla, Peter Allebeck, Amir Almasi-Hashiani, Hesham M. Al-Mekhlafi, Jordi Alonso, Khalid A. Altirkawi, Mostafa Amini-Rarani, Fatemeh Amiri, Dickson A. Amugsi, Robert Ancuceanu, Deanna Anderlini, Jason A. Anderson, Catalina Liliana Andrei, Tudorel Andrei, Colin Angus, Mina Anjomshoa, Fereshteh Ansari, Alireza Ansari-Moghaddam, Ippazio Cosimo Antonazzo, Carl Abelardo T. Antonio, Catherine M. Antony, Ernoiz Antriyandarti, Davood Anvari, Razique Anwer, Seth Christopher Yaw Appiah, Jalal Arabloo, Morteza Arab-Zozani, Filippo Ariani, Bahram Armoon, Johan Ärnlöv, Afsaneh Arzani, Mehran Asadi-Aliabadi, Ali A. Asadi-Pooya, Charlie Ashbaugh, Michael Assmus, Zahra Atafar, Desta Debalkie Atnafu, Maha Moh d.Wahbi Atout, Floriane Ausloos, Marcel Ausloos, Beatriz Paulina Ayala Quintanilla, Getinet Ayano, Martin Amogre Ayanore, Samad Azari, Ghasem Azarian, Zelalem Nigussie Azene, Alaa Badawi, Ashish D. Badiye, Mohammad Amin Bahrami, Mohammad Hossein Bakhshaei, Ahad Bakhtiari, Shankar M. Bakkannavar, Alberto Baldasseroni, Kylie Ball, Shoshana H. Ballew, Daniela Balzi, Maciej Banach, Srikanta K. Banerjee, Agegnehu Bante Bante, Adhanom Gebreegziabher Baraki, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Lope H. Barrero, Celine M. Barthelemy, Lingkan Barua, Sanjay Basu, Bernhard T. Baune, Mohsen Bayati, Jacob S. Becker, Neeraj Bedi, Ettore Beghi, Yannick Béjot, Michellr L. Bell, Fiona B. Bennitt, Isabela M. Bensenor, Kidanemaryam Berhe, Adam E. Berman, Akshaya Srikanth Bhagavathula, Reshmi Bhageerathy, Neeraj Bhala, Dinesh Bhandari, Krittika Bhattacharyya, Zulfiqar A. Bhutta, Ali Bijani, Boris Bikbov, Muhammad Shahdaat Bin Sayeed, Antonio Biondi, Binyam Minuye Birihane, Catherine Bisignano, Raaj Kishore Biswas, Helen Bitew, Somayeh Bohlouli, Mehdi Bohluli, Alexandra S. Boon-Dooley, Guilherme Borges, Antonio Maria Borzì, Shiva Borzouei, Cristina Bosetti, Soufiane Boufous, Dejana Braithwaite, Nicholas J.K. Breitborde, Susanne Breitner, Hermann Brenner, Paul Svitil Briant, Andrey Nikolaevich Briko, Nikolay Ivanovich Briko, Gabrielle B. Britton, Dana Bryazka, Blair R. Bumgarner, Katrin Burkart, Richard Thomas Burnett, Sharath Burugina Nagaraja, Zahid A. Butt, Florentino Luciano Caetano dos Santos, Leah E. Cahill, Luis LA Alberto Cámera, Ismael R. Campos-Nonato, Rosario Cárdenas, Giulia Carreras, Juan J. Carrero, Felix Carvalho, Joao Mauricio Castaldelli-Maia, Carlos A. Castañeda-Orjuela, Giulio Castelpietra, Franz Castro, Kate Causey, Christopher R. Cederroth, Kelly M. Cercy, Ester Cerin, Joht Singh Chandan, Kai Lan Chang, Fiona J. Charlson, Vijay Kumar Chattu, Sarika Chaturvedi, Nicolas Cherbuin, Odgerel Chimed-Ochir, Daniel Youngwhan Cho, Jee Young Jasmine Choi, Hanne Christensen, Dinh Toi Chu, Michael T. Chung, Sheng Chia Chung, Flavia M. Cicuttini, Liliana G. Ciobanu, Massimo Cirillo, Thomas Khaled Dwayne Classen, Aaron J. Cohen, Kelly Compton, Owen R. Cooper, Vera Marisa Costa, Ewerton Cousin, Richard G. Cowden, Di H. Cross, Jessica A. Cruz, Saad M.A. Dahlawi, Albertino Antonio Moura Damasceno, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, William James Dangel, Anna Karin Danielsson, Paul I. Dargan, Aso Mohammad Darwesh, Ahmad Daryani, Jai K. Das, Rajat Das Gupta, José das Neves, Claudio Alberto Dávila-Cervantes, Dragos Virgil Davitoiu, Diego De Leo, Louisa Degenhardt, Marissa DeLang, Robert Paul Dellavalle, Feleke Mekonnen Demeke, Gebre Teklemariam Demoz, Desalegn Getnet Demsie, Edgar Denova-Gutiérrez, Nikolaos Dervenis, Govinda Prasad Dhungana, Mostafa Dianatinasab, Diana Dias da Silva, Daniel Diaz, Zahra Sadat Dibaji Forooshani, Shirin Djalalinia, Hoa Thi Do, Klara Dokova, Fariba Dorostkar, Leila Doshmangir, Tim Robert Driscoll, Bruce B. Duncan, Andre Rodrigues Duraes, Arielle Wilder Eagan, David Edvardsson, Nevine El Nahas, Iman El Sayed, Maha El Tantawi, Iffat Elbarazi, Islam Y. Elgendy, Shaimaa I. El-Jaafary, Iqbal RF Elyazar, Sophia Emmons-Bell, Holly E. Erskine, Sharareh Eskandarieh, Saman Esmaeilnejad, Alireza Esteghamati, Kara Estep, Arash Etemadi, Atkilt Esaiyas Etisso, Jessica Fanzo, Mohammad Farahmand, Mohammad Fareed, Roghiyeh Faridnia, Andrea Farioli, Andre Faro, Mithila Faruque, Farshad Farzadfar, Nazir Fattahi, Mehdi Fazlzadeh, Valery L. Feigin, Rachel Feldman, Seyed Mohammad Fereshtehnejad, Eduarda Fernandes, Giannina Ferrara, Alize J. Ferrari, Manuela L. Ferreira, Irina Filip, Florian Fischer, James L. Fisher, Luisa Sorio Flor, Nataliya A. Foigt, Morenike Oluwatoyin Folayan, Artem Alekseevich Fomenkov, Lisa M. Force, Masoud Foroutan, Richard Charles Franklin, Marisa Freitas, Weijia Fu, Takeshi Fukumoto, João M. Furtado, Mohamed M. Gad, Emmanuela Gakidou, Silvano Gallus, Alberto L. Garcia-Basteiro, William M. Gardner, Biniyam Sahiledengle Geberemariyam, Assefa Ayalew Ayalew Ayalew Gebreslassie, Abraham Geremew, Anna Gershberg Hayoon, Peter W. Gething, Maryam Ghadimi, Keyghobad Ghadiri, Fatemeh Ghaffarifar, Mansour Ghafourifard, Farhad Ghamari, Ahmad Ghashghaee, Hesam Ghiasvand, Nermin Ghith, Asadollah Gholamian, Rakesh Ghosh, Paramjit Singh Gill, Themba G.G. Ginindza, Giorgia Giussani, Elena V. Gnedovskaya, Salime Goharinezhad, Sameer Vali Gopalani, Giuseppe Gorini, Houman Goudarzi, Alessandra C. Goulart, Felix Greaves, Michal Grivna, Giuseppe Grosso, Mohammed Ibrahim Mohialdeen Gubari, Harish Chander Gugnani, Rafael Alves Guimarães, Rashid Abdi Guled, Gaorui Guo, Yuming Guo, Rajeev Gupta, Tarun Gupta, Beatrix Haddock, Nima Hafezi-Nejad, Abdul Hafiz, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Brian J. Hall, Iman Halvaei, Randah R. Hamadeh, Samer Hamidi, Melanie S. Hammer, Graeme J. Hankey, Hamidreza Haririan, Josep Maria Haro, Ahmed I. Hasaballah, Md Mehedi Hasan, Edris Hasanpoor, Abdiwahab Hashi, Soheil Hassanipour, Hadi Hassankhani, Rasmus J. Havmoeller, Simon I. Hay, Khezar Hayat, Golnaz Heidari, Reza Heidari-Soureshjani, Hannah J. Henrikson, Molly E. Herbert, Claudiu Herteliu, Fatemeh Heydarpour, Thomas R. Hird, Hans W. Hoek, Ramesh Holla, Praveen Hoogar, H. Dean Hosgood, Naznin Hossain, Mostafa Hosseini, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Mowafa Househ, Mohamed Hsairi, Vivian Chia rong Hsieh, Guoqing Hu, Kejia Hu, Tanvir M. Huda, Ayesha Humayun, Chantal K. Huynh, Bing Fang Hwang, Vincent C. Iannucci, Segun Emmanuel Ibitoye, Nayu Ikeda, Kevin S. Ikuta, Olayinka Stephen Ilesanmi, Irena M. Ilic, Milena D. Ilic, Leeberk Raja Inbaraj, Helen Ippolito, Usman Iqbal, Seyed Sina Naghibi Irvani, Caleb Mackay Salpeter Irvine, M. Mofizul Islam, Sheikh Mohammed Shariful Islam, Hiroyasu Iso, Rebecca Q. Ivers, Chidozie C.D. Iwu, Chinwe Juliana Iwu, Ihoghosa Osamuyi Iyamu, Jalil Jaafari, Kathryn H. Jacobsen, Hussain Jafari, Morteza Jafarinia, Mohammad Ali Jahani, Mihajlo Jakovljevic, Farzad Jalilian, Spencer L. James, Hosna Janjani, Tahereh Javaheri, Javad Javidnia, Panniyammakal Jeemon, Ensiyeh Jenabi, Ravi Prakash Jha, Vivekanand Jha, John S. Ji, Lars Johansson, Oommen John, Yetunde O. John-Akinola, Catherine Owens Johnson, Jost B. Jonas, Farahnaz Joukar, Jacek Jerzy Jozwiak, Mikk Jürisson, Ali Kabir, Zubair Kabir, Hamed Kalani, Rizwan Kalani, Leila R. Kalankesh, Rohollah Kalhor, Tanuj Kanchan, Neeti Kapoor, Behzad Karami Matin, André Karch, Mohd Anisul Karim, Getachew Mullu Kassa, Srinivasa Vittal Katikireddi, Gbenga A. Kayode, Ali Kazemi Karyani, Peter Njenga Keiyoro, Cathleen Keller, Laura Kemmer, Parkes J. Kendrick, Nauman Khalid, Mohammad Khammarnia, Ejaz Ahmad Khan, Maseer Khan, Khaled Khatab, Mona M. Khater, Mahalaqua Nazli Khatib, Maryam Khayamzadeh, Salman Khazaei, Christian Kieling, Yun Jin Kim, Ruth W. Kimokoti, Adnan Kisa, Sezer Kisa, Mika Kivimäki, Luke D. Knibbs, Ann Kristin Skrindo Knudsen, Jonathan M. Kocarnik, Sonali Kochhar, Jacek A. Kopec, Vladimir Andreevich Korshunov, Parvaiz A. Koul, Ai Koyanagi, Moritz U.G. Kraemer, Kewal Krishan, Kris J. Krohn, Hans Kromhout, Barthelemy Kuate Defo, G. Anil Kumar, Vivek Kumar, Om P. Kurmi, Dian Kusuma, Carlo La Vecchia, Ben Lacey, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Faris Hasan Lami, Iván Landires, Justin J. Lang, Sinéad M. Langan, Anders O. Larsson, Savita Lasrado, Paolo Lauriola, Jeffrey V. Lazarus, Paul H. Lee, Shaun Wen Huey Lee, Kate E. LeGrand, James Leigh, Matilde Leonardi, Haley Lescinsky, Janni Leung, Miriam Levi, Shanshan Li, Lee Ling Lim, Shai Linn, Shiwei Liu, Simin Liu, Yang Liu, Justin Lo, Alan D. Lopez, Jaifred Christian F. Lopez, Platon D. Lopukhov, Stefan Lorkowski, Paulo A. Lotufo, Alton Lu, Alessandra Lugo, Emilie R. Maddison, Phetole Walter Mahasha, Mokhtar Mahdavi Mahdavi, Morteza Mahmoudi, Azeem Majeed, Afshin Maleki, Shokofeh Maleki, Reza Malekzadeh, Deborah Carvalho Malta, Abdullah A. Mamun, Ana Laura Manda, Helena Manguerra, Fariborz Mansour-Ghanaei, Borhan Mansouri, Mohammad Ali Mansournia, Ana M. Mantilla Herrera, Joemer C. Maravilla, Ashley Marks, Randall V. Martin, Santi Martini, Francisco Rogerlândio Martins-Melo, Anthony Masaka, Seyedeh Zahra Masoumi, Manu Raj Mathur, Kunihiro Matsushita, Pallab K. Maulik, Colm McAlinden, John J. McGrath, Martin McKee, Man Mohan Mehndiratta, Fereshteh Mehri, Kala M. Mehta, Ziad A. Memish, Walter Mendoza, Ritesh G. Menezes, Endalkachew Worku Mengesha, Alibek Mereke, Seid Tiku Mereta, Atte Meretoja, Tuomo J. Meretoja, Tomislav Mestrovic, Bartosz Miazgowski, Tomasz Miazgowski, Irmina Maria Michalek, Ted R. Miller, Edward J. Mills, G. K. Mini, Mohammad Miri, Andreea Mirica, Erkin M. Mirrakhimov, Hamed Mirzaei, Maryam Mirzaei, Roya Mirzaei, Mehdi Mirzaei-Alavijeh, Awoke Temesgen Misganaw, Prasanna Mithra, Babak Moazen, Dara K. Mohammad, Yousef Mohammad, Naser Mohammad Gholi Mezerji, Abdollah Mohammadian-Hafshejani, Noushin Mohammadifard, Reza Mohammadpourhodki, Ammas Siraj Mohammed, Hussen Mohammed, Jemal Abdu Mohammed, Shafiu Mohammed, Ali H. Mokdad, Mariam Molokhia, Lorenzo Monasta, Meghan D. Mooney, Ghobad Moradi, Masoud Moradi, Maziar Moradi-Lakeh, Rahmatollah Moradzadeh, Paula Moraga, Lidia Morawska, Joana Morgado-da-Costa, Shane Douglas Morrison, Abbas Mosapour, Jonathan F. Mosser, Simin Mouodi, Seyyed Meysam Mousavi, Amin Mousavi Khaneghah, Ulrich Otto Mueller, Satinath Mukhopadhyay, Erin C. Mullany, Kamarul Imran Musa, Saravanan Muthupandian, Ashraf F. Nabhan, Mehdi Naderi, Ahamarshan Jayaraman Nagarajan, Gabriele Nagel, Mohsen Naghavi, Behshad Naghshtabrizi, Mukhammad David Naimzada, Farid Najafi, Vinay Nangia, Jobert Richie Nansseu, Morteza Naserbakht, Vinod C. Nayak, Ionut Negoi, Josephine W. Ngunjiri, Cuong Tat Nguyen, Huong Lan Thi Nguyen, Minh Nguyen, Yeshambel T. Nigatu, Rajan Nikbakhsh, Molly R. Nixon, Chukwudi A. Nnaji, Shuhei Nomura, Bo Norrving, Jean Jacques Noubiap, Christoph Nowak, Virginia Nunez-Samudio, Adrian Oţoiu, Bogdan Oancea, Christopher M. Odell, Felix Akpojene Ogbo, In Hwan Oh, Emmanuel Wandera Okunga, Morteza Oladnabi, Andrew T. Olagunju, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, Muktar Omer Omer, Kanyin L. Ong, Obinna E. Onwujekwe, Heather M. Orpana, Alberto Ortiz, Osayomwanbo Osarenotor, Frank B. Osei, Samuel M. Ostroff, Nikita Otstavnov, Stanislav S. Otstavnov, Simon Øverland, Mayowa O. Owolabi, Mahesh P A, Jagadish Rao Padubidri, Raffaele Palladino, Songhomitra Panda-Jonas, Anamika Pandey, Charles D.H. Parry, Maja Pasovic, Deepak Kumar Pasupula, Sangram Kishor Patel, Mona Pathak, Scott B. Patten, George C. Patton, Hamidreza Pazoki Toroudi, Amy E. Peden, Alyssa Pennini, Veincent Christian Filipino Pepito, Emmanuel K. Peprah, David M. Pereira, Konrad Pesudovs, Hai Quang Pham, Michael R. 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Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)

Abstract

Background: Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. Methods: GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk–outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk–outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk–outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. Findings: The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51–12·1) deaths (19·2% [16·9–21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12–9·31) deaths (15·4% [14·6–16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253–350) DALYs (11·6% [10·3–13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0–9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10–24 years, alcohol use for those aged 25–49 years, and high systolic blood pressure for those aged 50–74 years and 75 years and older. Interpretation: Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Funding: Bill & Melinda Gates Foundation.

Original languageEnglish
Pages (from-to)1223-1249
Number of pages27
JournalThe Lancet
Volume396
Issue number10258
DOIs
Publication statusPublished - Oct 17 2020

ASJC Scopus subject areas

  • Medicine(all)

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