ArticlesGlobal, 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 analysis for the Global Burden of Disease Study 2013
Introduction
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. Quantification of functional health loss and mortality by disease and injury is an important input to more informed health policy, as is the contribution of different risk factors to patterns of disease and injury across countries. Risk factor quantification, particularly for modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention.
The Global Burden of Disease study 2010 (GBD 2010) provided the most comprehensive comparative assessment of risk factors covering 67 risk factors or clusters of risks for 21 regions from 1990 to 2010.1 The GBD comparative risk assessment (CRA) brings together data for excess mortality and disability associated with risk factors, data for exposure to risks, and evidence-based assumptions on the desired counterfactual distribution of risk exposure to estimate how much of the burden observed in a given year can be attributed to risk exposure in that year and in all previous years. GBD 2010 generated broad interest in the scientific community and public health agencies.2, 3, 4 GBD 2010 also generated several scientific debates on topics such as the magnitude of burden related to diet, the low estimates of burden related to unsafe water and sanitation, and exclusion of some risk–outcome pairs from the analysis.2, 5, 6, 7, 8, 9, 10 Additionally, new studies have been published since the release of GBD 2010 that inform both estimates of relative risks and exposure in different countries.11, 12, 13, 14, 15
The GBD 2013 provides a timely opportunity to update each aspect of the CRA with new data for exposure, add new risk–outcome pairs meeting study inclusion criteria, and incorporate new data for relative risks and the appropriate counterfactual risk distribution. Important insights from scientific debates on GBD 2010 have been used in revised approaches. This analysis supersedes all previous GBD CRA results by providing a complete revised time-series of attributable burden from 1990 to 2013, for 188 countries, with consistent definitions and methods. This CRA also allows us to explore how much of the burden of disease around the world is not explained by the behavioural, environmental and occupational, and metabolic risks included in this study.
Section snippets
Overview
In general, this analysis follows the CRA methods used in GBD 2010.1 Conceptually, the CRA approach evaluates how much of the burden of disease observed in a given year can be attributed to past exposure to a risk. Attributable burden is estimated by comparing observed health outcomes to those that would have been observed if a counterfactual level of exposure had occurred in the past. Given that different risks lead to different health outcomes, assessments are undertaken separately for
Results
The risk factors included in this analysis are estimated to account for a widely varying proportion of deaths and DALYs across causes at the global level. Figure 2 uses tree maps to represent the PAFs for all risks combined for each disease and injury for level 2 causes in the GBD hierarchical cause list for deaths and DALYs. Across the level 2 causes, the attributable fractions for deaths range from 0% for neonatal disorders to 88·7% (95% UI 86·6–90·6) for cardiovascular and circulatory
Discussion
Our analysis of 79 risks divided into three broad groups of behavioural, environmental and occupational, and metabolic risk factors shows that together they explain slightly greater than 57% of global deaths and more than 41% of global DALYs. Each of the risk factors included in this analysis is modifiable, pointing to the huge potential of prevention to improve human health. Globally, behavioural risk factors are the most important followed by metabolic and environmental and occupational risk
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