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.

Using an ‘interpretative model’ for contextual design of heritage landscape databases: The case of St Helena Island National Park in Queensland, Australia

Due to the increasing speed of landscape changes and the massive development of computer technologies, the methods of representing heritage landscapes using digital tools have become a worldwide concern in conservation research. The aim of this paper is to demonstrate how an ‘interpretative model’ can be used for contextual design of heritage landscape information systems. This approach is explored through building a geographic information system database for St Helena Island national park in Moreton Bay, South East Queensland, Australia. Stakeholders' interpretations of this landscape were collected through interviews, and then used as a framework for designing the database. The designed database is a digital inventory providing contextual descriptions of the historic infrastructure remnants on St Helena Island. It also reveals the priorities of different sites in terms of historic research, landscape restoration, and tourism development. Additionally, this database produces thematic maps of the intangible heritage values, which could be used for landscape interpretation. This approach is different from the existing methods because building a heritage information system is deemed as an interpretative activity, rather than a value-free replication of the physical environment. This approach also shows how a cultural landscape methodology can be used to create a flexible information system for heritage conservation. The conclusion is that an ‘interpretative model’ of database design facilitates a more explicit focus on information support, and is a potentially effective approach to user-centred design of geographic information systems.

Incorporating dugong habitats into the marine protected area design for the Great Barrier Reef Marine Park, Queensland, Australia.

Dugong habitats were considered in the design for the new zoning network for the Great Barrier Reef Marine Park as part of the Representative Areas Program. One of the specific design guidelines developed as part of the biophysical operational principles recommended that 50% of all high priority dugong habitats should be incorporated in the network of no-take areas. The high priority dugong habitat incorporated in no-take protection increased from 1396 to 3476 km2 (or 16.9-42.0% of all identified sites). Although this increase in protection fell short of the recommended 50%, overall the level of protection afforded by the Great Barrier Reef Marine Park Zoning Plan 2003 increased for all the locations identified.

Melaleuca densispicata in Currawinya National Park, South-West Queensland: Ecology and preliminary implications for management of a rare plant species

Melaleuca densispicata Byrnes is an uncommon species with a limited distribution, comprising disjunct populations in inland southern Queensland and northern New South Wales, Australia. It is a dense, woody shrub, 2–4 m in height, which exhibits a marked 'clumping' growth habit. It has thick, papery bark and displays many white flowers during spring or early summer. Although it has long been known to exist, M. densispicata was only formally described in 1984, and very little is currently known about its ecology or specific management requirements. There are only seven known subpopulations of the species across its range. A major population at the western limit of its distribution occurs on Currawinya National Park (28°52'S, 144°30'E). Here, it is locally abundant and listed as a noteworthy plant species under the Management Plan (Queensland Parks & Wildlife Service 2001). This study aimed to identify patterns in the distribution of M. densispicata in Currawinya National Park, describe its ecological niche and role, and provide management recommendations for the species within the study area. Recent anecdotal observations of recruitment failure in south-western Queensland (Peter McRae, QPWS, October 2004, pers. comm.; Dick O'Connell, local grazier, July 2005 pers. comm.) caused additional emphasis to be placed on the examination of recruitment and recruitment factors.

Gottschalk family in the park; Hannover, Germany. Portraits Family

Left to right: Therese Godshaw (Gottschalk) nee Molling, Walter, Freddy, Grandmother Henriette Gottschalk nee Rothschild, Ursula, Hal and Kurt

Alfred Lichtenstein with his first wife Gerda and their daughter Sylvia seated on a park bench; Buenos Aires.

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Ruth Augusta Beatrice Goldschmidt outside the Richmond Park Hotel; Karlsbad Portraits Women

Born 1923?

Martin Goldschmidt reading on a park bench Portraits Men

Handwritten postcard addressed to Ruth Goldschmidt in Italy and dated 1937 from Zurich

Ruth Augusta Beatrice Goldschmidt with her parents Paula Goldschmidt née Harmelin and Martin Goldschmidt, walking on the street outside the Richmond Park Hotel; Karlsbad Portraits Family

Paula Goldschmidt, née Harmelin, born 1880; Martin Goldschmidt, born circa 1879; Ruth Augusta Beatrice Goldschmidt, born 1923?

Markus Dublon with his wife reading newspapers on a park bench Portraits Couples

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Samuel Eliasberg in a park with his son Georg Eliasberg; Berlin Portraits Family

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Young Herbert Strauss (center) with four friends seated on a park bench on the Sabbath; Würzburg.

To the right of Herbert Strauss are Anne Chrenbacher and Walther Reis, to his left are Heinz Ostheim and an unidentified woman

Portrait of a family and their dog sitting in a park Portraits Family

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