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. 2024 May 18;403(10440):2162-2203.
doi: 10.1016/S0140-6736(24)00933-4.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

Collaborators

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 Risk Factors Collaborators. Lancet. .

Erratum in

  • Department of Error.
    [No authors listed] [No authors listed] Lancet. 2024 Jul 20;404(10449):244. doi: 10.1016/S0140-6736(24)01458-2. Lancet. 2024. PMID: 39033009 No abstract available.

Abstract

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests S Afzal reports support for the present manuscript from King Edward Medical University, which provided study material, research articles, valid data sources, and authentic real-time information for this manuscript; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events and webinars with King Edward Medical University and collaborative partners including University of Johns Hopkins, University of California, University of Massachusetts, KEMCAANA, KEMCA UK international scientific conferences, webinars, and meetings; support for attending meetings or travel, or both, from King Edward Medical University; participation on a data safety monitoring board or advisory board with the National Bioethics Committee Pakistan, King Edward Medical University Ethical Review Board, and the Ethical Review Board (Fatima Jinnah Medical University and Sir Ganga Ram Hospital); leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with the Pakistan Association of Medical Editors and as a Fellow of Faculty of Public Health (Royal Colleges, UK), Society of Prevention, Advocacy And Research, King Edward Medical University (SPARK), and as a Member of the Pakistan Society of Infectious Diseases; other financial or non-financial interests as Dean of Public Health and Preventive Medicine (King Edward Medical University), Chief Editor Annals (King Edward Medical University), Director of Quality Enhancement Cell (King Edward Medical University), and a Fellow of Faculty of Public Health United Kingdom, an Advisory Board Member and Chair Scientific Session, KEMCA-UK Chairperson International Scientific Conference, KEMCAANA (at national level), Member Research and Publications Higher Education Commission, HEC Pakistan, Member Research and Journals Committee (Pakistan Medical and Dental Council), Pakistan Member National Bioethics Committee, Pakistan (at Punjab level), Member Corona Experts Advisory Group, a Member of the Dengue Experts Advisory Group, and Chair of the Punjab Residency Program Research Committee; outside the submitted work. E Ammirati reports grants or contracts from Italian Ministry of Health (GR-2019-12368506) and NextGenerationEU (PNRR-MAD-2022-12376225); consulting fees from Cytokinetics, Kiniksa, and AstraZeneca; outside the submitted work. R Ancuceanu reports consulting fees from AbbVie, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AbbVie, Sandoz, B Braun, and Laropharm; outside the submitted work. J Ärnlöv reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AstraZeneca; and participation on a data safety monitoring board or advisory board with AstraZeneca and Astella; outside the submitted work. P Atorkey reports support from the present manuscript from the Australian College of Applied Professions (Discipline of Psychological Sciences, Sydney, Australia) and the School of Medicine and Public Health (The University of Newcastle, Australia). J L Baker reports grants or contracts from the World Cancer Research Fund, Novo Nordisk Foundation, and the Independent Research Fund Denmark; Consulting feeds from Novo Nordisk A/S Denmark; leadership or fiduciary roles in board, society, committee or advocacy groups, unpaid as an executive member of the European Association for the Study of Obesity; outside the submitted work. O C Baltatu reports support for the present manuscript from the National Council for Scientific and Technological Development (CNPq, 304224/2022-7) and Anima Institute (AI research professor fellowship); leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with São José dos Campos Technology Park as a Biotech Board Member; outside the submitted work. T W Bärnighausen reports grants or contracts from the US National Institutes of Health (NIH), Alexander von Humboldt Foundation, German National Research Foundation (DFG), European Union, German Ministry of Education and Research, German Ministry of the Environment, Wellcome Trust, and KfW; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from PLOS Medicine as the editor-in-chief; participation on a data safety monitoring board or advisory board for NIH-funded research projects in Africa on climate change and health; and stock ownership in CHEERS; outside the submitted work. S Barteit reports grants or contracts from Carl-Zeiss Foundations and the German Research Foundation; and stock or stock options with CHEERS; outside the submitted work. 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L Belo reports support from Fundacao para a Ciencia e a Tecnologia in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of UCIBIO and the project LA/P/0140/2020 of i4HB; outside the submitted work. A Beloukas reports grants or contracts from Gilead and GSK; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Gilead and GSK; support for attending meetings or travel, or both, from Gilead; receipt of equipment, materials, drugs, medical writing, gifts or other services from Cepheid; outside the submitted work. P G Bettencourt reports patents planned, issued, or pending: WO2020229805A1, EP3965809A1, US2023173050A1, EP4275700A2, BR112021022592A2, OA1202100511, EP4265271A2, EP4265271A3; other financial or non-financial support as a project reviewer at the Botnar Foundation; outside the submitted work. 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A Ortiz reports grants from Sanofi and grants or contracts from the Catedra Mundipharma-UAM for diabetic kidney disease and the Catedra AstraZeneca-UAM for chronic kidney disease and electrolytes (paid to Universidad Autonoma de Madrid); consulting fees from Advicciene, Astellas, AstraZeneca, Amicus, Amgen, Fresenius Medical Care, GSK, Bayer, Sanofi-Genzyme, Menarini, Kyowa Kirin, Alexion, Idorsia, Chiesi, Otsuka, Novo-Nordisk, and Vifor Fresenius Medical Care Renal Pharma; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Advicciene, Astellas, AstraZeneca, Amicus, Amgen, Fresenius Medical Care, GSK, Bayer, Sanofi-Genzyme, Menarini, Kyowa Kirin, Alexion, Idorsia, Chiesi, Otsuka, Novo-Nordisk, and Vifor Fresenius Medical Care Renal Pharma; support for attending meetings or travel, or both, from Advicciene, Astellas, AstraZeneca, Fresenius Medical Care, Bayer, Sanofi-Genzyme, Menarini, Chiesi, and Otsuka; participation on a data safety monitoring board or advisory board with Astellas, AstraZeneca, Fresenius Medical Care, Bayer, Sanofi-Genzyme, Idorsia, Chiesi, and Otsuka; leadership or fiduciary roles in other board, society, committee or advocacy groups, unpaid on the Council of the European Renal Association and SOMANE; outside the submitted work. R Passera reports participation on a data safety monitoring board or advisory board for the non-profit clinical trial “Consolidation with ADCT-402 (loncastuximab tesirine) after immunochemotherapy: a phase II study in BTKi-treated/ineligible Relapse/Refractory Mantle Cell Lymphoma (MCL) patients” - sponsor FIL, Fondazione Italiana Linfomi, Alessandria-I; leadership or fiduciary roles in other board, society, committee or advocacy groups, unpaid as a member of the Statistical Committee of the EBMT, the European Society for Bone and Marrow Transplantation, Paris, a Member of the COST CA18218 working group - European Burden of Disease Network (burden-eu), the European Cooperation in Science & Technology, Brussels; outside the submitted work. A E Peden reports support for the present manuscript from the Australian National Health and Medical Research Council (Grant Number: APP2009306). V C F Pepito reports grants or contracts from Sanofi Consumer Healthcare and the International Initiative for Impact Evaluation; outside the submitted work. M Pigeolet reports grants or contracts from The Belgian Kids’ Fund for Pediatric Research; outside the submitted work. C D Pond reports grants or contracts from Valley to Coast Charitable Trust as payments to the University of Newcastle; consulting fees from HNECC Primary Health Network, SW Sydney Primary Health Network, Australian Department of Health and Aged Care, NSW Health, Royal Australian College of General Practitioners, Dementia Training Australia, Palliative Care Australia, University of Sydney, Monash University, Biogen, Roche, Medicines Australia, Dementia Training Australia, Sydney North Health Network, and In Vivo Academy; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Dementia Training Australia, Sydney North Health Network, and In Vivo Academy; payment for expert testimony from Legal Aid NSW; support for attending meetings or travel, or both, from the Royal Australian College of General Practitioners and Palliative Care Australia; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as Provost, NSW Faculty, RACGP, Vice President, Doctors Reform Society, Chair, WONCA Special Interest Group, Ageing and Health, Board Member, Hunter Postgraduate Medical Institute, Adjunct Professor, School of Rural Medicine, University of New England, Adjunct Professor, School of Nursing and Midwifery, Western Sydney University, Clinical Professor, Wicking Dementia Research Education Centre, University of Tasmania, and Professor of General Practice, University of Newcastle (until August, 2021); all outside the submitted work. A Radfar reports other financial or non-financial interests in Avicenna Medical and Clinical Research Institute through their financial and logistical support, outside the submitted work. A Rane reports stock or stock options with Agios Pharmaceuticals as a full-time employee, outside the submitted work. A Ranta reports grants or contracts from NZ Health Research Council and NZ Ministry of Health; participation on a data safety monitoring board or advisory board with Phase II, Multicenter, Double-Blinded, Randomized, Placebo-Controlled, Parallel-Group, Single-Dose Study to Determine the Safety, Preliminary Efficacy, and Pharmacokinetics of ARG-007 in Acute Ischemic Stroke Patients; leadership or fiduciary roles in other board, society, committee, or advocacy groups, paid or unpaid with Australia and NZ Stroke Organization, World Stroke Organization, and NZ Stroke Foundation; outside the submitted work. L F Reyes reports grants or contracts from GSK; royalties for licences from GSK; consulting fees from GSK; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from GSK; payment for expert testimony from GSK; support for attending meetings or travel, or both, from GSK and Pfizer; and stock or stock options from GSK; outside the submitted work. S Sacco reports grants or contracts from Novartis and Uriach; consulting fees from Novartis, Allergan-AbbVie, Teva, Lilly, Lundbeck, Pfizer, NovoNordisk, Abbott, and AstraZeneca; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Novartis, Allergan-AbbVie, Teva, Lilly, Lundbeck, Pfizer, NovoNordisk, Abbott, AstraZeneca; support for attending meetings or travel, or both, from Lilly, Novartis, Teva, Lundbeck, and Pfizer; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as the President elect European Stroke Organization and Editor-in-Chief of Cephalalgia; receipt of equipment, materials, drugs, medical writing, gifts or other services from Allergan-AbbVie and NovoNordisk; outside the submitted work. P S Sachdev reports grants or contracts from the National Health and Medical Research Council of Australia and the NIH; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Alkem Labs; participation on a data safety monitoring board or advisory board with Biogen Australia Medical Advisory Committee in 2020 and the 2021 Roche Australia Medical Advisory Committee in 2022; leadership or fiduciary roles in other board, society, committee or advocacy groups, unpaid with VASCOG Society on the executive committee and the World Psychiatric Association on the planning committee; outside the submitted work. Y L Samodra reports grants or contracts from Taipei Medical University; leadership or fiduciary roles in other board, society, committee, or advocacy groups, paid or unpaid as co-founder of Benang Merah Research Center; all outside the submitted work. J Sanabria reports support for attending meetings or travel, or both, from the Continuing Medical Education section of the University of Marshall School of Medicine; one patent issued and one patent pending; participation on a data safety monitoring board or advisory board with the Marshall University Department of Surgery; leadership or fiduciary roles in other board, society, committee, or advocacy groups, paid or unpaid, with the American Society of Transplant Surgeons, Society of Surgical Oncology, American Board of Surgery, Americas Hepato-Pancreato-Biliary Association, and International Hepato-Pancreato Biliary Association; all outside the submitted work. A E Schutte reports grants or contracts from the National Health and Medical Research Council of Australia (Investigator Grant); consulting feeds from Abbott, Medtronic, Servier, and Skylabs; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Abbott, Medtronic, Servier, Skylabs, Aktiia, Sanofi, Omron, and Novartis; support for attending meetings or travel, or both, from Medtronic and Servier; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as Co-Chair of the National Hypertension Taskforce of Australia, Secretary of the Australian Cardiovascular Alliance, Board Member of Hypertension Australia; outside the submitted work. A Sharifan reports leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid from Cochrane; receipt of equipment, materials, drugs, medical writing, gifts, or other services from Elsevier; outside the submitted work. V Sharma acknowledges support from DFSS (MHA)'s research project (DFSS28(1)2019/EMR/6) at the Institute of Forensic Science & Criminology, Panjab University (Chandigarh, India); outside the submitted work. V Shivarov reports one patent pending and one utility model with the Bulgarian Patent Office; stock or stock options from RSUs with ICONplc; and a salary from ICONplc; outside the submitted work. S Shrestha reports support from the School of Pharmacy, Monash University Malaysia and the Graduate Research Merit Scholarship; outside the submitted work. C R Simpson reports grants or contracts from the Health Research Council of New Zealand, Ministry of Health (New Zealand), Ministry of Business, Innovation, and Employment (New Zealand), Chief Scientist Office (UK), and MRC (UK); leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as Data Ethics Advisory Group Chair for the New Zealand Government; outside the submitted work. J A Singh reports consulting fees from Schipher, Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, ANI Pharmaceuticals/Exeltis USA, Adept Field Solutions, Clinical Care options, ClearView Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, and Practice Point Communications; and the NIH and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events as a member of the speaker's bureau of Simply Speaking; support for attending meetings or travel, or both, as a past steering committee member of OMERACT; participation on a data safety monitoring board or advisory board with the US Food and Drug Administration (FDA) Arthritis Advisory Committee; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as a past steering committee member of the OMERACT, an international organization that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, Chair of the Veterans Affairs Rheumatology Field Advisory Committee, and editor/Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis; stock or stock options in Atai Life Sciences, Kintara Therapeutics, Intelligent Biosolutions, Acumen Pharmaceuticals, TPT Global Tech, Vaxart Pharmaceuticals, Aytu BioPharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals Holding, Aebona Pharmaceuticals, and Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna Pharmaceuticals; outside the submitted work. S T Skou reports grants or contracts from the European Research Council, European Union's Horizon 2020 research innovation programme, Region Zealand; Royalties or licences from Munksgaard and TrustMe-Ed; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Nestlé Health Science; other financial support as a co-founder of GLA:D; outside the submitted work. R Somayaji reports grants or contracts through clinical research funding from the Canadian Institutes of Health Research, Cystic Fibrosis Foundation, Vertex Pharmaceuticals, and the University of Calgary; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from educational events from Vertex Pharmaceuticals; participation on a data safety monitoring board or advisory board with Oncovir and the Cystic Fibrosis Foundation; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid, with the Canadian Pressure Injury Advisory Panel; all outside the submitted work. D J Stein reports personal fees from Discovery Vitality, Johnson & Johnson, Kanna, L’Oreal, Lundbeck, Orion, Sanofi, Servier, Takeda, and Vistagen; outside the submitted work. J H V Ticaolu reports leadership or fiduciary roles in other board, society, committee, or advocacy group, paid or unpaid, with the Benang Merah Research Center as co-founder, outside the submitted work. F Topouzis reports grants or contracts from Thea, Omikron, Pfizer, Alcon, AbbVie, and Bayer; consulting fees from Omikron, Thea, and Bausch and Lomb; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Omikron, AbbVie, and Roche; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid, with the European Glaucoma Society, Greek Glaucoma Society, and World Glaucoma Association; all outside the submitted work. S J Tromans reports grants or contracts from NHS Digital via the Department of Health and Social Care; leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid, with the Neurodevelopmental Psychiatry Special Interest Group and the Royal College of Psychiatrists; all outside the submitted work. E Upadhyay reports patents planned, issued, or pending: “A system and method of reusable filters for anti-pollution mask” (published), “A system and method for electricity generation through crop stubble by using microbial fuel cells” (published), “A system for disposed personal protection equipment (PPE) into biofuel through pyrolysis and method” (published), “A novel herbal pharmaceutical aid for formulation of gel and method thereof” (published), “Herbal drug formulation for treating lung tissue degenerated by particulate matter exposure” (filed), “A method to transform cow dung into the wall paint by using natural materials and composition thereof” (filed); leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as Joint Secretary of Indian Meteorological Society, Jaipur Chapter (India), Member Secretary of the DSTPURSE Program; outside the submitted work. P Willeit reports consulting fees from Novartis Pharmaceuticals; outside the submitted work. Y Yasufuku reports grants or contracts from Shionogi & Co; outside the submitted work. M Zielińska reports other financial or non-financial interests in AstraZeneca as their employee, outside the submitted work. A Zumla reports support for the present manuscript from the Pan-African Network on Emerging and Re-Emerging Infections (PANDORA-ID-NET) funded by the EDCTP - the EU Horizon 2020 Framework Programme, the UK NIHR Senior Investigator Award, Mahathir Science Award and EU-EDCTP Pascoal Mocumbi Prize Laureate; participation on a data safety monitoring board or advisory board as a member of the Scientific Expert Committee of the EC-EDCTP-Global Health Program; outside the submitted work. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Global DALYs attributable to Level 1 risk factors, 1990–2021 (A) Global DALY counts attributable to Level 1 risks, 1990 to 2021. (B) Age-standardised DALY rates attributable to Level 1 risks, 1990 to 2021. (C) Global total DALY counts that were unattributed, due to COVID-19, or attributable to Level 1 risk factors, 2021. Mean estimates by Level 1 risk factor in panels A and B are represented by coloured lines; the shading indicates 95% uncertainty intervals. For panel C, ∩ refers to a burden that is attributed to two or all three Level 1 risk factors (ie, the intersecting set of DALYs that belong to both or all three risk factors). Mean estimates in panels A and B are aggregated to include all DALYs attributable exclusively to the specific Level 1 risk factor plus those attributable to the intersection of that risk and one or both of the other Level 1 risk factors (ie, for a single year, the DALY counts combined across the three lines sum to more than the total number of attributable DALYs for that year). DALYs due to COVID-19 were estimated as part of a separate GBD 2021 analysis by the GBD 2021 Diseases and Injuries Collaborators. They have been separated in this figure from the DALYs unattributed to a risk factor because attribution of COVID-19 DALYs to risk exposure was not conducted as part of this analysis. In GBD 2021, 41·4% of total global DALYs—or 44·7% excluding COVID-19 DALYs—were attributable to risk factors (see also appendix 2 figure S4); whereas in GBD 2019, 47·8% of total global DALYs were attributable to risk factors. DALY=disability-adjusted life-year. Environmental risks=environmental and occupational risks. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.
Figure 2
Figure 2
Leading 25 Level 3 risk factors by attributable DALYs, percentage of total DALYs (2000 and 2021), and percentage change in attributable DALY counts and age-standardised DALY rates from 2000 to 2021 Each column displays the top 25 risks in descending order for the specified year. Risk factors are connected by lines between time periods; solid lines represent an increase or lateral shift in ranking, dashed lines represent a decrease in rank. DALY=disability-adjusted life-year. UI=uncertainty interval.
Figure 3
Figure 3
Age-standardised DALY rate attributable to the five leading Level 2 risk factors in 2000 and 2021 by location (A) Child and maternal malnutrition, 2000. (B) Child and maternal malnutrition, 2021. (C) Air pollution, 2000. (D) Air pollution, 2021. (E) High systolic blood pressure, 2000. (F) High systolic blood pressure, 2021. (G) Tobacco, 2000. (H) Tobacco, 2021. (I) Dietary risks, 2000. (J) Dietary risks, 2021. DALY=disability-adjusted life-year.
Figure 3
Figure 3
Age-standardised DALY rate attributable to the five leading Level 2 risk factors in 2000 and 2021 by location (A) Child and maternal malnutrition, 2000. (B) Child and maternal malnutrition, 2021. (C) Air pollution, 2000. (D) Air pollution, 2021. (E) High systolic blood pressure, 2000. (F) High systolic blood pressure, 2021. (G) Tobacco, 2000. (H) Tobacco, 2021. (I) Dietary risks, 2000. (J) Dietary risks, 2021. DALY=disability-adjusted life-year.
Figure 3
Figure 3
Age-standardised DALY rate attributable to the five leading Level 2 risk factors in 2000 and 2021 by location (A) Child and maternal malnutrition, 2000. (B) Child and maternal malnutrition, 2021. (C) Air pollution, 2000. (D) Air pollution, 2021. (E) High systolic blood pressure, 2000. (F) High systolic blood pressure, 2021. (G) Tobacco, 2000. (H) Tobacco, 2021. (I) Dietary risks, 2000. (J) Dietary risks, 2021. DALY=disability-adjusted life-year.
Figure 3
Figure 3
Age-standardised DALY rate attributable to the five leading Level 2 risk factors in 2000 and 2021 by location (A) Child and maternal malnutrition, 2000. (B) Child and maternal malnutrition, 2021. (C) Air pollution, 2000. (D) Air pollution, 2021. (E) High systolic blood pressure, 2000. (F) High systolic blood pressure, 2021. (G) Tobacco, 2000. (H) Tobacco, 2021. (I) Dietary risks, 2000. (J) Dietary risks, 2021. DALY=disability-adjusted life-year.
Figure 3
Figure 3
Age-standardised DALY rate attributable to the five leading Level 2 risk factors in 2000 and 2021 by location (A) Child and maternal malnutrition, 2000. (B) Child and maternal malnutrition, 2021. (C) Air pollution, 2000. (D) Air pollution, 2021. (E) High systolic blood pressure, 2000. (F) High systolic blood pressure, 2021. (G) Tobacco, 2000. (H) Tobacco, 2021. (I) Dietary risks, 2000. (J) Dietary risks, 2021. DALY=disability-adjusted life-year.
Figure 4
Figure 4
Annualised rate of change in age-standardised attributable DALY rates, 2000–21, for the leading ten Level 3 risk factors in 2021, by SDI quintile and GBD region For each region and SDI quintile, Level 3 risk factors are ranked by attributable DALY counts from left (first) to right (tenth). Risk factors are coloured by their annualised rates of change in age-standardised rates of attributable DALYs from 2000 to 2021. DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. SDI=Socio-demographic Index.
Figure 5
Figure 5
Percentage change in global DALY counts attributable to Level 4 risk factors from 2000 to 2021, due to population growth, population ageing, changes in risk factor exposure, and changes in risk-deleted DALY rates (A) Category I risk factors. (B) Category II risk factors. (C) Category III risk factors. This decomposition analysis visualises changes in risk-specific attributable DALYs from 2000 to 2021 due to changes in risk exposure, population growth, population age structure, and risk-deleted DALYs. Risk-deleted DALY rates are DALY rates after removing the effect of a risk factor or combination of risk factors on overall rates. They are calculated as the overall DALY rate multiplied by one minus the PAF for the risk or set of risks; this isolates the underlying changes in DALY rates unattributable to risk factors. Broadly grouped into three categories, category I risk factors are those for which the risk-attributable burden declined due in large part to decreased risk exposure, but in some cases also due to proportional declines in young populations due to population ageing. Category II risk factors are those for which the risk-attributable burden increased moderately despite decreased risk factor exposure, due largely to population ageing. Category III risk factors are those for which the risk-attributable burden increased considerably, due to both increased risk factor exposure and population ageing. DALY=disability-adjusted life-year. PAF=population attributable fraction.
Figure 6
Figure 6
Annualised rate of change in age-standardised risk-attributable DALY rates by Level 1 risk, by SDI quintile and country or territory, 2000–21 The grey dashed lines depict the linear regression line. Country and territory points are categorised by GBD super-region. Selected countries and territories are labelled by ISO 3 codes. AFG=Afghanistan. AGO=Angola. BDI=Burundi. BFA=Burkina Faso. BWA=Botswana. CAF=Central African Republic. CIV=Côte D’Ivoire. COD=DR Congo. DALY=disability-adjusted life-year. EST=Estonia. ETH=Ethiopia. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. GMB=The Gambia. GNB=Guinea-Bissau. GNQ=Equatorial Guinea. IRL=Ireland. KAZ=Kazakhstan. KEN=Kenya. LAO=Laos. LBY=Libya. LSO=Lesotho. MCO=Monaco. MDA=Moldova. MDV=Maldives. MLI=Mali. MNG=Mongolia. MOZ=Mozambique. NAM=Namibia. NER=Niger. PNG=Papua New Guinea. PRK=North Korea. RWA=Rwanda. SDI=Socio-demographic Index. SLB=Solomon Islands. SOM=Somalia. SSD=South Sudan. TCD=Chad. TKL=Tokelau. TZA=Tanzania. UGA=Uganda. WSM=Samoa. ZWE=Zimbabwe.
Figure 7
Figure 7
Global risk-attributable DALYs and risk–outcome score categorised by star rating for all risk–outcome pairs submitted to BPRF analysis, 2021 Risk–outcome score star ratings indicate a conservative assessment of the effect size and strength of evidence for each risk–outcome pair analysed using the BPRF framework. Each point represents a single risk–outcome pair, coloured by Level 1 risk factor category and shaped by type of PAF calculation. Risk–outcome pairs evaluated with direct PAFs and PAF=1 were not submitted to a BPRF analysis and thus did not receive a risk–outcome score or star rating. Risk–outcome pairs associated with more than 15 million attributable DALYs are labelled. BMI=high body-mass index. BPRF=burden of proof risk function. CKD=chronic kidney disease. COPD=chronic obstructive pulmonary disease. DALY=disability-adjusted life-year. Iron=iron deficiency. Diet iron def=dietary iron deficiency. FPG=high fasting plasma glucose. HHD=hypertensive heart disease. IHD=ischaemic heart disease. Larynx C=larynx cancer. LDL=high LDL cholesterol. LRI=lower respiratory infection. Occ injury=occupational injury. PAF=population attributable fraction. PM2·5=particulate matter pollution. SBP=high systolic blood pressure.
Figure 8
Figure 8
Level 3 risk factors rank ordered by risk-attributable DALYs inclusive of all GBD risk–outcome pairs versus GBD risk–outcome pairs excluding one-star and two-star associations, 2021 Each column displays Level 3 risk factors in descending order by risk-attributable DALYs. Risk factors for which no risk–outcome pairs have a better than two-star association are indicated in the right column with lighter shading and no attributable DALYs. One-star and two-star associations are those that are either or both weakly associated or lacking strong evidence, based on BPRF analysis. Risk factors are connected by lines, with solid lines representing an increase or lateral shift in risk-attributable burden ranking and dashed lines representing a decrease in rank. A number of risk factors—including low birthweight and short gestation, low bone mineral density, childhood sexual abuse, intimate partner violence, suboptimal breastfeeding, and all occupational risks—have not yet been submitted to BPRF analysis, and therefore no associated DALYs were removed due to low star rating. BPRF=burden of proof risk function. DALY=disability-adjusted life-year. UI=uncertainty interval.

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