Distribution of major health risks: findings from the Global Burden of Disease study
Anthony Rodgers, Majid Ezzati, Stephen Vander Hoorn, Alan D Lopez, Ruey-Bin Lin, Christopher J L Murray, Comparative Risk Assessment Collaborating Group, Anthony Rodgers, Majid Ezzati, Stephen Vander Hoorn, Alan D Lopez, Ruey-Bin Lin, Christopher J L Murray, Comparative Risk Assessment Collaborating Group
Abstract
Background: Most analyses of risks to health focus on the total burden of their aggregate effects. The distribution of risk-factor-attributable disease burden, for example by age or exposure level, can inform the selection and targeting of specific interventions and programs, and increase cost-effectiveness.
Methods and findings: For 26 selected risk factors, expert working groups conducted comprehensive reviews of data on risk-factor exposure and hazard for 14 epidemiological subregions of the world, by age and sex. Age-sex-subregion-population attributable fractions were estimated and applied to the mortality and burden of disease estimates from the World Health Organization Global Burden of Disease database. Where possible, exposure levels were assessed as continuous measures, or as multiple categories. The proportion of risk-factor-attributable burden in different population subgroups, defined by age, sex, and exposure level, was estimated. For major cardiovascular risk factors (blood pressure, cholesterol, tobacco use, fruit and vegetable intake, body mass index, and physical inactivity) 43%-61% of attributable disease burden occurred between the ages of 15 and 59 y, and 87% of alcohol-attributable burden occurred in this age group. Most of the disease burden for continuous risks occurred in those with only moderately raised levels, not among those with levels above commonly used cut-points, such as those with hypertension or obesity. Of all disease burden attributable to being underweight during childhood, 55% occurred among children 1-3 standard deviations below the reference population median, and the remainder occurred among severely malnourished children, who were three or more standard deviations below median.
Conclusions: Many major global risks are widely spread in a population, rather than restricted to a minority. Population-based strategies that seek to shift the whole distribution of risk factors often have the potential to produce substantial reductions in disease burden.
Conflict of interest statement
Competing Interests: The authors have declared that no competing interests exist. ADL is a member of the editorial board of PLoS Medicine.
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References
- World Health Organization. Geneva: World Health Organization; 2002. The world health report 2002: Reducing risks, promoting healthy life; 250 pp.
- Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347–1360.
- Rodgers A, Lawes C, MacMahon S. The global burden of cardiovascular disease conferred by raised blood pressure. Benefits of reversal of blood pressure-related cardiovascular risk in Eastern Asia. J Hypertens. 2000;18:S3–S5.
- Cook NR, Cohen J, Hebert P, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med. 1995;155:701–709.
- Murray CJL, Lauer JA, Hutubessy RCW, Niessen L, Tomijima N, et al. Effectiveness and costs of interventions to reduce systolic blood pressure and cholesterol: A global and regional analysis on reduction of cardiovascular-disease risk. Lancet. 2003;361:717–725.
- Peto R, Lopez AD, Boreham J, Thun M, Heath CW. Mortality from tobacco in developed countries: Indirect estimates from national vital statistics. Lancet. 1992;339:1268–1278.
- Rodgers A, MacMahon S. Blood pressure and the global burden of cardiovascular disease. Clin Exp Hypertens. 1999;21:543–552.
- Rose G. Oxford: Oxford University Press; 1992. The strategy of preventive medicine; 138 pp.
- Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14:32–38.
- Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am J Epidemiol. 1974;99:325–332.
- Murray CJL, Lopez AD, editors. Cambridge (Massachusetts): Harvard University Press; 1996. The global burden of disease; 990 pp.
- Ezzati M, Vander Hoorn S, Rodgers A, Lopez AD, Mathers CD, et al. Estimates of global and regional potential health gains from reducing multiple selected major risk factors. Lancet. 2003;362:271–280.
- Curtis V, Cairncross S, Yonli R. Domestic hygiene and diarrhoea—Pinpointing the problem. Trop Med Int Health. 2000;5:22–32.
- James WPT, Jackson-Leach R, Ni Mhurchu C, Kalamara E, Shayeghi M, et al. Geneva: World Health Organization; 2004. Body mass index and the global burden of disease. In: Ezzati M, Lopez A, Rodgers A, Vander Hoorn S, Murray C, editors. Comparative quantification of health risks: Global and regional burden of disease due to selected major risk factors; pp. 497–596.
- Eastern Stroke and Coronary Heart Disease Collaborative Group. Blood pressure, cholesterol and stroke in eastern Asia. Lancet. 1998;352:1801–1807.
- Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ. 1994;308:367–373.
- Horton R. Common sense and figures: The rhetoric of validity in medicine (Bradford Hill Memorial Lecture 1999) Stat Med. 2000;19:3149–3164.
- Commission on Macroeconomics and Health. Macroeconomics and health: Investing in health for economic development. World Health Organization. 2001 Available: . Accessed 25 August 2004.
- Kreitman N. Alcohol consumption and the preventive paradox. Br J Addict. 1986;81:353–363.
- Lemmens P. Chichester (United Kingdom): John Wiley and Sons; 2001. Relationship of alcohol consumption and alcohol problems at the population level. In: Heather N, Peters TJ, Stockwell T, editors. International handbook of alcohol dependence and problems.
- Skog OJ. Prevention paradox revisited. Addiction. 1999;94:751–757.
- MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, et al. Blood pressure, stroke, and coronary heart disease. Part I, prolonged differences in blood pressure: Prospective observational studies corrected for the regression dilution bias. Lancet. 335:765–774.
Source: PubMed