Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: 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. Methods: 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. Findings: 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). Interpretation: 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. Funding: Bill & Melinda Gates Foundation

Efeito das mudanças climáticas na disponibilidade hídrica da bacia hidrográfica do Rio Paracatu Effect of the climate change on the water availability in the Paracatu river basin

O aumento da demanda pelo uso da água na bacia do Rio Paracatu vem ocasionando sérios problemas ambientais e conflitos entre os usuários. Para a gestão mais eficiente dos recursos hídricos, é importante o conhecimento do comportamento hidrológico da bacia hidrográfica, no presente e no futuro, devido às fortes evidências de mudanças climáticas no planeta. O objetivo deste trabalho foi estimar a tendência de variação da disponibilidade hídrica na bacia hidrográfica do Rio Paracatu, até o final deste século, considerando dois cenários contrastantes de mudanças climáticas, um para altas emissões de CO2 (A2) e outro para baixas (B2). Para atingir esse objetivo, foi realizado o downscaling das precipitações mensais para os anos de 2001 a 2099, simulados pelo modelo de circulação geral do Hadley Centre (HadCM3). As precipitações interpoladas serviram como entrada em modelo do tipo precipitação-vazão, que possibilitou a estimativa das vazões mínimas em 21 estações fluviométricas distribuídas na bacia. Para o cenário A2, verificou-se tendência de aumento na disponibilidade hídrica em todas as estações fluviométricas, variando de 31 a 131% até 2099. Para o cenário B2, não foi verificada nenhuma tendência significativa.<br>The increase of water use in the Paracatu basin is leading to deep environmental problems and conflicts among the users. For a more efficient water resources management, the knowledge of the basin's hydrologic behavior is important, in the present and in the future, due to the strong climatic changes evidences in the planet. The aim of this work is to estimate the water availability variation trends in the Paracatu river basin, from the beginning until the end of this century, considering two contrasting climate change scenarios, the first one to take account of high CO2 emissions (A2) and the other one for low emissions (B2). To achieve this objective, the monthly precipitation downscaling was accomplished, using data from 2001 to 2099 simulated by the Hadley Centre´s global circulation model (HadCM3). The precipitations were used as data input in a precipitation-flow model, which made possible the estimate of the minimum discharges in 21 gauged stations distributed in the basin. For the A2 scenario, an increase trend was verified in the water availability in all of the stations from 2001 to 2099, varying from 31 to 131%. For the B2 scenario no significant trend was verified