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

Brauer, Michael and Roth, Gregory A. and Aravkin, Aleksandr Y. and Zheng, Peng and Abate, Kalkidan Hassen and Abate, Yohannes Habtegiorgis and Abbafati, Cristiana and Abbasgholizadeh, Rouzbeh and Abbasi, Madineh Akram and Abbasian, Mohammadreza and Abbasifard, Mitra and Abbasi-Kangevari, Mohsen and ElHafeez, Samar Abd and Abd-Elsalam, Sherief and Abdi, Parsa and Abdollahi, Mohammad and Abdoun, Meriem and Abdulah, Deldar Morad and Abdullahi, Auwal and Abebe, Mesfin and Abedi, Aidin and Abedi, Armita and Abegaz, Tadesse M. and Zuniga, Roberto Ariel Abeldano and Abiodun, Olumide and Abiso, Temesgen Lera and Aboagye, Richard Gyan and Abolhassani, Hassan and Abouzid, Mohamed and Aboye, Girma Beressa and Abreu, Lucas Guimaraes and Abualruz, Hasan and Abubakar, Bilyaminu and Abu-Gharbieh, Eman and Abukhadijah, Hana Jihad Jihad and Aburuz, Salahdein and Abu-Zaid, Ahmed and Adane, Mesafint Molla and Addo, Isaac Yeboah and Addolorato, Giovanni and Adedoyin, Rufus Adesoji and Adekanmbi, Victor and Aden, Bashir and Adetunji, Juliana Bunmi and Adeyeoluwa, Temitayo Esther and Adha, Rishan and Adibi, Amin and Estiningtyas, Qorinah and Adnani, Sakilah and Adzigbli, Leticia Akua and Afolabi, Aanuoluwapo Adeyimika and Afolabi, Rotimi Felix and Afshin, Ashkan and Afyouni, Shadi and Afzal, Muhammad Sohail and Afzal, Saira and Agampodi, Suneth Buddhika and Agbozo, Faith and Aghamiri, Shahin and Agodi, Antonella and Agrawal, Anurag and Agyemang-Duah, Williams and Ahinkorah, Bright Opoku and Ahmad, Aqeel and Ahmad, Danish and Ahmad, Firdos and Ahmad, Noah and Ahmad, Shahzaib and Ahmad, Tauseef and Ahmed, Ali and Ahmed, Anisuddin and Ahmed, Ayman and Ahmed, Luai A. and Ahmed, Muktar Beshir and Ahmed, Safoora and Ahmed, Syed Anees and Ajami, Marjan and Akalu, Gizachew Taddesse and Akara, Essona Matatom and Akbarialiabad, Hossein and Akhlaghi, Shiva and Akinosoglou, Karolina and Akinyemiju, Tomi and Akkaif, Mohammed Ahmed and Akkala, Sreelatha and Akombi-Inyang, Blessing and Al Awaidy, Salah and Al Hasan, Syed Mahfuz and Alahdab, Fares and AL-Ahdal, Tareq Mohammed Ali and Alalalmeh, Samer O. and Alalwan, Tariq A. and Al-Aly, Ziyad and Alam, Khurshid and Alam, Nazmul and Alanezi, Fahad Mashhour and Alanzi, Turki M. and Albakri, Almaza and AlBataineh, Mohammad T. and Aldhaleei, Wafa A. and Aldridge, Robert W. and Alemayohu, Mulubirhan Assefa and Alemu, Yihun Mulugeta and Al-Fatly, Bassam and Al-Gheethi, Adel Ali Saeed and Al-Habbal, Khairat and Alhabib, Khalid F. and Alhassan, Robert Kaba and Ali, Abid and Ali, Amjad and Ali, Beriwan Abdulqadir and Ali, Iman and Ali, Liaqat and Ali, Mohammed Usman and Ali, Rafat and Ali, Syed Shujait Shujait and Ali, Waad and Alicandro, Gianfranco and Alif, Sheikh Mohammad and Aljunid, Syed Mohamed and Alla, Francois and Al-Marwani, Sabah and Al-Mekhlafi, Hesham M. and Almustanyir, Sami and Alomari, Mahmoud A. and Alonso, Jordi and Alqahtani, Jaber S. and Alqutaibi, Ahmed Yaseen and Al-Raddadi, Rajaa M. and Alrawashdeh, Ahmad and Al-Rifai, Rami Hani and Alrousan, Sahel Majed and Al-Sabah, Salman Khalifah and Alshahrani, Najim Z. and Altaany, Zaid and Altaf, Awais and Al-Tawfiq, Jaffar A. and Altirkawi, Khalid A. and Aluh, Deborah Oyine and Alvis-Guzman, Nelson and Alvis-Zakzuk, Nelson J. and Alwafi, Hassan and Al-Wardat, Mohammad Sami and Al-Worafi, Yaser Mohammed and Aly, Hany and Aly, Safwat and Alzoubi, Karem H. and Al-Zyoud, Walid Adnan and Amaechi, Uchenna Anderson and Mohammadi, Masous Aman and Amani, Reza and Amiri, Sohrab and Amirzade-Iranaq, Mohammad Hosein and Ammirati, Enrico and Amu, Hubert and Amugsi, Dickson A. and Amusa, Ganiyu Adeniyi and Ancuceanu, Robert and Anderlini, Deanna and Anderson, Jason A. and Andrade, Pedro Prata and Andrei, Catalina Liliana and Andrei, Tudorel and Anenberg, Susan C. and Angappan, Dhanalakshmi and Angus, Colin and Anil, Abhishek and Anil, Sneha and Anjum, Afifa and Anoushiravani, Amir and Antonazzo, Ippazio Cosimo and Antony, Catherine M. and Antriyandarti, Ernoiz and Anuoluwa, Boluwatife Stephen and Anvari, Davood and Anvari, Saeid and Anwar, Saleha and Anwar, Sumadi Lukman and Anwer, Razique and Anyabolo, Ekenedilichukwu Emmanuel and Anyasodor, Anayochukwu Edward and Apostol, Geminn Louis Carace and Arabloo, Jalal and Bahri, Razman Arabzadeh and Arafat, Mosab and Areda, Demelash and Aregawi, Brhane Berhe and Aremu, Abdulfatai and Armocida, Benedetta and Arndt, Michael Benjamin and Arnlov, Johan and Arooj, Mahwish and Artamonov, Anton A. and Artanti, Kurnia Dwi and Aruleba, Idowu Thomas and Arumugam, Ashokan and Asbeutah, Akram M. and Asgary, Saeed and Asgedom, Akeza Awealom and Ashbaugh, Charlie and Ashemo, Mubarek Yesse and Ashraf, Tahira and Askarinejad, Amir and Assmus, Michael and Astell-Burt, Thomas and Athar, Mohammad and Athari, Seyyed Shamsadin and Atorkey, Prince and Atreya, Alok and Aujayeb, Avinash and Ausloos, Marcel and Avila-Burgos, Leticia and Awoke, Andargie Abate and Quintanilla, Beatriz Paulina Ayala and Ayatollahi, Haleh and Portugal, Carlos Ayestas and Ayuso-Mateos, Jose L. and Azadnajafabad, Sina and Azevedo, Rui M. S. and Azhar, Gulrez Shah and Azizi, Hosein and Azzam, Ahmed Y. and Backhaus, Insa Linnea and Badar, Muhammad and Badiye, Ashish D. and Bagga, Arvind and Baghdadi, Soroush and Bagheri, Nasser and Bagherieh, Sara and Taghanaki, Pegah Bahrami and Bai, Ruhai and Baig, Atif Amin and Baker, Jennifer L. and Bakkannavar, Shankar M. and Balasubramanian, Madhan and Baltatu, Ovidiu Constantin and Bam, Kiran and Bandyopadhyay, Soham and Banik, Biswajit and Banik, Palash Chandra and Banke-Thomas, Aduragbemi and Bansal, Hansi and Barchitta, Martina and Bardhan, Mainak and Bardideh, Erfan and Barker-Collo, Suzanne Lyn and Barnighausen, Till Winfried and Barone-Adesi, Francesco and Barqawi, Hiba Jawdat and Barrero, Lope H. and Barrow, Amadou and Barteit, Sandra and Basharat, Zarrin and Basiru, Afisu and Basso, Joao Diogo and Bastan, Mohammad-Mahdi and Basu, Sanjay and Batchu, Sai and Batra, Kavita and Batra, Ravi and Baune, Bernhard T. and Bayati, Mohsen and Bayileyegn, Nebiyou Simegnew and Beaney, Thomas and Behnoush, Amir Hossein and Beiranvand, Maryam and Bejot, Yannick and Bekele, Alehegn and Belgaumi, Uzma Iqbal and Bell, Arielle Wilder and Bell, Michelle L. and Bello, Muhammad Bashir and Bello, Olorunjuwon Omolaja and Belo, Luis and Beloukas, Apostolos and Bendak, Salaheddine and Bennett, Derrick A. and Bennitt, Fiona B. and Bensenor, Isabela M. and Benzian, Habib and Beran, Azizullah and Berezvai, Zombor and Bernabe, Eduardo and Bernstein, Robert S. and Bettencourt, Paulo J. G. and Bhagavathula, Akshaya Srikanth and Bhala, Neeraj and Bhandari, Dinesh and Bhardwaj, Nikha and Bhardwaj, Pankaj and Bhaskar, Sonu and Bhat, Ajay Nagesh and Bhat, Vivek and Bhatti, Gurjit Kaur and Bhatti, Jasvinder Singh and Bhatti, Manpreet S. and Bhatti, Rajbir and Bhuiyan, Mohiuddin Ahmed and Bhutta, Zulfiqar A. and Bikbov, Boris and Bishai, Jessica Devin and Bisignano, Catherine and Biswas, Atanu and Biswas, Bijit and Biswas, Raaj Kishore and Bjorge, Tone and Boachie, Micheal Kofi and Boakye, Hosea and Bockarie, Moses John and Bodolica, Virginia and Bodunrin, Aadam Olalekan and Bogale, Eyob Ketema and Bolla, Srinivasa Rao and Boloor, Archith and Hashemi, Milad Bonakdar and Boppana, Sri Harsha and Basara, Berrak Bora and Borhany, Hamed and Carvajal, Alejandro Botero and Bouaoud, Souad and Boufous, Soufiane and Bourne, Rupert and Boxe, Christopher and Braithwaite, Dejana and Brant, Luisa C. and Brar, Amanpreet and Breitborde, Nicholas J. K. and Breitner, Susanne and Brenner, Hermann and Briko, Andrey Nikolaevich and Britton, Gabrielle and Brown, Colin Stewart and Browne, Annie J. and Brunoni, Andre R. and Bryazka, Dana and Bulamu, Norma B. and Bulto, Lemma N. and Buonsenso, Danilo and Burkart, Katrin and Burns, Richard A. and Busse, Reinhard and Bustanji, Yasser and Butt, Nadeem Shafique and Butt, Zahid A. and dos Santos, Florentino Luciano Caetano and Cagney, Jack and Cahuana-Hurtado, Lucero and Calina, Daniela and Camera, Luis Alberto and Campos, Luciana Aparecida and Campos-Nonato, Ismael R. and Cao, Chao and Cao, Fan and Cao, Yubin and Capodici, Angelo and Cardenas, Rosario and Carr, Sinclair and Carreras, Giulia and Carrero, Juan J. and Carugno, Andrea and Carvalho, Felix and Carvalho, Marcia and Castaldelli-Maia, Joao Mauricio and Castaneda-Orjuela, Carlos A. and Castelpietra, Giulio and Catala-Lopez, Ferran and Catapano, Alberico L. and Cattaruzza, Maria Sofia and Caye, Arthur and Cederroth, Christopher R. and Cegolon, Luca and Cenderadewi, Muthia and Cercy, Kelly M. and Cerin, Ester and Chadwick, Joshua and Chakraborty, Chiranjib and Chakraborty, Promit Ananyo and Chakraborty, Sandip and Chan, Jeffrey Shi Kai and Chan, Raymond N. C. and Chandan, Joht Singh and Chandika, Rama Mohan and Chaturvedi, Pankaj and Chen, An-Tian and Chen, Catherine S. and Chen, Haowei and Chen, Meng Xuan and Chen, Mingling and Chen, Simiao and Cheng, Ching-Yu and Cheng, Esther T. W. and Cherbuin, Nicolas and Chi, Gerald and Chichagi, Fatemeh and Chimed-Ochir, Odgerel and Chimoriya, Ritesh and Ching, Patrick R. and Chirinos-Caceres, Jesus Lorenzo and Chitheer, Abdulaal and Cho, William C. S. and Chong, Bryan and Chopra, Hitesh and Chowdhury, Rajiv and Christopher, Devasahayam J. and Chu, Dinh-Toi and Chukwu, Isaac Sunday and Chung, Eric and Chung, Sheng-Chia and Chutiyami, Muhammad and Cioffi, Iolanda and Cogen, Rebecca M. and Cohen, Aaron J. and Columbus, Alyssa and Conde, Joao and Corlateanu, Alexandru and Cortese, Samuele and Cortesi, Paolo Angelo and Costa, Vera Marisa and Costanzo, Simona and Criqui, Michael H. and Cruz, Jessica A. and Cruz-Martins, Natalia and Culbreth, Garland T. and da Silva, Alanna Gomes and Dadras, Omid and Dai, Xiaochen and Dai, Zhaoli and Daikwo, Patience Unekwuojo and Dalli, Lachlan L. and Damiani, Giovanni and D'Amico, Emanuele and D'Anna, Lucio and Darwesh, Aso Mohammad and Das, Jai K. and Das, Subasish and Dash, Nihar Ranjan and Dashti, Mohsen and Davila-Cervantes, Claudio Alberto and Weaver, Nicole Davis and Davitoiu, Dragos Virgil and De la Hoz, Fernando Pio and de la Torre-Luque, Alejandro and De Leo, Diego and Debopadhaya, Shayom and Degenhardt, Louisa and Del Bo, Cristian and Delgado-Enciso, Ivan and Delgado-Saborit, Juana Maria and Demoze, Chalachew Kassaw and Denova-Gutierrez, Edgar and Dervenis, Nikolaos and Dervisevic, Emina and Desai, Hardik Dineshbhai and Desai, Rupak and Devanbu, Vinoth Gnana Chellaiyan and Dewan, Syed Masudur Rahman and Dhali, Arkadeep and Dhama, Kuldeep and Dhane, Amol S. and Dhimal, Mandira Lamichhane and Dhimal, Meghnath and Dhingra, Sameer and Dhulipala, Vishal R. and Dhungana, Raja Ram and da Silva, Diana Dias and Diaz, Daniel and Diaz, Luis Antonio and Diaz, Michael J. and Dima, Adriana and Ding, Delaney D. and Dinu, Monica and Djalalinia, Shirin and Do, Thanh Chi and Do, Thao Huynh Phuong and do Prado, Camila Bruneli and Dodangeh, Masoud and Dohare, Sushil and Dokova, Klara Georgieva and Dong, Wanyue and Dongarwar, Deepa and D'Oria, Mario and Dorostkar, Fariba and Dorsey, E. Ray and Doshi, Rajkumar and Doshmangir, Leila and Dowou, Robert Kokou and Driscoll, Tim Robert and Dsouza, Ashel Chelsea and Dsouza, Haneil Larson and Dumith, Samuel C. and Duncan, Bruce B. and Duraes, Andre Rodrigues and Duraisamy, Senbagam and Dushpanova, Anar and Dzianach, Paulina Agnieszka and Dziedzic, Arkadiusz Marian and Ebrahimi, Alireza and Echieh, Chidiebere Peter and Ed-Dra, Abdelaziz and Edinur, Hisham Atan and Edvardsson, David and Edvardsson, Kristina and Efendi, Ferry and Eftekharimehrabad, Aziz and Eini, Ebrahim and Ekholuenetale, Michael and Ekundayo, Temitope Cyrus and El Arab, Rabie Adel and Zaki, Maysaa El Sayed and El-Dahiyat, Faris and Elemam, Noha Mousaad and Elgar, Frank J. and ElGohary, Ghada Metwally Tawfik and Elhabashy, Hala Rashad and Elhadi, Muhammed and Elmehrath, Ahmed O. and Elmeligy, Omar Abdelsadek Abdou and Elshaer, Mohammed and Elsohaby, Ibrahim and Emeto, Theophilus I. and Esfandiari, Negin and Eshrati, Babak and Eslami, Majid and Esmaeili, Sayed Vahid and Estep, Kara and Etaee, Farshid and Fabin, Natalia and Fagbamigbe, Adeniyi Francis and Fagbule, Omotayo Francis and Fahimi, Saman and Falzone, Luca and Fareed, Mohammad and Farinha, Carla Sofia e Sa and Faris, MoezAlIslam Ezzat Mahmoud and Faris, Pawan Sirwan and Faro, Andre and Fasina, Folorunso Oludayo and Fatehizadeh, Ali and Fauk, Nelsensius Klau and Fazylov, Timur and Feigin, Valery L. and Feng, Xiaoqi and Fereshtehnejad, Seyed-Mohammad and Feroze, Abdullah Hamid and Ferrara, Pietro and Ferrari, Alize J. and Ferreira, Nuno and Fetensa, Getahun and Feyisa, Bikila Regassa and Filip, Irina and Fischer, Florian and Fitriana, Ida and Flavel, Joanne and Flohr, Carsten and Flood, David and Flor, Luisa S. and Foigt, Nataliya A. and Folayan, Morenike Oluwatoyin and Force, Lisa M. and Fortuna, Daniela and Foschi, Matteo and Franklin, Richard Charles and Freitas, Alberto and Friedman, Sara D. and Fux, Blima and Sridevi, G. and Gaal, Peter Andras and Gaihre, Santosh and Gajdacs, Mario and Galali, Yaseen and Gallus, Silvano and Gandhi, Aravind P. and Ganesan, Balasankar and Ganiyani, Mohammad Arfat and Garcia, Vanessa and Gardner, William M. and Garg, Ravindra K. and Gautam, Rupesh K. and Gebi, Tilaye Gebru and Gebregergis, Miglas W. and Gebrehiwot, Mesfin and Gebremariam, Tesfay B. B. and Gebremeskel, Teferi Gebru and Gerema, Urge and Getacher, Lemma and Getahun, Genanew K. A. and Getie, Molla and Ghadirian, Fataneh and Ghafarian, Sadegh and Jolfayi, Amir Ghaffari and Ghailan, Khalid Yaser and Ghajar, Alireza and Ghasemi, MohammadReza and Dabaghi, Ghazal Ghasempour and Ghasemzadeh, Afsaneh and Ghassemi, Fariba and Ghazy, Ramy Mohamed and Gholami, Ali and Gholamrezanezhad, Ali and Gholizadeh, Nasim and Ghorbani, Mahsa and Gil, Artyom Urievich and Gil, Gabriela Fernanda and Gilbertson, Nora M. and Gill, Paramjit Singh and Gill, Tiffany K. and Gindaba, Ebisa Zerihun and Girmay, Alem and Glasbey, James C. and Gnedovskaya, Elena V. and Gobolos, Laszlo and Godinho, Myron Anthony and Goel, Amit and Golechha, Mahaveer and Goleij, Pouya and Golinelli, Davide and Gomes, Nelson G. M. and Gopalani, Sameer Vali and Gorini, Giuseppe and Goudarzi, Houman and Goulart, Alessandra C. and Gouravani, Mahdi and Goyal, Anmol and Graham, Simon Matthew and Grivna, Michal and Grosso, Giuseppe and Guan, Shi-Yang and Guarducci, Giovanni and Ibrahim, Mohammed and Gubari, Mohialdeen and Guha, Avirup and Guicciardi, Stefano and Gulati, Snigdha and Gulisashvili, David and Gunawardane, Damitha Asanga and Guo, Cui and Gupta, Anish Kumar and Gupta, Bhawna and Gupta, Mohak and Gupta, Rahul and Das Gupta, Rajat and Gupta, Rajeev and Gupta, Sapna and Gupta, Veer Bala and Gupta, Vijai Kumar and Gupta, Vivek Kumar and Habibzadeh, Farrokh and Habibzadeh, Parham and Hadaro, Tesfahun Simon and Hadian, Zahra and Haep, Nils and Haghi-Aminjan, Hamed and Haghmorad, Dariush and Hagins, Hailey and Haile, Demewoz and Hailu, Alemayehu and Ali, Adel Hajj and Halboub, Esam S. and Halimi, Aram and Hall, Brian J. and Haller, Sebastian and Halwani, Rabih and Hamadeh, Randah R. and Hamdy, Nadia M. and Hameed, Sajid and Hamidi, Samer and Hammoud, Ahmad and Hanif, Asif and Hanifi, Nasrin and Haq, Zaim Anan and Haque, Md Rabiul and Harapan, Harapan and Hargono, Arief and Haro, Josep Maria and Hasaballah, Ahmed I. and Hasan, Ikramul and Hasan, Mohammad Jahid and Hasan, S. M. Mahmudul and Hasani, Hamidreza and Hasanian, Mohammad and Hashmeh, Nadim and Hasnain, Md Saquib and Hassan, Amr and Hassan, Ikrama and Tabatabaei, Mahgol Sadat Hassan Zadeh and Hassani, Shokoufeh and Hassanipour, Soheil and Hassankhani, Hadi and Haubold, Johannes and Havmoeller, Rasmus J. and Hay, Simon I. and Hebert, Jeffrey J. and Hegazi, Omar E. and Hegena, Tadele Yohannes and Heidari, Golnaz and Heidari, Mohammad and Helfer, Bartosz and Hemmati, Mehdi and Henson, Claire A. and Herbert, Molly E. and Herteliu, Claudiu and Heuer, Austin and Hezam, Kamal and Hinneh, Thomas Kwadwo and Hiraike, Yuta and Hoan, Nguyen Quoc and Holla, Ramesh and Hon, Julia and Hoque, Mohammad Enamul and Horita, Nobuyuki and Hossain, Sahadat and Hosseini, Seyed Ehsan and Hosseinzadeh, Hassan and Hosseinzadeh, Mehdi and Hostiuc, Mihaela and Hostiuc, Sorin and Hoven, Hanno and Hsairi, Mohamed and Hsu, Johnathan M. and Hu, Chengxi and Huang, Junjie and Huda, Md Nazmul and Hulland, Erin N. and Hultstrom, Michael and Hushmandi, Kiavash and Hussain, Javid and Hussein, Nawfal R. and Huynh, Chantal K. and Huynh, Hong-Han and Ibitoye, Segun Emmanuel and Idowu, Oluwatope Olaniyi and Ihler, Audrey L. and Ikeda, Nayu and Ikuta, Kevin S. and Ilesanmi, Olayinka Stephen and Ilic, Irena M. and Ilic, Milena D. and Imam, Mohammad Tarique and Immurana, Mustapha and Inbaraj, Leeberk Raja and Irham, Lalu Muhammad and Isa, Mustafa Alhaji and Islam, Md Rabiul and Ismail, Faisal and Ismail, Nahlah Elkudssiah and Iso, Hiroyasu and Isola, Gaetano and Iwagami, Masao and Iwu, Chidozie C. D. and Iwu-Jaja, Chinwe Juliana and Vinothini, J. and Jaafari, Jalil and Jacob, Louis and Jacobsen, Kathryn H. and Jadidi-Niaragh, Farhad and Jahankhani, Kasra and Jahanmehr, Nader and Jahrami, Haitham and Jain, Akhil and Jain, Nityanand and Jairoun, Ammar Abdulrahman and Jaiswal, Abhishek and Jakovljevic, Mihajlo and Yengejeh, Reza Jalilzadeh and Jamora, Roland Dominic G. and Jatau, Abubakar Ibrahim and Javadov, Sabzali and Javaheri, Tahereh and Jayaram, Shubha and Jeganathan, Jayakumar and Jeswani, Bijay Mukesh and Jiang, Heng and Johnson, Catherine O. and Jokar, Mohammad and Jomehzadeh, Nabi and Jonas, Jost B. and Joo, Tamas and Joseph, Abel and Joseph, Nitin and Joshi, Vivek and Joshua, Charity Ehimwenma and Jozwiak, Jacek Jerzy and Jurisson, Mikk and Kaambwa, Billingsley and Kabir, Ali and Kabir, Zubair and Kadashetti, Vidya and Kahn, Ethan M. and Kalani, Rizwan and Kaliyadan, Feroze and Kalra, Sanjay and Kamath, Rajesh and Kanagasabai, Thanigaivelan and Kanchan, Tanuj and Kandel, Himal and Kanmiki, Edmund Wedam and Kanmodi, Kehinde Kazeem and Kansal, Sushil Kumar and Kapner, Daniel John and Kapoor, Neeti and Karagiannidis, Efstratios and Karajizadeh, Mehrdad and Karakasis, Paschalis and Karanth, Shama D. and Karaye, Ibraheem M. and Karch, Andre and Karim, Asima and Karimi, Hanie and Karmakar, Shilpi and Kashoo, Faizan Zaffar and Kasraei, Hengameh and Kassahun, Woldeteklehaymanot Dagne and Kassebaum, Nicholas J. and Kassel, Molly B. and Katikireddi, Srinivasa Vittal and Kauppila, Joonas H. and Kawakami, Norito and Kaydi, Neda and Kayode, Gbenga A. and Kazemi, Foad and Keiyoro, Peter Njenga and Kemmer, Laura and Kempen, John H. and Kerr, Jessica A. and Kesse-Guyot, Emmanuelle and Khader, Yousef Saleh and Khafaie, Morteza Abdullatif and Khajuria, Himanshu and Khalaji, Amirmohammad and Khalil, Mariam and Khalilian, Alireza and Khamesipour, Faham and Khan, Asaduzzaman and Khan, M. Nuruzzaman and Khan, Maseer and Khan, Mohammad Jobair and Khan, Moien A. B. and Khanmohammadi, Shaghayegh and Khatab, Khaled and Khatatbeh, Haitham and Khatatbeh, Moawiah Mohammad and Khatib, Mahalaqua Nazli and Khavandegar, Armin and Kashani, Hamid Reza Khayat and Khidri, Feriha Fatima and Khodadoust, Elaheh and Khormali, Moein and Khorrami, Zahra and Khosla, Atulya Aman and Khosrowjerdi, Mahmood and Khreis, Haneen and Khusun, Helda and Kifle, Zemene Demelash and Kim, Kwanghyun and Kim, Min Seo and Kim, Yun Jin and Kimokoti, Ruth W. and Kisa, Adnan and Kisa, Sezer and Knibbs, Luke D. and Knudsen, Ann Kristin Skrindo and Koh, David S. 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R. 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(2024) 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. LANCET, 403 (10440). pp. 2162-2203. ISSN 0140-6736

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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.

Item Type: Article
Uncontrolled Keywords: health, consumption, mortality, growth, policy
Subjects: R Medicine > RP Public Health and Nutrition
Divisions: Faculty of Medicine, Public Health and Nursing > Public Health and Nutrition
Depositing User: Mukhotib Mukhotib
Date Deposited: 08 Aug 2025 04:08
Last Modified: 08 Aug 2025 04:08
URI: https://ir.lib.ugm.ac.id/id/eprint/16240

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