GLOBAL HEALTH RISKS

Mortality and burden of disease attributable to selected major risks

GLOBAL HEALTH RISKS
Mortality and burden of disease
attributable to selected major risks
 World Health Organization

WHO Library Cataloguing-in-Publication Data

Global health risks: mortality and burden of disease attributable to selected major risks.

1. Risk factors. 2. World health. 3. Epidemiology. 4. Risk assessment. 5. Mortality - trends. 6. Morbidity -
trends. 7. Data analysis, Statistical. I. World Health Organization.

ISBN 978 92 4 156387 1

(NLM classification: WA 105)

© World Health Organization 2009

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Acknowledgements

This publication was produced by the Department of Health Statistics and Informatics in the Information,
Evidence and Research Cluster of the World Health Organization (WHO). The analyses were primarily
carried out by Colin Mathers, Gretchen Stevens and Maya Mascarenhas, in collaboration with other WHO
staff, WHO technical programmes and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
The report was written by Colin Mathers, Gretchen Stevens and Maya Mascarenhas.

We wish to particularly thank Majid Ezzati, Goodarz Danaei, Stephen Vander Hoorn, Steve Begg and
Theo Vos for valuable advice and information relating to other international and national comparative risk
assessment studies. Valuable inputs were provided by WHO staff from many departments and by experts
outside WHO. Although it is not possible to name all those who contributed to this effort, we would like
to particularly note the assistance and inputs provided by Bob Black, Ties Boerma, Sophie Bonjour, Fiona
Bull, Diarmid Campbell-Lendrum, Mercedes de Onis, Regina Guthold, Mie Inoue, Doris Ma Fat, Annette
Prüss-Ustün, Jürgen Rehm, George Schmid and Petra Schuster.

Figures were prepared by Florence Rusciano, and design and layout were by Reto Schürch.

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 GLOBAL HEALTH RISKS

Contents
Tables................................................................................................................................................................................................................ iv
Figures.............................................................................................................................................................................................................. iv
Summary........................................................................................................................................................................................................... v
Abbreviations.................................................................................................................................................................................................... vi

1 Introduction 1
1.1 Purpose of this report................................................................................................................................................................................ 1
1.2 Understanding the nature of health risks.................................................................................................................................................. 1
1.3 The risk transition...................................................................................................................................................................................... 2
1.4 Measuring impact of risk........................................................................................................................................................................... 4
1.5 Risk factors in the update for 2004............................................................................................................................................................ 5
1.6 Regional estimates for 2004...................................................................................................................................................................... 7

2 Results 9
2.1 Global patterns of health risk..................................................................................................................................................................... 9
2.2 Childhood and maternal undernutrition.................................................................................................................................................. 13
2.3 Other diet-related risk factors and physical inactivity.............................................................................................................................. 16
2.4 Sexual and reproductive health............................................................................................................................................................... 19
2.5 Addictive substances............................................................................................................................................................................... 21
2.6 Environmental risks................................................................................................................................................................................. 23
2.7 Occupational and other risks................................................................................................................................................................... 25

3 Joint effects of risk factors 28

3.1 Joint contribution of risk factors to specific diseases................................................................................................................................ 28
3.2 Potential health gains from reducing multiple risk factors...................................................................................................................... 29
3.3 Conclusions.............................................................................................................................................................................................. 31

Annex A: Data and methods 32

A1.1 Estimating population attributable fractions........................................................................................................................................... 32
A1.2 Risk factors.............................................................................................................................................................................................. 33
Table A1: Definitions, theoretical minima, disease outcomes and data sources for the selected global risk factors.......................................... 41
Table A2: Summary prevalence of selected risk factors by income group in WHO regions, 2004...................................................................... 46
Table A3: Attributable mortality by risk factor and income group in WHO regions, estimates for 2004........................................................... 50
Table A4: Attributable DALYs by risk factor and income group in WHO regions, estimates for 2004.................................................................. 52
Table A5: Countries grouped by WHO region and income per capita in 2004.................................................................................................... 54

References 55

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 World Health Organization

Tables
Table 1: Ranking of selected risk factors: 10 leading risk factor causes of death by income group, 2004.......................................................... 11
Table 2: Ranking of selected risk factors: 10 leading risk factor causes of DALYs by income group, 2004.......................................................... 12
Table 3: Deaths and DALYs attributable to six risk factors .
for child and maternal undernutrition, and to six risks combined; countries grouped by income, 2004................................................... 14
Table 4: Deaths and DALYs attributable to six diet-related risks and physical inactivity, and to all six risks combined, by region, 2004............ 17
Table 5: Deaths and DALYs attributable to alcohol, tobacco and illicit drug use, and to all three .
risks together, by region, 2004................................................................................................................................................................ 22
Table 6: Deaths and DALYs attributable to five environmental risks, and to all five risks combined by region, 2004......................................... 24
Table 7: Percentage of total disease burden due to 5 and 10 leading risks and all 24 risks in this report, world, 2004 ..................................... 30
Table 8: Percentage of total disease burden due to 10 leading risks, by region and income group, 2004 . ....................................................... 30
Table A1: Definitions, theoretical minima, disease outcomes and data sources for the selected global risk factors.......................................... 41
Table A2: Summary prevalence of selected risk factors by income group in WHO regions, 2004...................................................................... 46
Table A3: Attributable mortality by risk factor and income group in WHO regions, estimates for 2004........................................................... 50
Table A4: Attributable DALYs by risk factor and income group in WHO regions, estimates for 2004.................................................................. 52
Table A5: Countries grouped by WHO region and income per capita in 2004.................................................................................................... 54

Figures
Figure 1: The causal chain.................................................................................................................................................................................. 2
Figure 2: The risk transition................................................................................................................................................................................ 3
Figure 3: An observed population distribution of average systolic blood pressure .
and the ideal population distribution of average systolic blood pressure................................................................................................... 4
Figure 4: Counterfactual attribution................................................................................................................................................................... 6
Figure 5: Low- and middle-income countries grouped by WHO region, 2004..................................................................................................... 7
Figure 6: Deaths attributed to 19 leading risk factors, by country income level, 2004...................................................................................... 10
Figure 7: Percentage of disability-adjusted life years (DALYs) attributed to 19 leading risk factors, by country income level, 2004.................. 10
Figure 8: Major causes of death in children under 5 years old with disease-specific contribution of undernutrition, 2004. . ........................... 14
Figure 9: Attributable DALY rates for selected diet-related risk factors, and all six risks together, .
by WHO region and income level, 2004................................................................................................................................................... 18
Figure 10: Burden of disease attributable to lack of contraception, by WHO region, 2004................................................................................ 20
Figure 11: Percentage of deaths over age 30 years caused by tobacco, 2004.................................................................................................... 22
Figure 12: Disease burden attributable to 24 global risk factors, by income and WHO region, 2004................................................................. 29
Figure 13: Potential gain in life expectancy in the absence of selected risks to health, world, 2004................................................................. 30

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Summary
The leading global risks for mortality in the world Five leading risk factors identified in this report
are high blood pressure (responsible for 13% of (childhood underweight, unsafe sex, alcohol use,
deaths globally), tobacco use (9%), high blood glu- unsafe water and sanitation, and high blood pres-
cose (6%), physical inactivity (6%), and overweight sure) are responsible for one quarter of all deaths
and obesity (5%). These risks are responsible for in the world, and one fifth of all DALYs. Reducing
raising the risk of chronic diseases such as heart exposure to these risk factors would increase global
disease, diabetes and cancers. They affect countries life expectancy by nearly 5 years.
across all income groups: high, middle and low. Eight risk factors (alcohol use, tobacco use, high
The leading global risks for burden of disease as blood pressure, high body mass index, high choles-
measured in disability-adjusted life years (DALYs) terol, high blood glucose, low fruit and vegetable
are underweight (6% of global DALYs) and unsafe intake, and physical inactivity) account for 61% of
sex (5%), followed by alcohol use (5%) and unsafe cardiovascular deaths. Combined, these same risk
water, sanitation and hygiene (4%). Three of these factors account for over three quarters of ischaemic
risks particularly affect populations in low-income heart disease: the leading cause of death worldwide.
countries, especially in the regions of South-East Although these major risk factors are usually asso-
Asia and sub-Saharan Africa. The fourth risk – alco- ciated with high-income countries, over 84% of the
hol use – shows a unique geographic and sex pat- total global burden of disease they cause occurs in
tern, with its burden highest for men in Africa, in low- and middle-income countries. Reducing expo-
middle-income countries in the Americas and in sure to these eight risk factors would increase global
some high-income countries. life expectancy by almost 5 years.
This report uses a comprehensive framework A total of 10.4 million children died in 2004,
for studying health risks developed for The world mostly in low- and middle-income countries. An
health report 2002, which presented estimates for estimated 39% of these deaths (4.1 million) were
the year 2000. The report provides an update for the caused by micronutrient deficiencies, underweight,
year 2004 for 24 global risk factors. It uses updated suboptimal breastfeeding and preventable envi-
information from WHO programmes and scien- ronmental risks. Most of these preventable deaths
tific studies for both exposure data and the causal occurred in the WHO African Region (39%) and the
associations of risk exposure to disease and injury South-East Asia Region (43%).
outcomes. The burden of disease attributable to risk Nine environmental and behavioural risks,
factors is measured in terms of lost years of healthy together with seven infectious causes, are respon-
life using the metric of the disability-adjusted life sible for 45% of cancer deaths worldwide. For spe-
year. The DALY combines years of life lost due to cific cancers, the proportion is higher: for example,
premature death with years of healthy life lost due to tobacco smoking alone causes 71% of lung cancer
illness and disability. deaths worldwide. Tobacco accounted for 18% of
Although there are many possible definitions of deaths in high-income countries.
“health risk”, it is defined in this report as “a factor Health risks are in transition: populations are age-
that raises the probability of adverse health out- ing owing to successes against infectious diseases; at
comes”. The number of such factors is countless and the same time, patterns of physical activity and food,
the report does not attempt to be comprehensive. alcohol and tobacco consumption are changing.
For example, some important risks associated with Low- and middle-income countries now face a dou-
exposure to infectious disease agents or with anti- ble burden of increasing chronic, noncommunica-
microbial resistance are not included. The report ble conditions, as well as the communicable diseases
focuses on selected risk factors which have global that traditionally affect the poor. Understanding the
spread, for which data are available to estimate pop- role of these risk factors is important for developing
ulation exposures or distributions, and for which the clear and effective strategies for improving global
means to reduce them are known. health.

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 World Health Organization

Abbreviations
AIDS............ acquired immunodeficiency syndrome
BMI............. body mass index
CRA.............. comparative risk assessment
DALY............ disability-adjusted life year
GBD............. global burden of disease
HIV.............. human immunodeficiency virus
IUGR............ intrauterine growth restriction
MET............. metabolic equivalent (energy expenditure measured in units of resting energy expenditure)
PAF.............. population attributable fraction
UNAIDS........ Joint United Nations Programme on HIV/AIDS
UNICEF......... United Nations Children’s Fund
WHO............ World Health Organization
YLD.............. years lost due to disability
YLL.............. years of life lost (due to premature mortality)

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