Lancet. 2017 Sep 16;390(10100):1345-1422. doi: 10.1016/S0140-6736(17)32366-8.
The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.
We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.
Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.
Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.
The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.
全球疾病、伤害和危险因素研究 2016 年（GBD 2016）提供了风险因素暴露和归因于疾病的负担的全面评估。通过提供长时间序列的估计，这项研究可以监测对健康监测至关重要的风险暴露趋势，并为在特定背景下解决风险的重要性提供政策辩论信息。
我们使用之前迭代的 GBD 中开发的比较风险评估框架，来估计 1990 年至 2016 年期间，84 种行为、环境和职业以及代谢风险或风险群，以及 481 种风险-结局对，在年龄组、性别、年份和地点的暴露水平和趋势。这项研究包括 481 种风险-结局对，它们满足 GBD 研究因果关系的令人信服或可能的证据标准。我们根据 GBD 2016 来源计数方法，从 22717 项随机对照试验、队列、合并队列、家庭调查、人口普查数据、卫星数据和其他来源中提取相对风险（RR）和暴露估计值。使用理论最小风险暴露水平（TMREL）的反事实情景，我们估计了给定风险可归因于的死亡和残疾调整生命年（DALY）的部分。最后，我们探讨了归因于负担的趋势的四个驱动因素：人口增长、人口老龄化、风险暴露趋势以及所有其他因素的综合影响。
自 1990 年以来，30 种风险的暴露显著增加，4 种风险的暴露没有显著变化，31 种风险的暴露显著减少。在导致疾病负担的主要风险因素中，儿童生长迟缓和家庭空气污染显示出最显著的下降，而代谢风险，如体重指数和高空腹血糖水平，显示出显著的增加。2016 年，在全球层面，男性归因于 DALY 的三个主要风险因素按等级排列依次为吸烟（12410 万 DALY [95%UI 11120 万至 13700 万]）、收缩压升高（12220 万 DALY [11030 万至 13330 万]）和低出生体重和早产（8300 万 DALY [7830 万至 8770 万]），女性则是收缩压升高（8990 万 DALY [8090 万至 9820 万]）、体重指数升高（6480 万 DALY [4440 万至 8760 万]）和高空腹血糖（6380 万 DALY [5320 万至 7630 万]）。2016 年，在 113 个国家中，归因于 DALY 的主要风险因素是代谢风险因素。在 109 个国家中，吸烟仍然是导致 DALY 的五个主要风险因素之一，而在 38 个国家中，低出生体重和早产是导致 DALY 的主要风险因素，尤其是在撒哈拉以南非洲和南亚。在归因于风险因素的负担变化趋势的重要驱动因素方面，2006 年至 2016 年期间，风险暴露的下降解释了全球层面死亡人数下降 9.3%（6.9-11.6），DALY 减少 10.8%（8.3-13.1），而人口老龄化占死亡人数的 14.9%（12.7-17.5），占 DALY 的 6.2%（3.9-8.7），人口增长占死亡人数的 12.4%（10.1-14.9）和 DALY 的 12.4%（10.1-14.9）。风险暴露趋势对疾病负担的影响最大的是 1 岁至 4 岁之间的年龄组，在 2006 年至 2016 年期间，DALY 变化的 27.3%（24.9-29.7）可归因于风险暴露的下降。
对风险暴露趋势和每个风险-结局对的 RR 的更详细的理解，提供了对归因于风险的健康损失的严重程度的深入了解，以及风险暴露的改变如何有助于健康趋势。由于代谢风险对全球疾病负担的贡献巨大，呈上升趋势，且在同一发展水平的国家之间存在差异，因此特别需要注意这些风险。GBD 2016 的研究结果表明，尽管它有巨大的潜力来改善健康，但在过去十年中，风险改变的作用相对较小。
比尔及梅琳达·盖茨基金会、彭博慈善基金会。
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