A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study

Stephen Lim, Theo Vos, Abraham Flaxman, Goodarz Danaei, Kenji Shibuya, Heather Adair-Rohani, Mohammad Almazroa, Markus Amann, H Anderson, Kathryn Andrews, Martin Aryee, Charles Atkinson, Loraine Bacchus, Adil Meng, Kalpana Balakrishnan, John Balmes, Suzanne Barker-Collo, Amanda Baxter, Michelle Bell, Jed BloreFiona Blyth, Carissa Bonner, Gilherme Borges, Rupert Bourne, Michel Boussinesq, Michael Brauer, peter brooks, Nigel Brude, Bert Brunekreef, Claire Bryan-Hancock, C bucello, Rachelle Buchbinder, F Bull, Richard Burnett, TIme Byers, Bianca Calabria, Johathan Carapetis, Emily Carnahan, Z Chafe, Fiona Charlson, Honglei Chen, Jian Shen Chen, Andre Cheng, Jennifer Child, Aaron Cohen, K Colson, Benjamin Cowie, Sarah C. Darby, Susan Darling, Adrian Davis, Louisa Degenhardt, Frank Dentener, Don Jarlais, Karen Devries, Mukesh Dharani, Eric Ding, E Dorsey, Tim Driscoll, Karen Edmond, Suad Ali, Rebecca Engell, Patricia Erwin, Saman Fahimi, Gail Falder, Farshad Farzadfar, alize Ferrari, Mariel Finucane, Seth Flaxman, Francis Fowkes, Greg Freedman, Michael Freeman, Emmanuela Gakidou, Santu Ghosh, Edward Giovannucci, Gerhard Gmel, Kathryn Graham, Rebecca Grainger, Bridget Grant, David Gunnell, Hialy Gutierrez, Wayne Hall, Hans Hoek, Anthony Hogan, H hosgood, Damian Hoy, Howard Hu, Bryan Hubbell, Sally Hutchings, Sydney Ibeanusi, Gemma Jacklyn, Rashmi JAsrasaria, Jost Jonas, Haidong Kan, John Kanis, Nicholas Kassebaum, Norito kawakami, Young-Ho Khang, Khatibzadeh shahab, Jon-Paul Khoo, Cindy Kok, Francine Laden, Ratilal Lalloo, Qing Lan, Tim Lathlean, Janet Leasher, James Leigh, Yang Li, John Lin, Steven Lipshultz, Stephine London, Rafael Lozano, Yuan Lu, joelle Mak, Reza Malekzadeh, Leslie Mallinger, wagner MArcenes, Lyn March, Robin Marks, Randall Martin, Paul McGale, John McGrath, Sumi metha, Ziad memish, George Mensah, Tony Merriman, Renata Micha, Catherine Michaud, Vinod Mishra, Khayriyyah Hanafiah, Ali Mokdad, Lidia Morawska, Dariush Mozaffarian, Tasha Murphy, Mohsen Naghavi, Bruce Neal, Paul Nelson, Joan Nolla, Rosana Norman, Casey Olives, Saad Omer, Jessica Orchard, Richard Osborne, Bart Ostro, Andrew Page, Kiran Pandey, Charles Parry, Erin Passmore, Jayadeep Patra, Neil Pearce, Pamela Pelizzari, Max Petzold, Michael Phillips, Dan Pope, C Pope, John Powles, Mayuree Rao, Homie Razavi, Eva Rehfuess, Jurgen Rehm, Beate Ritz, Frederick Rivara, Thomas Roberts, Carolyn Robinson, Jose Rodriguez-Portales, Isabelle Romieu, Robin Room, Lisa Rosenfeld, Ananya Roy, Lesley Rushton, Joshua Salomon, Uchechukwu Sampson, Lidia Sanchez-Riera, Ella Sanman, Amir Sapkota, Soraya Seedat, Peilin Shi, Kevin Shield, Pupak Shivakoti, Gitanjali Singh, David Sleet, Emma Smith, kirk Smith, Nicholas Stapelberg, Kyle Steenland, Heidi Stockl, Lars Stovner, Kurt Straif, Lahn Straney, GEorge Thurston, Jimmy Tran, Rita Van Dingenen, Aaron Van Donkelaar, J Veerman, Lakshmi Vijayakumar, Robert Weintraub, Myrna Weissman, Richard White, Harvey Whiteford, Steven Wiersma, James Wilkison, Hywel Williams, Warwick Williams, Nicholas Wilson, Anthony Woolf, Paul Yip, Jan Zielinski, Alan lopez, Christopher Murray, Majid Ezzati

Research output: Contribution to journalArticlepeer-review

9360 Citations (Scopus)


Background Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time.

Methods We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden.

Findings In 2010, the three leading risk factors for global disease burden were high blood pressure (7.0% [95% uncertainty interval 6.2-7.7] of global DALYs), tobacco smoking including second-hand smoke (6.3% [5.5-7.0]), and alcohol use (5.5% [5.0-5.9]). In 1990, the leading risks were childhood underweight (7.9% [6.8-9.4]), household air pollution from solid fuels (HAP; 7.0% [5.6-8.3]), and tobacco smoking including second-hand smoke (6.1% [5.4-6.8]). Dietary risk factors and physical inactivity collectively accounted for 10.0% (95% UI 9.2-10.8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0.9% (0.4-1.6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania.

Interpretation Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children
Original languageEnglish
Pages (from-to)2224-2260
Number of pages37
Publication statusPublished - 2012
Externally publishedYes


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