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

HAPEX-Sahel

Groundwater level measurements taken over a 4-year period from an extensive network of wells and boreholes within the HAPEX-Sahel (Hydrologic Atmospheric Pilot Experiment in the Sahel) degree square (south Niger), together with existing data, have provided an insight into infiltration and recharge processes taking place in the porous phreatic aquifer of the Continental Terminal formation. Despite high spatial and temporal variability of aquifer response to rainfall (rises of between 0 and 9 m are recorded), a pattern of recharge can be recognised. Aquifer responses vary from site to site, but the type of response at any single point tends to be consistent from year to year. Recharge is dominated by infiltration from temporary drainage networks (pools and streams) and aquifer response depends to a large extent on aquifer hydraulic characteristics and distance from the nearest infiltrating zone. In many wells, for which data extending back to 1987 is available, water levels show a consistent year by year rise. This is interpreted as a process of aquifer recovery following the severe drought of the 1970s and early 1980s, though part may also be attributable to changing patterns of land management (e.g. woodland clearance). Initial estimates of regional recharge are from 50-60 mm/y, or in other words about 10% of annual rainfall. The figure is supported by other methods of investigation (hydrochemical analyses ; water budgets of pools). (Résumé d'auteur

HAPEX-Sahel

The HAPEX-Sahel experiment took place in the midst of the most severe drought that has ever plagued the region since rainfall records have been available in the Sahel. The aim of this paper is to describe the rainfall conditions that were observed during HAPEX-Sahel by a network of 100 recording raingauges, and to analyse them in the perspective of the long-term statistics at the Niamey station. Globally it is found that the average rainfall over the HAPEX-Sahel study area, as well as over Niger as a whole, during the experiment has been moderately (1991 and 1992) to markedly dry (1990 and 1993), indicating that the drought of the past 20 years has not ended. More detailed statistics point to the high intermittency of the Sahelian rainfall, both in space (each year the ratio between the maximum and minimum recorded seasonal rainfall was of the order of 2) and in time (half the annual rain falls in 5 h). Particular attention is paid to the climatology of the rainy events. The point event rainfall is nearly exponentially distributed with a mean of about 14 mm, while the average areal event rainfall over the HAPEX-Sahel 1° x 1° square is of the order of 10.5 mm. The probability of zero rainfall is thus close to 1/4. Rain rates are often heavy, with half the annual rain falling at rain rates higher than 35 mm/h and one third of it falling at rain rates higher than 50 mm/h. The year to year statistics of both the event rainfall and the rain rates vary little, indicating that most of the inter-annual rainfall variability is due to the variation of the number of rainfall events, rather than to variations in rainfall intensities or in the mean event rainfall. (Résumé d'auteur