Lancet. 2024 May 18;403(10440):2162-2203. doi: 10.1016/S0140-6736(24)00933-4.
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.
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.
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).
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.
Bill & Melinda Gates Foundation.
了解与风险因素暴露相关的健康后果对于为公共卫生政策和实践提供信息是必要的。为了系统地量化风险因素暴露对特定健康结果的贡献，全球疾病、伤害和风险因素研究（GBD）2021 旨在为 204 个国家和地区和 811 个次国家地点提供 88 种风险因素的综合暴露水平、相对健康风险和归因于疾病的负担的全面估计，时间范围为 1990 年至 2021 年。
GBD 2021 风险因素分析使用了来自 54561 个独特数据源的数据，为总共 631 种风险-结果对中的 88 种风险因素及其相关健康结果产生了流行病学估计。基于对风险-结果关联的数据分析，确定了风险-结果关联的配对。在全球、区域和国家各级生成了年龄-性别-地点-年份特异性的估计值。我们的方法遵循比较风险评估框架，该框架基于分层组织、潜在可组合、可修改的风险的因果网络。为每个风险-结果对单独估计了特定结果发生的给定风险因素暴露的相对风险（RR），并为每个风险因素估计了代表风险加权暴露流行率的综合暴露值（SEV）和理论最小风险暴露水平（TMREL）。这些估计用于计算人群归因分数（PAF；即如果将风险因素暴露降低到 TMREL，健康风险的变化比例）。给定结果的疾病负担的乘积（以残疾调整生命年（DALY）衡量），得出归因于负担（即特定风险因素或风险因素组合导致的总疾病负担的比例）的措施。为了考虑间接通过中间风险对结果产生影响的风险因素之间的关系，应用了中介调整。归因于负担的估计值按社会人口指数（SDI）五分位数进行分层，并以计数、年龄标准化率和排名呈现。为了补充 RR 和归因于负担的估计值，新开发的负担证明风险函数（BPRF）方法根据基础证据的一致性，提供了基于风险-结果关联的保守解释，同时考虑了来自不同研究的输入数据之间未解释的异质性。报告的估计值代表分布的 500 次抽取的平均值，95%置信区间（UI）计算为 500 次抽取的第 2.5 和第 97.5 百分位数。
在本研究分析的特定风险因素中，颗粒物空气污染是 2021 年全球疾病负担的主要原因，占总 DALY 的 8.0%（95%UI 为 6.7-9.4），其次是高收缩压（SBP；7.8%[6.4-9.2]）、吸烟（5.7%[4.7-6.8]）、低出生体重和早产（5.6%[4.8-6.3]）和空腹血糖高（5.4%[4.8-6.0]）。对于年龄较小的人群（即 0-4 岁和 5-14 岁），低出生体重和早产以及不安全的水、环境卫生和手卫生（WaSH）等风险是主要风险因素，而对于年龄较大的年龄组，代谢风险如高 SBP、高体重指数（BMI）、高空腹血糖和高低密度脂蛋白胆固醇的影响更大。从 2000 年到 2021 年，全球健康挑战发生了明显转变，主要表现为行为风险（减少 20.7%[13.9-27.7]）和环境与职业风险（减少 22.0%[15.5-28.8]）归因的所有年龄 DALY 数量下降，再加上代谢风险归因的 DALY 增加了 49.4%（42.3-56.9），这反映了全球人口老龄化和生活方式的变化。高 BMI 和高空腹血糖的全球年龄标准化 DALY 率显著上升（高 BMI 为 15.7%[9.9-21.7]，高空腹血糖为 7.9%[3.3-12.9]），这一时期，这些风险的暴露率以每年 1.8%（1.6-1.9）的速度增加高 BMI 和每年 1.3%（1.1-1.5）的速度增加高空腹血糖。相比之下，许多其他风险因素的全球风险归因负担和暴露率下降，特别是儿童生长发育不良和不安全水源的风险，年龄标准化归因于 DALY 的儿童生长发育不良减少了 71.5%（64.4-78.8），不安全水源减少了 66.3%（60.2-72.0）。我们根据随时间变化的轨迹将风险因素分为三组：由于风险暴露下降（例如反式脂肪和家庭空气污染饮食）和儿童和青年人口比例较小（例如儿童和孕产妇营养不良）而归因于疾病负担下降的风险因素；尽管风险暴露下降但由于人口老龄化（例如吸烟）而导致负担适度增加的风险因素；以及由于风险暴露增加和人口老龄化而导致负担明显增加的风险因素（例如，环境空气中的颗粒物、高 BMI、高空腹血糖和高 SBP）。
在减少与一系列风险因素相关的全球疾病负担方面取得了重大进展，特别是与母婴健康、WaSH 和家庭空气污染相关的风险因素。为了维持在低社会发展指数地区的进展，有必要继续努力将这些风险因素的影响降到最低。通过减少风险暴露来减轻与吸烟相关的负担的成功突出了需要推进减少包括环境空气中的颗粒物和高 SBP 等其他主要风险因素暴露的政策。高空腹血糖、高 BMI 和其他与肥胖和代谢综合征相关的风险因素的令人不安的增加表明，迫切需要确定和实施干预措施。
比尔及梅琳达·盖茨基金会。
Zotero 插件
