Theoretical Minimum Risk Exposure Level Research Articles

Estimating effects of whole grain consumption on type 2 diabetes, colorectal cancer and cardiovascular disease: a burden of proof study

BackgroundPrevious studies on whole grain consumption had inconsistent findings and lacked quantitative assessments of evidence quality. Therefore, we aimed to summarize updated findings using the Burden of Proof analysis (BPRF) to investigate the relationship of whole grain consumption on type 2 diabetes (T2D), colorectal cancer (CRC), stroke, and ischemic heart disease (IHD).MethodsWe conducted a literature search in the Medline and Web of Science up to June 12, 2023, to identify related cohort studies and systematic reviews. The mean RR (relative risk) curve and uncertainty intervals (UIs), BPRF function, risk-outcome score (ROS), and the theoretical minimum risk exposure level (TMREL) were estimated to evaluate the level of four risk-outcome pairs.ResultsIn total, 27 prospective cohorts were included in our analysis. Consuming whole grain at the range of TMREL (118.5–148.1 g per day) was associated with lower risks: T2D (declined by 37.3%, 95% UI: 5.8 to 59.5), CRC (declined by 17.3%, 6.5 to 27.7), stroke (declined by 21.8%, 7.3 to 35.1), and IHD (declined by 36.9%, 7.1 to 58.0). For all outcomes except stroke, we observed a non-linear, monotonic decrease as whole grain consumption increased; For stroke, it followed a J-shaped curve (the greatest decline in the risk of stroke at consuming 100 g whole grain for a day). The relationships between whole grain consumption and four diseases are all two-star pairs (ROS: 0.087, 0.068, 0.062, 0.095 for T2D, CRC, stroke, and IHD, respectively).ConclusionConsuming 100 g of whole grains per day offers broad protective benefits. However, exceeding this threshold may diminish the protective effects against stroke. Our findings endorse replacing refined grains with whole grains as the main source of daily carbohydrates.Registry and registry number for systematic reviews or meta-analysesWe have registered our research in PROSPERO, and the identifier of our meta-analyses is CRD42023447345.

Interplay of Climate Change and Air Pollution- Projection of the under-5 mortality attributable to ambient particulate matter (PM2.5) in South Asia

Ambient fine particulate matter (PM2.5) pollution is a leading health risk factor for children under- 5 years, especially in developing countries. South Asia is a PM2.5 hotspot, where climate change, a potential factor affecting PM2.5 pollution, adds a major challenge. However, limited evidence is available on under-5 mortality attributable to PM2.5 under different climate change scenarios. This study aimed to project under-5 mortality attributable to long-term exposure to ambient PM2.5 under seven air pollution and climate change mitigation scenarios in South Asia. We used a concentration-risk function obtained from a previous review to project under-5 mortality attributable to ambient PM2.5. With a theoretical minimum risk exposure level of 2.4 μg/m3, this risk function was linked to gridded annual PM2.5 concentrations from atmospheric modeling to project under-5 mortality from 2010 to 2049 under different climate change mitigation scenarios. The scenarios were developed from the Aim/Endues global model based on end-of-pipe (removing the emission of air pollutants at the source, EoP) and 2 °C target measures. Our results showed that, in 2010–2014, about 306.8 thousand under-5 deaths attributable to PM2.5 occurred in South Asia under the Reference (business as usual) scenario. The number of deaths was projected to increase in 2045–2049 by 36.6% under the same scenario and 7.7% under the scenario where EoP measures would be partially implemented by developing countries (EoPmid), and was projected to decrease under other scenarios, with the most significant decrease (81.2%) under the scenario where EoP measures would be fully enhanced by all countries along with the measures to achieve 2 °C target (EoPmaxCCSBLD) across South Asia. Country-specific projections of under-5 mortality varied by country. The current emission control strategy would not be sufficient to reduce the number of deaths in South Asia. Robust climate change mitigation and air pollution control policy implementation is required.

All-cause mortality attributable to sitting time and physical inactivity in chilean adults

BackgroundEvidence on all-cause mortality attributable to joint sitting time and physical inactivity is lacking. In this study, we estimated the proportion and number of deaths attributable to sitting time and physical inactivity in Chilean adults.MethodsA sample of 5834 adults aged 20–96 years from a 2016–2017 Chilean National Health Survey was included to describe the prevalence of 16 joint categories of sitting time and physical activity. Relative risks for the joint association of sitting time and physical inactivity were obtained from a meta-analysis of individual participant data. We retrieved the number of deaths in adults ≥ 20 years in 2019 from the Chilean Ministry of Health.ResultsParticipants with high sitting time (> 8 h/day) and low physical activity (< 2.5 MET-hour/week) were more likely to be women, 20–64 years, non-indigenous ethnicity, lived in the urban areas, had middle education level and monthly household income, and had public health insurance. Reducing sitting time and increasing physical activity to a theoretical minimum risk exposure level could prevent up to 11,470 deaths or 10.4% of all deaths. Increasing physical activity to >35.5 MET-hour/week and maintaining sitting time could prevent approximately 10,477 deaths or 9.5% of all deaths. Reducing sitting time to < 4 h/day and maintaining physical activity would not reduce the number of deaths (-3.4% or 38 deaths).ConclusionReducing sitting time may be ancillary for preventing mortality. Therefore, increasing physical activity should be the primary focus of interventions and policies in Chile.

Burden of stroke attributable to high ambient temperature from 1990 to 2019: A global analysis.

Based on Global Burden of Disease Study 2019, deaths, disability-adjusted life year (DALYs), and age-standardized mortality rate (ASMR) and age-standardized rate of DALYs (ASDR) for stroke attributable to high temperature (i.e., a daily mean temperature warmer than the theoretical minimum-risk exposure level [TMREL]) were calculated in global, geographical location, and country and analyzed by age, sex, subtypes, and socio-demographic index (SDI) from 1990 to 2019. The trends in ASMR and ASDR from 1990 to 2019 were estimated by linear regression model. The regression coefficients (β) referred to a mean change of per year for ASMR or ASDR attributable to high temperature. The global burden of stroke attributable to high temperature had an increase trend from 1990 to 2019 (β = 0.005, 95% UI: 0.003-0.007 for ASMR and β = 0.104, 95% UI: 0.066-0.142 for ASDR, respectively). Globally, in 2019, an estimated 0.048 million deaths and 1.01 million DALYs of stroke were attributable to high temperature and the global ASMR and ASDR of stroke attributable to high temperature were 0.60 (95% UI, 0.07-1.30) and 13.31 (1.40-28.97) per 100,000 population, respectively. The largest burden occurred in Western Sub-Saharan Africa, followed by South Asia, Southeast Asia, and North Africa and the Middle East. ASMR and ASDR increased with age, and were higher in males and for intracerebral hemorrhage, and were highest in the low SDI regions. In 2019, the region with the largest percentage increase in AMSR and ASDR attributable to high temperature was Eastern Sub-Saharan Africa from 1990 to 2019. Stroke burden due to high temperature have been increasing and a higher burden was observed in people aged 65-75 years, males, and countries with a low SDI. Stroke burden attributable to high temperature constitutes a major global public health concern in the context of global warming.

Modifiable risk-attributable and age-related burden of lung cancer in China, 1990-2019.

There were limited studies on the quantification of the modifiable and nonmodifiable lung cancer burden over time in China. Furthermore, the potential effect of risk factor reduction for lung cancer on gains in life expectancy (LE) remains unknown. This study explored temporal trends in lung cancer deaths and disability-adjusted life years (DALY) attributable to modifiable risk factors from 1990 to 2019, based on the 2019 Global Burden of Disease Study. The abridged period life table method was used to quantify the effect of risk factors on LE. The authors used the decomposition approach to estimate contributions of aging metrics to change in the lung cancer burden. Nationally, the majority of lung cancer deaths and DALYs were attributable to behavioral and environmental risk clusters. Potential gains in life expectancy (PGLE) at birth would be 0.78years for males and 0.35years for females if the exposure to risk factors was mitigated to the theoretical minimum level. Tobacco use had the most robust impact on LE for both sexes (PGLE: 0.71years for males and 0.19years for females). From 1990 to 2019, risk-attributable age-standardized death and DALY rates of lung cancer showed an increasing trend in both sexes; adult population growth imposed 245.9 thousand deaths and 6.2 million DALYs for lung cancer. The modifiable risk-attributable lung cancer burden remains high in China. Effective tobacco control is the critical step toward addressing the lung cancer burden. Adult population growth was the foremost driver of transition in the age-related lung cancer burden. We estimate the lung cancer burden attributable to modifiable and nonmodifiable contributors and the effect of risk factor reduction for lung cancer on the life expectancy in China. The findings suggest that the majority of lung cancer deaths and disability-adjusted life years were attributable to behavioral risk clusters, and the risk-attributable lung cancer burden increased nationally from 1990 to 2019. The average gains in life expectancy would be 0.78years for males and 0.35years for females if the exposure to risk factors for lung cancer was reduced to the theoretical minimum risk exposure level. Adult population growth was identified as the foremost driver of variation in the aging lung cancer burden.

Global burden of chronic respiratory diseases and risk factors, 1990-2019: an update from the Global Burden of Disease Study 2019.

Updated data on chronic respiratory diseases (CRDs) are vital in their prevention, control, and treatment in the path to achieving the third UN Sustainable Development Goals (SDGs), a one-third reduction in premature mortality from non-communicable diseases by 2030. We provided global, regional, and national estimates of the burden of CRDs and their attributable risks from 1990 to 2019. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated mortality, years lived with disability, years of life lost, disability-adjusted life years (DALYs), prevalence, and incidence of CRDs, i.e. chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis, interstitial lung disease and pulmonary sarcoidosis, and other CRDs, from 1990 to 2019 by sex, age, region, and Socio-demographic Index (SDI) in 204 countries and territories. Deaths and DALYs from CRDs attributable to each risk factor were estimated according to relative risks, risk exposure, and the theoretical minimum risk exposure level input. In 2019, CRDs were the third leading cause of death responsible for 4.0 million deaths (95% uncertainty interval 3.6-4.3) with a prevalence of 454.6 million cases (417.4-499.1) globally. While the total deaths and prevalence of CRDs have increased by 28.5% and 39.8%, the age-standardised rates have dropped by 41.7% and 16.9% from 1990 to 2019, respectively. COPD, with 212.3 million (200.4-225.1) prevalent cases, was the primary cause of deaths from CRDs, accounting for 3.3 million (2.9-3.6) deaths. With 262.4 million (224.1-309.5) prevalent cases, asthma had the highest prevalence among CRDs. The age-standardised rates of all burden measures of COPD, asthma, and pneumoconiosis have reduced globally from 1990 to 2019. Nevertheless, the age-standardised rates of incidence and prevalence of interstitial lung disease and pulmonary sarcoidosis have increased throughout this period. Low- and low-middle SDI countries had the highest age-standardised death and DALYs rates while the high SDI quintile had the highest prevalence rate of CRDs. The highest deaths and DALYs from CRDs were attributed to smoking globally, followed by air pollution and occupational risks. Non-optimal temperature and high body-mass index were additional risk factors for COPD and asthma, respectively. Albeit the age-standardised prevalence, death, and DALYs rates of CRDs have decreased, they still cause a substantial burden and deaths worldwide. The high death and DALYs rates in low and low-middle SDI countries highlights the urgent need for improved preventive, diagnostic, and therapeutic measures. Global strategies for tobacco control, enhancing air quality, reducing occupational hazards, and fostering clean cooking fuels are crucial steps in reducing the burden of CRDs, especially in low- and lower-middle income countries.

Cardiovascular disease burden attributable to non-optimal temperature: analysis of the 1990-2019 global burden of disease.

Extreme temperatures are increasingly experienced as a result of climate change. Both high and low temperatures, impacted by climate change, have been linked with cardiovascular disease (CVD). Global estimates on non-optimal temperature-related CVD are not known. The authors investigated global trends of temperature-related CVD burden over the last three decades. The authors utilized the 1990-2019 global burden of disease methodology to investigate non-optimal temperature, low temperature- and high temperature-related CVD deaths, and disability-adjusted life years (DALYs) globally. Non-optimal temperatures were defined as above (high temperature) or below (low temperature) the location-specific theoretical minimum-risk exposure level or the temperature associated with the lowest mortality rates. Analyses were later stratified by sociodemographic index (SDI) and world regions. In 2019, non-optimal temperature contributed to 1 194 196 (95% uncertainty interval [UI]: 963 816-1 425 090) CVD deaths and 21 799 370 (95% UI: 17 395 761-25 947 499) DALYs. Low temperature contributed to 1 104 200 (95% UI: 897 783-1 326 965) CVD deaths and 19 768 986 (95% UI: 16 039 594-23 925 945) DALYs. High temperature contributed to 93 095 (95% UI: 10 827-158 386) CVD deaths and 2 098 989 (95% UI: 146 158-3 625 564) DALYs. Between 1990 and 2019, CVD deaths related to non-optimal temperature increased by 45% (95% UI: 32-63%), low temperature by 36% (95% UI: 25-48%), and high temperature by 600% (95% UI: -1879-2027%). Non-optimal temperature- and high temperature-related CVD deaths increased more in countries with low income than countries with high income. Non-optimal temperatures are significantly associated with global CVD deaths and DALYs, underscoring the significant impact of temperature on public health.

Global, regional, and national burden of preterm birth attributable to ambient and household PM2.5 from 1990 to 2019: Worsening or improving?

BackgroundMaternal exposure to fine particular matter (PM2.5) during pregnancy, including ambient and household PM2.5, has been linked with increased risk of preterm birth (PTB). However, the global spatio-temporal distribution of PTB-related deaths and disability-adjusted life years (DALYs) attributable to PM2.5 is not well documented. We estimated the global, regional, and national patterns and trends of PTB burden attributable to both ambient and household PM2.5 from 1990 to 2019. MethodsBased on the Global Burden of Disease Study (GBD) 2019 database, we obtained the numbers of deaths and DALYs as well as age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) of PTB attributable to total, ambient, and household PM2.5 by socio-demographic index (SDI) and sex during 1990–2019. The average annual percentage changes (AAPCs) were calculated to assess the temporal trends of attributable burdens. ResultsIn 2019, 126,752 deaths and 11.3 million DALYs related to PTB worldwide (two-thirds in Western Sub-Saharan Africa and South Asia) could be caused by excess PM2.5 above the theoretical minimum-risk exposure level (TMREL), of which 39 % and 61 % were attributable to ambient PM2.5 and household PM2.5, respectively. From 1990 to 2019, the global ASMR due to ambient PM2.5 increased slightly by 7.08 % whereas that due to household PM2.5 decreased substantially by 58.81 %, although the latter still dominated the attributable PTB burden, especially in low and low-middle SDI regions. Similar results were also observed for ASDRs. In addition, PTB burden due to PM2.5 was higher in male infants and in lower SDI regions. ConclusionsGlobally in 2019, PM2.5 remains a great concern on the PTB burden, especially in Western Sub-Saharan Africa and South Asia. Between 1990 and 2019, age-standardized burden of PTB due to ambient PM2.5 increased globally, while that due to household PM2.5 decreased markedly but still dominated in low and low-middle SDI regions.

Attributable disease burden related to low bone mineral density in Iran from 1990 to 2019: results from the Global Burden of Disease 2019.

Low bone mineral density (BMD) including low bone mass and osteoporosis is a bone state that carries the risk of fractures and the consequent burden. Since Iran has an aging population and is considered a high-risk country regarding fracture, the objective of this study was to report the low BMD attributable burden in Iran from 1990 to 2019 at national and subnational levels. In this study, the Global Burden of Disease (GBD) study 2019 estimates of exposure value and attributable burden were used. For each risk-outcome pair, following the estimation of relative risk, exposure level, and the Theoretical Minimum Risk Exposure Level (TMREL), the Population Attributable Fractions (PAFs) and attributable burden were computed. The Summary Exposure Value (SEV) index was also computed. Although the age-standardized DALYs and deaths decreased (- 41.0 [95% uncertainty interval: - 45.7 to - 33.2] and - 43.3 [- 48.9 to - 32.5]), attributable all age numbers in Iran increased from 1990 to 2019 (64.3 [50.6 to 89.1] and 66.8 [49.7 to 102.0]). The male gender had a higher low BMD attributed burden in Iran at national and subnational levels except for Tehran. Among low BMD-associated outcomes, motor vehicle road injuries and falls accounted for most of the low BMD-attributed burden in Iran. The SEV for low BMD remained constant from 1990 to 2019 in the country and females had higher SEVs. Low BMD and the associated outcomes has to gain attention in Iran's health system due to an aging population. Hence, timely interventions by health systems and the population at stake might assist in reducing the burden attributed to low BMD.

Health effects associated with vegetable consumption: a Burden of Proof study

Previous research suggests a protective effect of vegetable consumption against chronic disease, but the quality of evidence underlying those findings remains uncertain. We applied a Bayesian meta-regression tool to estimate the mean risk function and quantify the quality of evidence for associations between vegetable consumption and ischemic heart disease (IHD), ischemic stroke, hemorrhagic stroke, type 2 diabetes and esophageal cancer. Increasing from no vegetable consumption to the theoretical minimum risk exposure level (306–372 g daily) was associated with a 23.2% decline (95% uncertainty interval, including between-study heterogeneity: 16.4–29.4) in ischemic stroke risk; a 22.9% (13.6–31.3) decline in IHD risk; a 15.9% (1.7–28.1) decline in hemorrhagic stroke risk; a 28.5% (−0.02–51.4) decline in esophageal cancer risk; and a 26.1% (−3.6–48.3) decline in type 2 diabetes risk. We found statistically significant protective effects of vegetable consumption for ischemic stroke (three stars), IHD (two stars), hemorrhagic stroke (two stars) and esophageal cancer (two stars). Including between-study heterogeneity, we did not detect a significant association with type 2 diabetes, corresponding to a one-star rating. Although current evidence supports increased efforts and policies to promote vegetable consumption, remaining uncertainties suggest the need for continued research.

Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012.

Elevated sodium consumption is associated with increased blood pressure, a major risk factor for cardiovascular and chronic kidney disease. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high sodium intake in persons aged ≥25 years in South Africa (SA) for 2000, 2006 and 2012. Comparative risk assessment (CRA) methodology was used and population attributable fractions (PAFs) of high sodium intake, mediated through high blood pressure (BP), for cardiovascular and chronic kidney disease were estimated. This was done by taking the difference between the PAF for elevated systolic BP (SBP) based on the estimated SBP level in the population and the PAF based on the estimated SBP that would result if sodium intake levels were reduced to the theoretical minimum risk exposure level (1 g/day) according to population group and hypertension categories. A meta-regression based on data from nine national surveys conducted between 1998 and 2017 was used to estimate the prevalence of hypertension by age, sex and population group. Relative risks identified from international literature were used and the difference in PAFs was applied to local burden estimates from the second South African National Burden of Disease Study. Age-standardised rates were calculated using World Health Organization (WHO) standard population weights. The attributable burden was also estimated for 2012 using an alternative target of 2 g/day proposed in the National Strategic Plan for the Prevention and Control of Non-communicable Diseases (NSP). High sodium intake as mediated through high SBP was estimated to cause 8 071 (95% uncertainty interval (UI) 6 542 - 15 474) deaths in 2012, a drop from 9 574 (95% UI 8 158 - 16 526) in 2006 and 8 431 (95% UI 6 972 - 14 511) in 2000. In 2012, ischaemic heart disease caused the highest number of deaths in persons (n=1 832), followed by haemorrhagic stroke (n=1 771), ischaemic stroke (n=1 484) and then hypertensive heart disease (n=1 230). Ischaemic heart disease was the highest contributor to deaths for males (27%), whereas for females it was haemorrhagic stroke (23%). In 2012, 1.5% (95% UI 1.3 - 2.9) of total deaths and 0.7% (95% UI 0.6 - 1.2) of total DALYs were attributed to high sodium intake. If the NSP target of <2 g/day sodium intake had been achieved in 2012, ~2 943 deaths and 48 870 DALYs would have been averted. Despite a slight decreasing trend since 2006, high sodium intake mediated through raised BP accounted for a sizeable burden of disease in 2012. Realising SA's target to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation.

Estimating the changing disease burden attributable to raised low-density lipoprotein cholesterol in South Africa for 2000, 2006 and 2012.

Low-density lipoprotein cholesterol (LDL-C) is the most important contributor to atherosclerosis, a causal factor for ischaemic heart disease (IHD) and ischaemic stroke. Although raised LDL-C is a key contributor to cardiovascular disease (CVD), the exact attributable disease risk in South Africa (SA) is unknown. The the first SA comparative risk assessment (SACRA1) study assessed the attributable burden of raised total cholesterol, and not specifically LDL-C. To estimate the national mean serum LDL-C by age, year and sex and to quantify the burden of disease attributable to LDL-C in SA for 2000, 2006 and 2012. The comparative risk assessment (CRA) method was used. Estimates of the national mean of LDL-C, representing the 3 different years, were derived from 14 small observational studies using a meta-regression model. A theoretical minimum risk exposure level (TMREL) of 0.7 - 1.3 mmol/L was used. LDL-C estimates together with the relative risks from the Global Burden of Disease Study 2017 were used to calculate a potential impact fraction (PIF). This was applied to IHD and ischaemic stroke estimates sourced from the Second National Burden of Disease Study. Attributable deaths, years of life lost, years lived with disability and disability-adjusted life years (DALYs) were calculated. Uncertainty analysis was performed using Monte Carlo simulation. LDL-C declined from 2.74 mmol/L in 2000 to 2.58 mmol/L in 2012 for males, while in females it declined from 3.05 mmol/L in 2000 to 2.91 mmol/L in 2012. The PIFs for LDL-C showed a slight decline over time, owing to the slight decrease in LDL-C levels. Attributable DALYs increased between 2000 (n=286 712) and 2006 (n=315 125), but decreased thereafter in 2012 (n=270 829). Attributable age-standardised death rates declined between 2000 and 2012 in both sexes: in males from 98 per 100 000 members of the population in 2000 to 78 per 100 000 in 2012, and in females from 81 per 100 000 in 2000 to 58 per 100 000 in 2012. Mean LDL-C levels were close to 3 mmol/L, which is the recommended level at which cholesterol-lowering treatment should be initiated for people at low and moderate risk for cardiovascular outcomes. The decreasing trend in the age-standardised attributable burden due to LDL-C is encouraging, but it can be lowered further with the introduction of additional population-based CVD prevention strategies. This study highlights the fact that high LDL-C concentration in relation to the TMREL in SA is responsible for a large proportion of the emerging CVD, and should be targeted by health planners to reduce disease burden.

Overview.

South Africa (SA) faces multiple health challenges. Quantifying the contribution of modifiable risk factors can be used to identify and prioritise areas of concern for population health and opportunities for health promotion and disease prevention interventions. To estimate the attributable burden of 18 modifiable risk factors for 2000, 2006 and 2012. Comparative risk assessment (CRA), a standardised and systematic approach, was used to estimate the attributable burden of 18 risk factors. Risk exposure estimates were sourced from local data, and meta-regressions were used to model the parameters, depending on the availability of data. Risk-outcome pairs meeting the criteria for convincing or probable evidence were assessed using relative risks against a theoretical minimum risk exposure level to calculate either a potential impact fraction or population attributable fraction (PAF). Relative risks were sourced from the Global Burden of Disease, Injuries, and Risk Factors (GBD) study as well as published cohort and intervention studies. Attributable burden was calculated for each risk factor for 2000, 2006 and 2012 by applying the PAF to estimates of deaths and years of life lost from the Second South African National Burden of Disease Study (SANBD2). Uncertainty analyses were performed using Monte Carlo simulation, and age-standardised rates were calculated using the World Health Organization standard population. Unsafe sex was the leading risk factor across all years, accounting for one in four DALYs (26.6%) of the estimated 20.6 million DALYs in 2012. The top five leading risk factors for males and females remained the same between 2000 and 2012. For males, the leading risks were (in order of descending rank): unsafe sex; alcohol consumption; interpersonal violence; tobacco smoking; and high systolic blood pressure; while for females the leading risks were unsafe sex; interpersonal violence; high systolic blood pressure; high body mass index; and high fasting plasma glucose. Since 2000, the attributable age-standardised death rates decreased for most risk factors. The largest decrease was for household air pollution (-41.8%). However, there was a notable increase in the age-standardised death rate for high fasting plasma glucose (44.1%), followed by ambient air pollution (7%). This study reflects the continued dominance of unsafe sex and interpersonal violence during the study period, as well as the combined effects of poverty and underdevelopment with the emergence of cardiometabolic-related risk factors and ambient air pollution as key modifiable risk factors in SA. Despite reductions in the attributable burden of many risk factors, the study reveals significant scope for health promotion and disease prevention initiatives and provides an important tool for policy makers to influence policy and programme interventions in the country.

Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020

SummaryBackgroundThe health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.MethodsFor this analysis, we constructed burden-weighted dose–response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15–95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.FindingsThe burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15–39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0–0) and 0·603 (0·400–1·00) standard drinks per day, and the NDE varied between 0·002 (0–0) and 1·75 (0·698–4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0–0·403) to 1·87 (0·500–3·30) standard drinks per day and an NDE that ranged between 0·193 (0–0·900) and 6·94 (3·40–8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3–65·4) were aged 15–39 years and 76·9% (73·0–81·3) were male.InterpretationThere is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.FundingBill & Melinda Gates Foundation.

Abstract MP20: Global Burden Of Elevated Low-density Lipoprotein Cholesterol, 1990-2020: Findings From The Global Burden Of Disease Study 2020

We evaluated low-density lipoprotein (LDL) cholesterol patterns at the population level and quantified associated cardiovascular disease (CVD) morbidity and mortality for the Global Burden of Disease (GBD) 2020 study. Using all available high-quality data, we estimated the CVD burden attributable to elevated LDL (relative to the theoretical minimum risk exposure level of 1.3-1.7 mmol/L) by age, sex, country, and year among adults &gt;25 years from 1990 - 2020. We used a spatiotemporal Gaussian process regression to estimate LDL mean and microdata to estimate standard deviation (SD) and characterize the global LDL distribution. In a meta-regression, we pooled data from 52 randomized control trials to estimate the relative risks for ischemic heart disease (IHD) and ischemic stroke. These were then used to calculate the population attributable fraction and the burden attributable to elevated LDL. We report SD and 95% uncertainty intervals (UI) in brackets. From 1990 to 2020, LDL levels measured in mmol/L increased globally from 1.4 [0.4] to 1.7 [0.4] in males, and from 1.5 [0.4] to 1.8 [0.5] in females. The highest LDL levels over the 30-year period were observed in high-income countries and Central and Eastern Europe and Central Asia. Sub-Saharan Africa had the lowest LDL levels. In 2020, a third (2.9 million [95% UI: 1.2-4.5 million]) and a fifth (1.5 million [919,750-2.1 million]) of deaths due to IHD and ischemic stroke, respectively, were attributable to elevated LDL. The estimated number of deaths and disability-adjusted life-years (DALYs) attributable to high LDL increased since 1990 reaching 4.5 million [2.6 - 6.2] deaths and 91.8 million [53.6 - 127] DALYs in 2020. More DALYs from elevated LDL were experienced by men than women (52.8 [29.7 - 73.4] vs 39 [23.9 - 53.5] million). Over the study period, the global all-age rates for deaths and DALYs per 100,000, remained unchanged at 58 [34-80] and 1,177 [688-1,629], respectively. Age-standardized deaths and DALYs due to high LDL levels decreased from 90 [55-123] to 57 [34-79] deaths per 100,000 and from 1,657 [981-2,251] to 1,610 [650-1,532] DALYs per 100,000. Age-standardized DALYs attributable to high LDL cholesterol were highest in Eastern Europe, Central Asia and North Africa and the Middle East. The lowest levels were observed in high-income Asia Pacific and Andean Latin America. The CVD burden attributable to LDL is increasing globally. In 2020, a fifth of CVD deaths and DALYs were associated with LDL. Differences between the trends of all-ages and age-standardized rates suggest that the LDL burden has been driven partially by population growth and aging. Measurement and estimation error must be considered when interpreting these trends. In addition to safe and cost-effective pharmacological and behavioral interventions, novel population level strategies are needed to reduce the LDL burden.

Hypertensive heart disease burden attributable to high salt intake in the United States compared to the European Union and the global status: trends from 1990 to 2019

Abstract Background Hypertensive heart disease (HHD) is a major cause of heart failure, cardiovascular related hospitalizations, and mortality. Diet high in salt is one of modifiable risk factors of HHD that can be controlled by appropriate policies. Purpose This study aims to provide the HHD burden attributable to diet high in sodium in the United States compared to European and the global trends from 1990 to 2019. Methods Using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we calculated the HHD, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Diet high in sodium was defined as a diet with more than 1,000 milligrams of sodium per day. HHD deaths attributable to the diet high in sodium was estimated based on risk exposure, relative risks, and the theoretical minimum risk exposure level Trends of HHD attributable to diet high in sodium was estimated from 1990 to 2019. Results Globally, there were 170·3 thousand (95% uncertainty interval [UI] 31.2 to 459.5) deaths, YLLs, YLDs, DALYs due to HHD attributable to diet high in sodium, in 2019. In the United States, 4525 deaths happened because of HHD caused by the diet high in sodium, with 208.4% rise from 1990. In the European Union, 18,143 deaths happened because of HHD caused by the diet high in sodium, with 78.0% rise from 1990. To address the impact of population aging and population growth, we estimated the age standardized values for burden of HHD attributable to the diet high in sodium. From 1990 to 2019, worldwide age standardized YLL, YLD, and DALY rates per 100,000 for HHD attributable to the diet high in sodium changed by −44.0% (−63.6 to −30.6), +3.7% (−14.3 to +13.6), and −41.8% (−61.3 to −28.8), respectively (Figure 1). In the European Union, age standardized YLL, YLD, and DALY rates per 100,000 for HHD attributable to the diet high in sodium changed by −14.8% (−44.6 to −0.2), −13.5% (−45.8 to −14.0), and −14.8% (−43.5 to −0.9), respectively. Compared to the European Union and the worldwide trends, United Sates had the opposite increasing trend of HHD caused by the diet high in sodium. In the United States, age standardized YLL, YLD, and DALY rates per 100,000 for HHD attributable to the diet high in sodium changed by +110.4% (+42.0 to +631.0), +44.2% (+106.4 to +300.5), and −14.8% (−43.5 to −0.9), respectively. As shown in figure 2, the United States' increasing trend of HHD attributable to the diet high in sodium was caused mainly by the increasing trend observed in men. Conclusions Despite worldwide success in the restriction of the diet high in sodium, HHD burden attributable to high consumption of sodium is rising in the United States. This warning results requires public health attention to taking actions such as advocating for healthy diet, restricting foods high in sodium such as fast foods, and increasing the access to low salt foods for working groups. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Bill &amp; Melinda Gates Foundation Annual % DALY change of HHD due to saltTrend of HHD DALY in men vs women

Trend of ischemic heart disease mortality attributable to metabolic, behavioral, and environmental risk factors in the past two decades

Abstract Background Ischemic heart diseases (IHD) is the leading cause of mortality, worldwide. Understanding of the status of risk factors contributing to IHD and mortality helps control this public health issue. Purpose This study aims to provide global, regional, and national estimates of the trend of IHD burden and deaths attributable to the modifiable risk factors, from 1990 to 2019. Methods Using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the IHD incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). IHD deaths attributable to the different metabolic, behavioral and environmental risk factors were estimated based on risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on 2010 to 2019. Results Globally, there were 21·2 million (95% uncertainty interval [UI] 18·8–23·7) new cases, 9·1 million (8.4–9·7) deaths, and 182·0 million (170·2–193·5) DALYs due to IHD, in 2019. From 1990 to 2019, IHD incident cases, deaths and DALYs increased globally by 29.1·9% (27.0–31·3), 32·4% (25.3–37·8), and 53.9% (42·7–64·3), respectively. Although high SDI regions succeeded to reduce DLAYs due to IHDs by −36.7% (−33.8 to −39.2), low SDI regions faced an increase in DALYs due to IHDs by +104.4% (+75.0 to +135.3). In 2019, the five leading risk factors of deaths due to IHDs were; high systolic blood pressure [2.2 million deaths (1.7–2.7)], high LDL cholesterol [1.7 million deaths (1.2–2.3)], high fasting plasma glucose [1.1 million deaths (0.6–1.8)], high body-mass index [0.8 million deaths (0.5–1.1)], and diet low in whole grains [0.6 million deaths (0.2–0.8)]. From 1990 to 2019, high SDI regions succeeded to reduce the age standardized death rate of IHDs attributable to metabolic risk factors by −60.1% (−61.9 to −57.7), behavioral risk factors by −61.2% (−62.8 to −59.2) and environmental risk factors by −65.8% (−71.4 to −59.3). During the same period, the age standardized IHD death rate attributable to environmental risk factors decreased by −16.0% (−30.4 to −1.6), while the age standardized IHD death rate attributable to metabolic and behavioral risk factors didn't change significantly, in low SDI regions. Conclusions During the past two decades despite steadily increase in incident cases of IHDs, the age standardized burden of IHDs has decreased in high SDI regions most probably due to control of attributable risk factors. However, burden of IHDs has increased dramatically in low SDI regions. Preventive measures such as “polypills” for high blood pressure control programs and life-style modification should be prioritized in these settings. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Bill &amp; Melinda Gates Foundation Age-standardized DALY rates of IHD

Global, regional, and national burden of respiratory tract cancers and associated risk factors from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

SummaryBackgroundPrevention, control, and treatment of respiratory tract cancers are important steps towards achieving target 3.4 of the UN Sustainable Development Goals (SDGs)—a one-third reduction in premature mortality due to non-communicable diseases by 2030. We aimed to provide global, regional, and national estimates of the burden of tracheal, bronchus, and lung cancer and larynx cancer and their attributable risks from 1990 to 2019.MethodsBased on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer). Deaths from tracheal, bronchus, and lung cancer and larynx cancer attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on the 2010–19 period.FindingsGlobally, there were 2·26 million (95% uncertainty interval 2·07 to 2·45) new cases of tracheal, bronchus, and lung cancer, and 2·04 million (1·88 to 2·19) deaths and 45·9 million (42·3 to 49·3) DALYs due to tracheal, bronchus, and lung cancer in 2019. There were 209 000 (194 000 to 225 000) new cases of larynx cancer, and 123 000 (115 000 to 133 000) deaths and 3·26 million (3·03 to 3·51) DALYs due to larynx cancer globally in 2019. From 2010 to 2019, the number of new tracheal, bronchus, and lung cancer cases increased by 23·3% (12·9 to 33·6) globally and the number of larynx cancer cases increased by 24·7% (16·0 to 34·1) globally. Global age-standardised incidence rates of tracheal, bronchus, and lung cancer decreased by 7·4% (−16·8 to 1·6) and age-standardised incidence rates of larynx cancer decreased by 3·0% (−10·5 to 5·0) in males over the past decade; however, during the same period, age-standardised incidence rates in females increased by 0·9% (−8·2 to 10·2) for tracheal, bronchus, and lung cancer and decreased by 0·5% (−8·4 to 8·1) for larynx cancer. Furthermore, although age-standardised incidence and death rates declined in both sexes combined from 2010 to 2019 at the global level for tracheal, bronchus, lung and larynx cancers, some locations had rising rates, particularly those on the lower end of the SDI range. Smoking contributed to an estimated 64·2% (61·9–66·4) of all deaths from tracheal, bronchus, and lung cancer and 63·4% (56·3–69·3) of all deaths from larynx cancer in 2019. For males and for both sexes combined, smoking was the leading specific risk factor for age-standardised deaths from tracheal, bronchus, and lung cancer per 100 000 in all SDI quintiles and GBD regions in 2019. However, among females, household air pollution from solid fuels was the leading specific risk factor in the low SDI quintile and in three GBD regions (central, eastern, and western sub-Saharan Africa) in 2019.InterpretationThe numbers of incident cases and deaths from tracheal, bronchus, and lung cancer and larynx cancer increased globally during the past decade. Even more concerning, age-standardised incidence and death rates due to tracheal, bronchus, lung cancer and larynx cancer increased in some populations—namely, in the lower SDI quintiles and among females. Preventive measures such as smoking control interventions, air quality management programmes focused on major air pollution sources, and widespread access to clean energy should be prioritised in these settings.FundingBill & Melinda Gates Foundation.

Non-communicable diseases deaths attributable to high body mass index in Chile

We estimated the proportion and number of deaths from non-communicable diseases (NCD) attributable to high body mass index (BMI) in Chile in 2018. We used data from 5927 adults from a 2016–2017 Chilean National Health Survey to describe the distribution of BMI. We obtained the number of deaths from NCD from the Ministry of Health. Relative risks (RR) and 95% confidence intervals per 5 units higher BMI for cardiovascular disease, cancer, and respiratory disease were retrieved from the Global BMI Mortality Collaboration meta-analyses. The prevalences of overweight and obesity were 38.9% and 39.1%, respectively. We estimated that reducing population-wide BMI to a theoretical minimum risk exposure level (mean BMI: 22.0 kg/m2; standard deviation: 1) could prevent approximately 21,977 deaths per year (95%CI 13,981–29,928). These deaths represented about 31.6% of major NCD deaths (20.1–43.1) and 20.4% of all deaths (12.9–27.7) that occurred in 2018. Most of these preventable deaths were from cardiovascular diseases (11,474 deaths; 95% CI 7302–15,621), followed by cancer (5597 deaths; 95% CI 3560–7622) and respiratory disease (4906 deaths; 95% CI 3119–6684). A substantial burden of NCD deaths was attributable to high BMI in Chile. Policies and population-wide interventions are needed to reduce the burden of NCD due to high BMI in Chile.

Economic burden of colorectal and breast cancers attributable to lack of physical activity in Brazil

BackgroundThe increasing number of cancer patients has an escalating economic impact to public health systems (approximately, International dollars- Int$ 60 billion annually in Brazil). Physical activity is widely recognized as one important modifiable risk factor for cancer. Herein, we estimated the economic costs of colon and post-menopausal breast cancers in the Brazilian Unified Health System (SUS) attributable to lack of physical activity.MethodsPopulation attributable fractions were calculated using prevalence data from 57,962 adults who answered a physical activity questionnaire in the Brazilian National Health Survey, and relative risks of colon and breast cancer from a meta-analysis. Annual costs (1 Int$ = 2.1 reais) with hospitalization, chemotherapy and radiotherapy were obtained from the Hospital and Ambulatory Information Systems of the Brazilian SUS. Two counterfactual scenarios were considered: theoretical minimum risk exposure level (≥8000 MET-min/week) and physical activity guidelines (≥600 MET-min/week).ResultsAnnually, the Brazilian SUS expended Int$ 4.5 billion in direct costs related to cancer treatment, of which Int$ 553 million due to colon and breast cancers. Direct costs related to colon and breast cancers attributable to lack of physical activity were Int$ 23.4 million and Int$ 26.9 million, respectively. Achieving at least the physical activity guidelines would save Int$ 10.3 mi (colon, Int$ 6.4 mi; breast, Int$ 3.9 mi).ConclusionsLack of physical activity accounts for Int$ 50.3 million annually in direct costs related to colon and post-menopausal breast cancers. Population-wide interventions aiming to promote physical activity are needed to reduce the economic burden of cancer in Brazil.