Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Slow napalm

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. Slow Napalm, the first in series of short stories, works to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.

The Joke

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. 'The Joke', the second in series of short stories, works to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.

Experimental people

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. Experimental People, the third in series of short stories, works to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.

Study of Pinna nobilis growth from inner record: How biased are posterior adductor muscle scars estimates?

Previous studies have shown that the external growth records of the posterior adductor muscle scar (PAMS) of the bivalve Pinna nobilis are incomplete and do not produce accurate age estimations. We have developed a new methodology to study age and growth using the inner record of the PAMS, which avoids the necessity of costly in situ shell measurements or isotopic studies. Using the inner record we identified the positions of PAMS previously obscured by nacre and estimated the number of missing records in adult specimens with strong abrasion of the calcite layer in the anterior portion of the shell. The study of the PAMS and inner record of two shells that were 6 years old when collected showed that only 2 and 3 PAMS were observed, while 6 inner records could be counted, thus confirming our working methodology. Growth parameters of a P. nobilis population located in Moraira, Spain (western Mediterranean) were estimated with the new methodology and compared to those obtained using PAMS data and in situ measurements. For the comparisons, we applied different models considering the data alternatively as length-at-age (LA) and tag-recapture (TR). Among every method we tested to fit the Von Bertalanffy growth model, we observed that LA data from inner record fitted to the model using non-linear mixed effects and the estimation of missing records using the calcite width was the most appropriate. The equation obtained with this method, L = 573*(1 - e(-0.16(t-0.02))), is very similar to that calculated previously from in situ measurements for the same population.

Oh Holly, The Fish is Dead

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. ‘Oh Holly, the fish is dead’ is the fourth in a series of short stories that work to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.

Swing Low

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. ‘Swing Low’ is the fifth in a series of short stories that work to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.

Eating the Lonesome

From Kurt Vonnegut to Stephen King, many novelists use metanarrative techniques to insert fictional versions of themselves in the stories they tell. The function of deploying such techniques is often to draw attention to the liminal space between the fictional constructs inherent in the novel as a form, and the real world from which the constructs draw inspiration, and indeed, are read by an audience. For emerging writers working in short form narratives, however, the structural demands of the short story or flash fiction make the use of similar techniques problematic in the level of depth to which they can be deployed. ‘Eating The Lonesome’ is the sixth in a series of short stories that work to overcome the structural limitations of a succinct form by developing a fractured fictional version of the author over a number of pieces and published across a range of sites. The accumulative affect is a richer metanarrative textual arrangement that also allows for the individual short stories to function independently.