This document summarizes the findings of the Global Burden of Disease Study 2010 Comparative Risk Assessment. It analyzed the burden of disease attributable to 67 risk factors across 21 regions for 1990, 2005, and 2010. Key findings include that noncommunicable disease risks have overtaken communicable disease risks in children. High BMI and glucose emerged as major risks with a need for effective interventions. Diet and air pollution burdens were revised upwards. Risks varied regionally, with poverty-related factors dominating in sub-Saharan Africa. Limitations included data gaps and an inability to assess risk factor interactions.

1. A comparative risk assessment of burden of
disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions
A systematic analysis for the Global Burden of Disease Study 2010
Stephen Lim, on behalf of the GBD 2010
Comparative Risk Assessment Group
The Royal Society, 14 December 2012

2. Comparative Risk Assessment 2010
1. Reliable and comparable analysis of risks to health is a key
input for informing disease and injury prevention.
2. Previous topic-specific analyses, e.g., maternal and child
undernutrition, physical inactivity, use different methods and
data
3. No complete and comparable analysis across a large set of
risk factors since the CRA 2000.
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3. Methods
1. Calculate the proportion of deaths or disease burden holding
other independent factors unchanged.
2. Counterfactual analysis: What if risk exposure was at a
different level?
3. 67 risk factors and clusters of risk factors.
4. 20 age groups, both sexes, 187 countries, and for
1990, 2005, and 2010.
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4. GBD 2010 – risks quantified
Unimproved water and sanitation Tobacco smoking and secondhand smoke
Unimproved water Tobacco smoking
Unimproved sanitation Second-hand smoke
Air pollution Alcohol and other drugs
Ambient particulate matter pollution Alcohol use
Household air pollution from solid fuels Drug use (opioids, cannabis, amphetamines)
Ambient ozone pollution Physiological risks for chronic diseases
Other environmental risks High fasting plasma glucose
Residential radon High total cholesterol
Lead exposure High systolic blood pressure
Child and maternal undernutrition High body mass index
Suboptimal breastfeeding Low bone mineral density
Non-exclusive breastfeeding Sexual abuse and violence
Discontinued breastfeeding Childhood sexual abuse
Childhood underweight Intimate partner violence
Iron deficiency
Vitamin A deficiency
Zinc deficiency
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5. GBD 2010 – risks quantified (2)
Dietary risk factors and physical inactivity Occupational exposures
Diet low in fruits Occupational exposure to asbestos
Diet low in vegetables Occupational exposure to arsenic
Diet low in whole grains Occupational exposure to benzene
Diet low in nuts/seeds Occupational exposure to beryllium
Diet low in milk Occupational exposure to cadmium
Diet high in unprocessed red meat Occupational exposure to chromium
Diet high in processed meat Occupational exposure to diesel
Sugar-sweetened beverages Occupational exposure to formaldehyde
Diet low in fibre Occupational exposure to nickel
Diet low in calcium Occupational exposure to PAHs
Diet low in seafood omega-3 Occupational exposure to secondhand smoke
Diet low in polyunsaturated fatty acid (PUFA) Occupational exposure to silica
Diet high in trans fatty acids Occupational exposure to sulfuric acid
Diet high in sodium Occupational exposure to asthmagens
Physical inactivity and low physical activity Occupational exposure to particulates and gases
Occupational noise
Occupational risk factors for injury
Occupational low back pain
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6. Calculating risk factor burden
1. Select risk-outcome pairs;
2. Estimate exposure distributions to each risk factor in the
population;
3. Estimate cause effect sizes: relative risk per unit of exposure
for each risk-outcome pair;
4. Choose a counterfactual exposure distribution: theoretical
minimum risk exposure distribution (TMRED); and
5. Compute attributable burden, including uncertainty.
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7. Risk-outcome inclusion criteria
1. Likely importance of a risk factor to disease burden or policy;
2. Availability of sufficient data and methods to enable
estimation of exposure distributions by country for at least
one of the study periods;
3. Sufficient evidence for causal effect (convincing or probable
evidence) and to estimate outcome-specific effect sizes; and
4. Evidence to support generalizability of effect sizes to
populations other than those included in epidemiological
studies.
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8. Exposure: ambient PM pollution
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9. Exposure: ambient PM pollution (2)
• Satellite-based measures of aerosol optical depth (AOD)
• TM5 chemical transport models
• Calibrated against ground-based PM2.5 sensors
PM2.5 (µg per m3)
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10. Risk-outcome effect sizes
1. Recent or new systematic reviews and meta-analyses
2. New effect size estimates conducted for:
• Water and sanitation
• Air pollution: integrated exposure response (IERs)
• Dietary risk factors
3. Examined validity of single dietary risk factor effect sizes:
• Dietary pattern studies, e.g. Mediterranean diet
• Randomized controlled feeding studies, e.g. DASH, OMNI Heart
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11. DALYs 2010
attributable
to diet and
physical
inactivity
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12. Burden of disease attributable to 20 leading risk factors in 2010, expressed
as a percentage of global disability-adjusted life years, both sexes
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13. 95% uncertainty intervals for risk factors, 2010
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14. Comparing deaths and DALYs in 2010
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15. Global risk factor ranks with 95% UI for all ages and sexes
combined in 1990 and 2010, and percentage change
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16. Regional variation in leading risks, 2010
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17. Attributable burden for each risk factor as a
percentage of disability-adjusted life years in 2010
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18. Additional key findings
Important revisions compared to previous assessments:
• Unsafe water and sanitation
• Vitamin A and zinc deficiency
• Household and ambient PM pollution
• Physical inactivity and low physical activity
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19. Limitations
• Limited exposure distribution data.
• Potential for residual confounding, especially in the absence of
intervention studies.
• Uncertainty about generalizability of effect sizes across
populations.
• Exclusion of risk-outcomes based on insufficient data.
• Few risks for major communicable diseases.
• No adjustment for interactions between risk factors for
calculating joint effects.
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20. Summary
• Dramatic shift away from communicable disease risks in
children toward noncommunicable disease risks in adults.
• Global rise in high BMI and glucose emphasizes research
priorities given the absence of effective interventions.
• More nuanced understanding of the role of diet in preventing
chronic disease.
• Major revisions in the quantification of attributable burden of
micronutrient deficiencies and household and ambient air
pollution, among others.
• In much of sub-Saharan Africa, the leading risks continue to be
those associated with poverty.
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