Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

www. helance .com Vol 390 Sep embe 16, 2017 1345 Global Heal h Me ics Global, egional, and na ional compa a i e isk assessmen o 84 beha iou al, en i onmen al and occupa ional, and me abolic isks o clus e s o isks, 1990–2016: a sys ema ic analysis o he Global Bu den o Disease S udy 2016 GBD 2016 Risk Fac o s Collabo a o s* Summa y Backg ound The Global Bu den o Diseases, Inju ies, and Risk Fac o s S udy 2016 (GBD 2016) p o ides a comp ehensi e assessmen o isk ac o exposu e and a ibu able bu den o disease. By p o iding es ima es o e a long ime se ies, his s udy can moni o isk exposu e ends c i ical o heal h su eillance and in o m policy deba es on he impo ance o add essing isks in con ex . Me hods We used he compa a i e isk assessmen amewo k de eloped o p e ious i e a ions o GBD o es ima e le els and ends in exposu e, a ibu able dea hs, and a ibu able disabili y-adjus ed li e-yea s (DALYs), by age g oup, sex, yea , and loca ion o 84 beha iou al, en i onmen al and occupa ional, and me abolic isks o clus e s o isks om 1990 o 2016. This s udy included 481 isk-ou come pai s ha me he GBD s udy c i e ia o con incing o p obable e idence o causa ion. We ex ac ed ela i e isk (RR) and exposu e es ima es om 22 717 andomised con olled ials, coho s, pooled coho s, household su eys, census da a, sa elli e da a, and o he sou ces, acco ding o he GBD 2016 sou ce coun ing me hods. Using he coun e ac ual scena io o heo e ical minimum isk exposu e le el (TMREL), we es ima ed he po ion o dea hs and DALYs ha could be a ibu ed o a gi en isk. Finally, we explo ed ou d i e s o ends in a ibu able bu den: popula ion g ow h, popula ion ageing, ends in isk exposu e, and all o he ac o s combined. Findings Since 1990, exposu e inc eased signi ican ly o 30 isks, did no change signi ican ly o ou isks, and dec eased signi ican ly o 31 isks. Among isks ha a e leading causes o bu den o disease, child g ow h ailu e and household ai pollu ion showed he mos signi ican declines, while me abolic isks, such as body-mass index and high as ing plasma glucose, showed signi ican inc eases. In 2016, a Le el 3 o he hie a chy, he h ee leading isk ac o s in e ms o a ibu able DALYs a he global le el o men we e smoking (124·1 million DALYs [95% UI 111·2 million o 137·0 million]), high sys olic blood p essu e (122·2 million DALYs [110·3 million o 133·3 million], and low bi hweigh and sho ges a ion (83·0 million DALYs [78·3 million o 87·7 million]), and o women, we e high sys olic blood p essu e (89·9 million DALYs [80·9 million o 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million o 87·6 million]), and high as ing plasma glucose (63·8 million DALYs [53·2 million o 76·3 million]). In 2016 in 113 coun ies, he leading isk ac o in e ms o a ibu able DALYs was a me abolic isk ac o . Smoking emained among he leading i e isk ac o s o DALYs o 109 coun ies, while low bi hweigh and sho ges a ion was he leading isk ac o o DALYs in 38 coun ies, pa icula ly in sub-Saha an A ica and Sou h Asia. In e ms o impo an d i e s o change in ends o bu den a ibu able o isk ac o s, be ween 2006 and 2016 exposu e o isks explains an 9·3% (6·9–11·6) decline in dea hs and a 10·8% (8·3–13·1) dec ease in DALYs a he global le el, while popula ion ageing accoun s o 14·9% (12·7–17·5) o dea hs and 6·2% (3·9–8·7) o DALYs, and popula ion g ow h o 12·4% (10·1–14·9) o dea hs and 12·4% (10·1–14·9) o DALYs. The la ges con ibu ion o ends in isk exposu e o disease bu den is seen be ween ages 1 yea and 4 yea s, whe e a decline o 27·3% (24·9–29·7) o he change in DALYs be ween 2006 and 2016 can be a ibu ed o declines in exposu e o isks. In e p e a ion Inc easingly de ailed unde s anding o he ends in isk exposu e and he RRs o each isk-ou come pai p o ide insigh s in o bo h he magni ude o heal h loss a ibu able o isks and how modi ica ion o isk exposu e has con ibu ed o heal h ends. Me abolic isks wa an pa icula policy a en ion, due o hei la ge con ibu ion o global disease bu den, inc easing ends, and a iable pa e ns ac oss coun ies a he same le el o de elopmen . GBD 2016 indings show ha , while i has huge po en ial o imp o e heal h, isk modi ica ion has played a ela i ely small pa in he pas decade. Funding The Bill & Melinda Ga es Founda ion, Bloombe g Philan h opies. Copy igh © The Au ho (s). Published by Else ie L d. This is an Open Access a icle unde he CC BY 4.0 license. Lance 2017; 390: 1345–422 *Collabo a o s lis ed a he end o he A icle Fo mo e on Bloombe g Philan h opies see www.bloombe g.o g This online publica ion has been co ec ed. The co ec ed e sion i s appea ed a helance .com on Sep embe 18, 2017 Co espondence o: P o Emmanuela Gakidou, Ins i u e o Heal h Me ics and E alua ion, Sea le, WA 98121, USA [email protected] Global Heal h Me ics 1346 www. helance .com Vol 390 Sep embe 16, 2017 In oduc ion A co e p emise o public heal h is ha p e en ion can be a powe ul ins umen o imp o ing human heal h, one ha is o en cos -e ec i e and minimises ha m o indi iduals om ill heal h. The co e objec i es o p e en ion include he educ ion o modi ica ion o exposu e o isks including me abolic, beha iou al, en i onmen al, and occupa ional ac o s. Quan i ying isks o heal h and hus he a ge s o many public heal h ac ions is an essen ial p e equisi e o e ec i e public heal h. The e idence on he ela ion be ween isk exposu e and heal h is cons an ly e ol ing: new in o ma ion abou he ela i e isks (RRs) associa ed wi h di e en isks o di e en ou comes con inues o eme ge om coho s udies, andomised ials, and case- con ol s udies. These s udies can es ablish e idence o new isks o isk-ou come pai s o educe he s eng h o e idence o exis ing isks. New da a a e also egula ly collec ed on he le els o exposu e in di e en popula ions and in di e en se ings. Regula ly upda ed moni o ing o he e idence base on isk ac o s is c ucial o public heal h and o indi idual isk modi ica ion h ough p ima y ca e and sel -managemen . Se e al s udies explo e isk-a ibu able bu den o indi idual isks1–3 a he global, egional, o na ional le el. O he s udies p o ide assessmen s o exposu e o selec ed isks. Howe e , he Global Bu den o Diseases, Inju ies, and Risk Fac o s S udy (GBD) compa a i e isk assessmen (CRA) is he only comp ehensi e and compa able app oach o isk ac o quan i ica ion. The mos ecen o hese assessmen s was GBD 2015.4–6 Wi h each cycle o GBD, scien i ic discussions ha e eme ged on a ious dimensions o isk quan i ica ion ha ha e led o imp o emen s and modi ica ions o GBD. Many o hese a e ocused on he s eng h o e idence suppo ing a causal connec ion o speci ic isk-ou come pai s, while o he s ela e o measu emen challenges.7–9 Fu he , new isk ac o s ha e been added o impo an heal h condi ions included in GBD, such as neona al ou comes and Alzheime ’s demen ia,10 which ha e p e iously no had associa ed isk ac o s. The ecen ials on blood p essu e con ol a lowe le els o sys olic blood p essu e, including Resea ch in con ex E idence be o e his s udy The Global Bu den o Diseases, Inju ies, and Risk Fac o s S udy 2016 (GBD 2016) emains he mos comp ehensi e e o o conduc a popula ion-le el compa a i e isk assessmen ac oss coun ies and isks. O he sou ces o popula ion-le el es ima es o isk include WHO and UNICEF epo s as well as independen scien i ic publica ions. No able di e ences in me hods and de ini ions p oduce a ia ion in esul s, al hough in se e al cases he e is gene al ag eemen in egional o global pa e ns. The GBD s udy emains he only pee - e iewed, comp ehensi e, and annual assessmen o isk ac o bu den by age, sex, cause, and loca ion o a long ime se ies ha complies wi h he Guidelines o Accu a e and T anspa en Heal h Es ima es Repo ing (GATHER). Added alue o his s udy This s udy builds upon GBD 2015 and p o ides se e al impo an imp o emen s as well as he quan i ica ion o i e new isks. The inno a ions and imp o emen s om las yea can be summa ised as ollows. Ac oss all isk ac o s, he e we e 7155 addi ional da a sou ces, acco ding o he GBD 2016 sou ce coun ing me hods. Fo die , we included da a o die a y ecall, household budge , and ood equency ques ionnai es. We also inco po a ed sales da a om 170 coun ies as well as na ional accoun ing o ood a ailable o popula ions in a gi en yea . In GBD 2016, we a e p oducing es ima es o he ollowing i e new isks: smokeless obacco, low bi hweigh and sho ges a ion, low bi hweigh o ges a ion, sho ges a ion o bi hweigh , and die low in legumes. We also ex ended he high body-mass index (BMI) analysis o include childhood obesi y. We ha e also added 93 new isk-ou come pai s. Majo e isions o he es ima ion o he ollowing isk ac o s we e unde aken o GBD 2016. Fo second-hand smoke, we changed he es ima ion me hod o ensu e consis ency wi h he es ima es o smoking p e alence. Fo alcohol, we es ima ed new ela i e isks (RRs) o all ou comes, we inco po a ed mo e da a o exposu e and new adjus men s o ou ism and un eco ded consump ion, and we ede ined he heo e ical minimum isk exposu e le el (TMREL). Fo die , we es ima ed he disease bu den o die a y isks based on he absolu e le el o in ake a he han he in ake s anda dised o 2000 kcal pe day. We de eloped an ensemble model o di e en pa ame ic dis ibu ions o gene a e be e i s o he dis ibu ions o con inuous isk ac o s. Media ion e idence was e iewed and upda ed based on an analysis o en pooled coho s. We ha e expanded he analysis o geog aphic and empo al ends in isk exposu e and bu den by de elopmen , using he Socio-demog aphic Index (SDI), and ha e also explo ed whe e coun ies a e in he isk ansi ion. We also imp o ed and modi ied ou decomposi ion me hods so ha he esul s shown a e addi i e and can be agg ega ed o explain ends in all-cause and cause-speci ic mo ali y, as well as ends ac oss age g oups. The decomposi ion analysis has been ex ended o examine how isk ac o s ha e con ibu ed o ends in all-cause mo ali y by age and sex as well as by cause. Implica ions o all he a ailable e idence Inc easingly de ailed unde s anding o he ends in isk exposu e and he RRs o each isk-ou come pai p o ides insigh s in o bo h he magni ude o heal h loss a ibu able o isks and how modi ica ion o isk exposu e has con ibu ed o heal h ends. This analysis shows a misma ch be ween he po en ial o isk modi ica ion o imp o e heal h and he ela i ely modes ole ha isk modi ica ion has played in he pas gene a ion in imp o ing global heal h. Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1347 he Sys olic Blood P essu e In e en ion T ial (SPRINT)11 and Hea Ou comes P e en ion E alua ion-3 (HOPE-3) ial,12 ha e also b ough a en ion o he di e ence be ween a popula ion heal h pe spec i e on he quan i ica ion o isks and he clinical ques ion o isk e e sibili y. The CRA amewo k p o ides an impo an insigh in o he ole o di e en isks in con ibu ing o le els o popula ion heal h bu does no necessa ily p o ide all he in o ma ion necessa y o guide indi idual clinical decision making. The GBD 2016 CRA includes 84 isk ac o s and an associa ed 481 isk-ou come pai s. In addi ion o new da a and upda ed me hods, we ha e included i e new isks in he GBD 2016 CRA. The s udy was unde aken o 195 coun ies and e i o ies and p o ides es ima es o exposu e and a ibu able dea hs and disabili y- adjus ed li e-yea s (DALYs) o 1990 h ough o 2016. We explo ed how isks change wi h de elopmen , measu ed by he Socio-demog aphic Index (SDI), and also decomposed changes in dea hs and DALYs in o he con ibu ions o popula ion ageing, popula ion g ow h, ends in isk exposu e, and all o he ac o s combined. As wi h p e ious i e a ions o GBD, he GBD 2016 CRA esul s p esen ed he e supe sede all p e iously published GBD CRA es ima es. Me hods O e iew The CRA concep ual amewo k was de eloped by Mu ay and Lopez,13 who es ablished a causal web o hie a chically o ganised isks o causes ha con ibu e o heal h ou comes (me hod appendix; appendix 1 p 432), which allows quan i ica ion o isks o causes a any le el in he amewo k. In GBD 2016, as in p e ious i e a ions o GBD, we e alua ed a se o beha iou al, en i onmen al, and occupa ional, and me abolic isks, whe e isk- ou come pai s we e included based on e idence ules (appendix 1 p 344). These isks we e o ganised in o i e hie a chical le els as desc ibed in appendix 1 (p 374). A Le el 0, he GBD 2016 p o ides es ima es o all isk ac o s combined, a Le el 1 he GBD 2016 p o ides es ima es o h ee g oups: en i onmen al and occupa ional, me abolic, and beha io al isk ac o s. A Le el 2, he e a e 17 isks, a Le el 3 he e a e 50 isks, and a Le el 4 he e a e 67 isks, o a o al o 84 isks o clus e s o isks. To da e, we ha e no quan i ied he con ibu ion o o he classes o isk ac o s (appendix 1 p 376); howe e , using an analysis o he ela ion be ween isk exposu es and socio-demog aphic de elopmen , measu ed wi h he use o SDI, we p o ide some insigh s in o he po en ial magni ude o dis al social, cul u al, and economic ac o s. Two ypes o isk assessmen a e possible wi hin he CRA amewo k: a ibu able bu den and a oidable bu den.13 A ibu able bu den is he educ ion in cu en disease bu den ha would ha e been possible i pas popula ion exposu e had shi ed o an al e na i e o coun e ac ual dis ibu ion o isk exposu e. A oidable bu den is he po en ial educ ion in u u e disease bu den ha could be achie ed by changing he cu en dis ibu ion o exposu e o a coun e ac ual dis ibu ion o exposu e. Mu ay and Lopez13 iden i ied ou ypes o coun e ac ual exposu e dis ibu ions: heo e ical, plausible, easible, and cos -e ec i e minimum isk. In GBD s udies, o da e and in his s udy, we ocus on a ibu able bu den using he heo e ical minimum isk exposu e le el, which is he dis ibu ion o isk comp ising he le els o exposu e ha minimise isk o each indi idual in he popula ion. O e all, his analysis ollows he CRA me hods used in GBD 2015.4 The me hods desc ibed in his s udy p o ide a high-le el o e iew o he analy ical logic, ocusing on a eas o no able change om he me hods used in GBD 2015, wi h de ails p o ided in appendix 1 (p 10). This s udy complies wi h he Guidelines o Accu a e and T anspa en Heal h Es ima es Repo ing (GATHER) s a emen 14 (appendix 1 p 377). Geog aphical uni s o analysis and yea s o es ima ion In GBD 2016, loca ions a e a anged as a se o hie a chical ca ego ies: se en supe - egions, 21 egions nes ed wi hin he se en supe - egions, and 195 coun ies and e i o ies nes ed in he 21 egions. Addi ionally, we p esen es ima es a he subna ional le el o i e coun ies wi h a popula ion g ea e han 200 million in 2016: B azil, China, India, Indonesia, and he USA. We p oduced a comple e se o age-speci ic, sex-speci ic, cause-speci ic, and loca ion- speci ic es ima es o isk ac o exposu e and a ibu able bu den o 1990–2016 o all included isk ac o s. A ibu able bu den es ima ion Fou key componen s a e included in es ima ion o he bu den a ibu able o a gi en isk ac o : he me ic o bu den being assessed (numbe o dea hs, yea s o li e los [YLLs], yea s li ed wi h disabili y [YLDs], o DALYs [ he sum o YLLs and YLDs]), he exposu e le els o a isk ac o , he ela i e isk o a gi en ou come due o exposu e, and he coun e ac ual le el o isk ac o exposu e. Es ima es o a ibu able DALYs o a isk-ou come pai a e equal o DALYs o he ou come mul iplied by he popula ion a ibu able ac ion (PAF) o he isk-ou come pai o a gi en age, sex, loca ion, and yea . A simila logic applies o es ima ion o a ibu able dea hs, YLLs, o YLDs. Risks a e ca ego ised on he basis o how exposu e was measu ed: dicho omous, poly omous, o con inuous. The PAF ep esen s he p opo ion o ou come ha would be educed in a gi en yea i he exposu e o a isk ac o in he pas we e educed o he coun e ac ual le el o he heo e ical minimum isk exposu e le el (supplemen a y esul s, appendix 2 p 1). Causal e idence o isk-ou come pai s In his s udy, as in GBD 2015, we ha e included isk- ou come pai s ha we ha e assessed as mee ing he Wo ld Cance Resea ch Fund g ades o con incing o p obable e idence (see appendix 1 p 10 o de ini ions o See Online o appendix 1 See Online o appendix 2 Global Heal h Me ics 1348 www. helance .com Vol 390 Sep embe 16, 2017 hese g ades).15 Table 1 p o ides a summa y o he e idence suppo ing a causal ela ion be ween a isk and an ou come o each pai included in GBD 2016. Fo each isk-ou come pai , we used ecen sys ema ic e iews o iden i y independen p ospec i e s udies ( andomised con olled ials, non- andomised in e en ions, and coho s) ha e alua ed he pu a i e ela ionship. Fo isk-ou come pai s wi h ewe han i e p ospec i e s udies, we e alua ed e idence om case- con ol s udies as well (appendix 1 p 344). Table 1 summa ises he e idence using mul iple dimensions, which suppo s ou assessmen ha each included isk- ou come pai mee s he c i e ia o con incing o p obable e idence (appendix 1 p 10 con ains a jus i ica ion o he c i e ia p esen ed o suppo causali y). In his summa y o e idence, we ha e ocused on andomised con olled ials and p ospec i e obse a ional s udies, along wi h suppo ing e idence, like dose– esponse ela ionships and biologically plausible mechanisms. Es ima ion p ocess In o ma ion abou he da a sou ces, es ima ion me hods, compu a ional ools, and s a is ical analysis used in he de i a ion o ou es ima es a e p o ided in appendix 1 (p 10). The analy ical s eps o es ima ion o bu den a ibu able o single o clus e s o isk-ou come pai s a e summa ised in appendix 1 (p 10). Table 2 p o ides de ini ions o exposu e o each isk ac o , he heo e ical minimum isk exposu e le el (TMREL) used, and me ics o da a a ailabili y. Fo each isk, we es ima ed e ec size as a unc ion o age and sex and exposu e le el, mean exposu e, he dis ibu ion o exposu e ac oss indi iduals, and he TMREL. The app oach aken is la gely simila o GBD 2015 o each quan i y o each isk. Some me hodological imp o emen s ha e been implemen ed and new da a sou ces inco po a ed. Appendix 1 (p 34) p o ides de ails o each s ep by isk. Ci a ion in o ma ion o he da a sou ces used o ela i e isks a e p o ided in sea chable o m h ough an online sou ce ool. All poin es ima es a e epo ed wi h 95% unce ain y in e als (UIs). UIs include unce ain y om each ele an componen , consis ing o exposu e, ela i e isks, TMREL, and bu den a es. Whe e pe cen age change is epo ed (wi h 95% UIs), we compu ed i on he basis o he poin es ima es being compa ed. In GBD 2015, we p oduced a summa y measu e o exposu e o each isk, called he summa y exposu e alue (SEV), which is a me ic ha cap u es isk-weigh ed exposu e o a popula ion, o isk-weigh ed p e alence o an exposu e. The scale o SEV spans om 0% o 100%, such ha an SEV o 0% e lec s no isk exposu e in a popula ion and 100% indica es ha an en i e popula ion is exposu e o he maximum possible le el o ha isk. In GBD 2016, we show es ima es o SEVs o each isk ac o and p o ide de ails on how SEVs a e compu ed o ca ego ical and con inuous isks in appendix 1 (p 10). Fi ing a dis ibu ion o exposu e da a The mos in o ma i e da a desc ibing he dis ibu ion o isk ac o s wi hin a popula ion come om indi idual-le el da a; addi ional sou ces o da a include epo ed means and a iances. In cases when a isk ac o also de ines a disease, such as haemoglobin le el and anaemia, he p e alence o disease is also equen ly epo ed. To model he dis ibu ion o any pa icula isk ac o , we seek a amily o p obabili y densi y unc ions (PDFs), a i ing me hod, and a model selec ion c i e ion. To make use o he mos da a desc ibing mos popula ions, we used he me hod o momen s (MoM); he i s wo empi ical momen s om a popula ion, he mean and a iance, we e used o de e mine he PDF desc ibing he dis ibu ion o isk wi hin any popula ion, whe e excep ions o his ule a e jus i ied by con ex . We used he Kolmogo o -Smi no es o measu e he goodness o i (GoF), bu in some cases, he GoF was based on he p edic ion e o o he p e alence o disease. We used an ensemble echnique in which a model selec ion algo i hm is used o choose he bes model o each isk ac o .16 We d ew he ini ial se o candida e models om commonly used PDF amilies. We i ed each PDF candida e amily o each da ase using he MoM, and used he Kolmogo o -Smi no es 17 as he measu e o GoF. P elimina y analysis showed ha he GoF anking o PDF amilies a ied ac oss da ase s o any pa icula isk ac o and ha combining he p edic ions o di e en ly i ed PDF amilies could d ama ically imp o e he GoF o each da ase . The e o e, we de eloped a new model o p edic ion using he ensemble o candida e models, which is a weigh ed linea combina ion o all candida e models, { }, whe e a se o weigh s {w} is chosen such ha i is he sum o he weigh s equals o one and he alues o he weigh s we e de e mined by a second GoF c i e ion wi h i s own alida ion p ocess. Because o basic di e ences among isk ac o s, hei dis ibu ions, and he isk a ibu ion p ocess, he model selec ion p ocess was o en sligh ly di e en o each isk ac o . The de ails can be summa ised by (1) he summa y s a is ics o each da ase ; (2) a able showing he Kolmogo o -Smi no s a is ic o each candida e model and URD; (3) he c i e ion used o de e mining he o e all GoF; (4) summa y esul s o he alida ion p ocess; and (5) he weigh s de ining he inal ensemble model o each da ase . New isks and isks wi h signi ican changes in he es ima ion me hods compa ed wi h GBD 2015 We ook se e al s eps o imp o e he es ima ion o alcohol use as a isk ac o . Fi s , on he exposu e side, we added 26 su ey se ies, which con ibu ed 12 195 da apoin s in ou models. Second, we de eloped and implemen ed a me hod ha adjus s o al consump ion o ou ism and un eco ded consump ion o each loca ion-yea . Thi d, we calcula ed he TMREL. We chose TMREL as being he exposu e ha minimises an indi idual’s isk o su e ing bu den om any gi en cause ela ed o alcohol Fo he ool see h p://ghdx.heal hda a.o g/ Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1349 Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ 2 Unsa e wa e , sani a ion, and handwashing 3Unsa e wa e sou ce– chlo ina ion o sola (poin o use ea men ) Dia hoeal diseases 24 0 42 6 0 ·· ·· Yes ·· Yes No 3Unsa e wa e sou ce–piped Dia hoeal diseases 1 0 0 9 11 ·· ·· Yes ·· Yes No 3Unsa e wa e sou ce– il e Dia hoeal diseases 11 0 45 2 0 ·· ·· Yes ·· Yes No 3Unsa e wa e sou ce– imp o ed wa e Dia hoeal diseases 0 ·· ·· 5 0 ·· ·· Yes ·· Yes No 3 Unsa e sani a ion– piped Dia hoeal diseases 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 3 Unsa e sani a ion– imp o ed sani a ion Dia hoeal diseases 0 ·· ·· 9 0 ·· ·· Yes ·· Yes No 3No access o handwashing acili y Dia hoeal diseases 19 0 42 0 ·· ·· ·· No ·· Yes No 3No access o handwashing acili y Lowe espi a o y in ec ions 8 0 50 11 0 ·· ·· No ·· Yes No 2 Ai pollu ion 3 Ambien pa icula e ma e pollu ion Lowe espi a o y in ec ions 0 ·· ·· 19 0 ·· ·· No Yes Yes No 3 Ambien pa icula e ma e pollu ion T acheal, b onchus, and lung cance 0 ·· ·· 27 0 ·· ·· No Yes Yes Yes 3 Ambien pa icula e ma e pollu ion Ischaemic hea disease 0 ·· ·· 16 0 ·· ·· No Yes Yes Yes 3 Ambien pa icula e ma e pollu ion Ischaemic s oke 0 ·· ·· 25 0 ·· ·· No Yes Yes Yes 3 Ambien pa icula e ma e pollu ion Haemo hagic s oke 0 ·· ·· 25 0 ·· ·· No Yes Yes Yes 3 Ambien pa icula e ma e pollu ion Ch onic obs uc i e pulmona y disease 0 ·· ·· 12 0 ·· ·· No Yes Yes Yes 3 Household ai pollu ion om solid uels Lowe espi a o y in ec ions 0 ·· ·· 0 ·· 9 0 No Yes Yes No 3 Household ai pollu ion om solid uels T acheal, b onchus, and lung cance 0 ·· ·· 0 ·· 20 0 No Yes Yes Yes 3 Household ai pollu ion om solid uels Ischaemic hea disease 0 ·· ·· 16 0 ·· ·· No Yes Yes Yes 3 Household ai pollu ion om solid uels Ischaemic s oke 0 ·· ·· 25 0 ·· ·· No Yes Yes Yes 3 Household ai pollu ion om solid uels Haemo hagic s oke 0 ·· ·· 25 0 ·· ·· No Yes Yes Yes (Table 1 con inues on nex page) Global Heal h Me ics 1350 www. helance .com Vol 390 Sep embe 16, 2017 Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ (Con inued om p e ious page) 3 Household ai pollu ion om solid uels Ch onic obs uc i e pulmona y disease 0 ·· ·· 0 ·· 2 0 No Yes Yes Yes 3 Household ai pollu ion om solid uels Ca a ac 0 ·· ·· 0 ·· 11 0 No Yes Yes No 3Ambien ozone pollu ion Ch onic obs uc i e pulmona y disease 0 ·· ·· 4 0 0 0 No Yes Yes No 2 O he en i onmen al isks 3 Residen ial adon T acheal, b onchus, and lung cance 0 ·· ·· 1 0 29 0 No Yes Yes No 3 Lead exposu e Idiopa hic de elopmen al in ellec ual disabili y 0 ·· ·· 8 0 ·· ·· No Yes Yes No 3 Lead exposu e Sys olic blood p essu e 0 ·· ·· 3 0 1 0 No Yes Yes No 2 Occupa ional isks 4 Occupa ional exposu e o asbes os La ynx cance 0 ·· ·· 27 0 ·· ·· No ·· Yes Yes 4 Occupa ional exposu e o asbes os T acheal, b onchus, and lung cance 0 ·· ·· 18 0 ·· ·· Yes ·· Yes Yes 4 Occupa ional exposu e o asbes os O a ian cance 0 ·· ·· 15 0 ·· ·· No ·· Yes Yes 4 Occupa ional exposu e o asbes os Meso helioma 0 ·· ·· 5 0 ·· ·· Yes ·· Yes Yes 4 Occupa ional exposu e o a senic T acheal, b onchus, and lung cance 0 ·· ·· 9 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o benzene Leukaemia 0 ·· ·· 12 0 ·· ·· Yes ·· Yes No 4 Occupa ional exposu e o be yllium T acheal, b onchus, and lung cance 0 ·· ·· 3 0 2 0 No ·· Yes No 4 Occupa ional exposu e o cadmium T acheal, b onchus, and lung cance 0 ·· ·· 7 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o ch omium T acheal, b onchus, and lung cance 0 ·· ·· 26 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o diesel engine exhaus T acheal, b onchus, and lung cance 0 ·· ·· 17 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o second- hand smoke T acheal, b onchus, and lung cance 0 ·· ·· 25 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o o maldehyde Nasopha ynx cance 0 ·· ·· 2 0 6 0 No ·· Yes Yes (Table 1 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1351 Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ (Con inued om p e ious page) 4 Occupa ional exposu e o o maldehyde Leukaemia 0 ·· ·· 13 0 ·· ·· No ·· Yes Yes 4 Occupa ional exposu e o nickel T acheal, b onchus, and lung cance 0 ·· ·· 6 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o polycyclic a oma ic hyd oca bons T acheal, b onchus, and lung cance 0 ·· ·· 39 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o silica T acheal, b onchus, and lung cance 0 ·· ·· 17 0 ·· ·· No ·· Yes No 4 Occupa ional exposu e o sul u ic acid La ynx cance 0 ·· ·· 14 0 ·· ·· Yes ·· Yes No 4 Occupa ional exposu e o ichlo oe hylene Kidney cance 0 ·· ·· 20 0 ·· ·· No ·· Yes No 3 Occupa ional as hmagens As hma 0 ·· ·· 16 0 ·· ·· No ·· Yes No 3 Occupa ional pa icula e ma e , gases, and umes Ch onic obs uc i e pulmona y disease 0 ·· ·· 9 0 ·· ·· No ·· Yes No 3 Occupa ional noise Age- ela ed and o he hea ing loss 0 ·· ·· 5 0 ·· ·· Yes ·· Yes No 3 Occupa ional e gonomic ac o s Low back pain 0 ·· ·· 10 0 ·· ·· No ·· Yes No 2 Child and ma e nal malnu i ion 4 Non-exclusi e b eas eeding Dia hoeal diseases 0 ·· ·· 5 0 ·· ·· Yes ·· Yes No 4 Non-exclusi e b eas eeding Lowe espi a o y in ec ions 0 ·· ·· 6 0 ·· ·· Yes ·· Yes No 4 Discon inued b eas eeding Dia hoeal diseases 0 ·· ·· 2 0 ·· ·· No ·· Yes No 4Child unde weigh Dia hoeal diseases 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4Child unde weigh Lowe espi a o y in ec ions 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4Child unde weigh Measles 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4Child was ing Dia hoeal diseases 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4Child was ing Lowe espi a o y in ec ions 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4Child was ing Measles 0 ·· ·· 7 0 ·· ·· Yes ·· Yes No 4 Child s un ing Dia hoeal diseases 0 ·· ·· 7 0 ·· ·· No ·· Yes No (Table 1 con inues on nex page) Global Heal h Me ics 1352 www. helance .com Vol 390 Sep embe 16, 2017 Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ (Con inued om p e ious page) 4 Child s un ing Lowe espi a o y in ec ions 0 ·· ·· 7 0 ·· ·· No ·· Yes No 4 Child s un ing Measles 0 ·· ·· 7 0 ·· ·· No ·· Yes No 4 Sho ges a ion o bi hweigh Dia hoeal diseases 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Lowe espi a o y in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Uppe espi a o y in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh O i is media 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Pneumococcal meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Haemophilus in luenzae ype B meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Meningococcal in ec ion 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh O he meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Encephali is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Neona al p e e m bi h complica ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Neona al encephalopa hy due o bi h asphyxia and auma 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Neona al sepsis and o he neona al in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Haemoly ic disease and o he neona al jaundice 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh O he neona al diso de s 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Sho ges a ion o bi hweigh Sudden in an dea h synd ome 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Dia hoeal diseases 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Lowe espi a o y in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Uppe espi a o y in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes (Table 1 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1353 Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ (Con inued om p e ious page) 4 Low bi hweigh o ges a ion O i is media 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Pneumococcal meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Haemophilus in luenzae ype B meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Meningococcal in ec ion 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion O he meningi is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Encephali is 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Neona al p e e m bi h complica ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Neona al encephalopa hy due o bi h asphyxia and auma 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Neona al sepsis and o he neona al in ec ions 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Haemoly ic disease and o he neona al jaundice 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion O he neona al diso de s 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 4 Low bi hweigh o ges a ion Sudden in an dea h synd ome 0 ·· ·· 20 0 ·· ·· Yes Yes Yes Yes 3Vi amin A de iciency Dia hoeal diseases 19 0 63 0 ·· ·· ·· No ·· Yes No 3Vi amin A de iciency Measles 12 0 83 0 ·· ·· ·· Yes ·· Yes No 3Zinc de iciency Dia hoeal diseases 14 0 29 0 ·· ·· ·· No ·· Yes No 3Zinc de iciency Lowe espi a o y in ec ions 6 0 17 0 ·· ·· ·· No ·· Yes No 2 Tobacco 3 Smoking Tube culosis 0 ·· ·· 4 0 10 0 No ·· Yes Yes 3 Smoking Lip and o al ca i y cance 0 ·· ·· 5 0 ·· ·· Yes ·· Yes Yes 3 Smoking Nasopha ynx cance 0 ·· ·· 4 0 28 0 Yes ·· Yes Yes 3 Smoking Oesophageal cance 0 ·· ·· 5 0 ·· ·· Yes ·· Yes Yes 3 Smoking Colon and ec um cance 0 ·· ·· 19 0 ·· ·· No ·· Yes Yes 3 Smoking Li e cance 0 ·· ·· 54 0 ·· ·· Yes ·· Yes Yes 3 Smoking Gas ic cance 0 ·· ·· 19 0 ·· ·· No ·· Yes Yes (Table 1 con inues on nex page) Global Heal h Me ics 1360 www. helance .com Vol 390 Sep embe 16, 2017 (appendix1 p 22 o mo e de ail). Fou h, we pe o med a sys ema ic e iew o all coho and case-con ol s udies epo ing a RR, haza d a io, o odds a io o any isk- ou come pai s s udied in GBD 2016 and hen modelled a dose- esponse ela ionship using DisMod o dina y di e en ial equa ions (ODE).18 Fi h, we es ima ed inju y PAFs om coho s udies and adjus ed hem o accoun o ic ims. Risk Ou come RCTs (n) RCTs wi h signi ican e ec in he opposi e di ec ion (%) RCTs wi h null indings (%) P ospec i e obse a ional s udies (n)* P ospec i e obse a ional s udies wi h signi ican associa ion in he opposi e di ec ion (%) Case-con ol s udies assessing he isk- ou come pai ela ionship (n)† Case-con ol s udies ha show signi ican associa ion in he opposi e di ec ion (%) Lowe limi o RR >1·5 Dose– esponse ela ionship Biological plausibili y ‡ Analogy§ (Con inued om p e ious page) 2 High body-mass index (adul ) Ischaemic s oke 0 ·· ·· 102 ·· ·· ·· No Yes Yes Yes 2 High body-mass index (adul ) Haemo hagic s oke 0 ·· ·· 129 ·· ·· ·· No Yes Yes Yes 2 High body-mass index (adul ) Hype ensi e hea disease 0 ·· ·· 85 ·· ·· ·· No Yes Yes Yes 2 High body-mass index (adul ) A ial ib illa ion and lu e 0 ·· ·· 5 0 ·· ·· ·· No Yes Yes 2 High body-mass index (adul ) As hma 0 ·· ·· 7 0 ·· ·· ·· Yes Yes No 2 High body-mass index (adul ) Alzheime ’s disease and o he demen ias 0 ·· ·· 6 0 ·· ·· ·· No Yes No 2 High body-mass index (adul ) Gallbladde disease 0 ·· ·· 16 0 ·· ·· ·· Yes Yes Yes 2 High body-mass index (adul ) Diabe es melli us 0 ·· ·· 85 .. ·· ·· Yes Yes Yes No 2 High body-mass index (adul ) Ch onic kidney disease 0 ·· ·· 57 ·· ·· ·· No Yes Yes No 2 High body-mass index (adul ) Os eoa h i is 0 ·· ·· 32 0 ·· ·· No Yes Yes Yes 2 High body-mass index (adul ) Low back pain 0 ·· ·· 5 0 ·· ·· No Yes Yes Yes 2 High body-mass index (adul ) Gou 0 ·· ·· 10 0 ·· ·· .. Yes Yes No 2 High body-mass index (adul ) Ca a ac 0 ·· ·· 17 0 ·· ·· .. Yes Yes No 2 High body-mass index (child) As hma 0 ·· ·· 5 0 ·· ·· No Yes Yes No 2 Low bone mine al densi y Inju ies 0 ·· ·· 12 .. ·· ·· No Yes Yes Yes 2 Impai ed kidney unc ion Ischaemic hea disease 0 ·· ·· 6 0 ·· ·· Yes ·· Yes Yes 2 Impai ed kidney unc ion Ischaemic s oke 0 ·· ·· 6 0 ·· ·· Yes ·· Yes Yes 2 Impai ed kidney unc ion Haemo hagic s oke 0 ·· ·· 8 0 ·· ·· Yes ·· Yes Yes 2 Impai ed kidney unc ion Pe iphe al ascula disease 0 ·· ·· 5 0 ·· ·· Yes ·· Yes Yes 2 Impai ed kidney unc ion Gou 0 ·· ·· 3 0 0 0 Yes ·· Yes No I mul iple epo s exis ed om he same s udy, we coun ed hem as one s udy. We only assessed he dose– esponse ela ionship o con inuous isks. To e alua e he magni ude o he e ec size o con inuous isks, we e alua ed he ela i e isk compa ing he 75 h pe cen ile wi h he 25 h pe cen ile o he exposu e dis ibu ion a he global le el. RCT= andomised con olled ial. RR= ela i e isk. *P ospec i e coho s udies o non- andomised in e en ions. †Case-con ol s udies we e included o hose isk-ou come pai s whe e he sum o RCT and p ospec i e obse a ional s udies included was less han i e (whe e applicable). ‡Whe he o no any biological o mechanis ic pa hway exis s ha could po en ially explain he ela ionship o he isk-ou come pai . §Whe he o no he isk is associa ed wi h ano he ou come om he same ca ego y and whe he o no any e idence exis s ha i can cause he cu en ou come h ough he same pa hway. Table 1: Desc ip i e ca aloguing o he epidemiological e idence used o assess whe he each isk-ou come pape mee s he causal c i e ia o inclusion in he Global Bu den o Disease S udy 2016 by isk le el Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1361 Risk ac o s Exposu e de ini ion Theo e ical minimum isk exposu e le el Da a ep esen a i eness index <2006 2006–16 To al 0 All ·· ·· 100·0% 100·0% 100·0% 1 En i onmen al and occupa ional isks ·· ·· 100·0% 100·0% 100·0% 2Unsa e wa e , sani a ion, and handwashing ·· ·· 58·0% 75·4% 70·0% 3Unsa e wa e sou ce P opo ion o households wi h access o di e en wa e sou ces (unimp o ed, imp o ed excep piped, piped wa e supply) and epo ed use o household wa e ea men me hods (boiling o il e ing, chlo ina ing o sola il e ing, no ea men ) All households ha e access o wa e om a piped wa e supply ha is also boiled o il e ed be o e d inking 70·1% 88·4% 83·5% 3 Unsa e sani a ion P opo ion o households wi h access o di e en sani a ion acili ies (unimp o ed, imp o ed excep sewe , sewe connec ion) All households ha e access o oile s wi h sewe connec ion 69·5% 88·4% 83·5% 3 No access o handwashing acili y P opo ion o households wi h access o handwashing acili y wi h soap, wa e , and wash s a ion All households ha e access o handwashing acili y wi h soap, wa e , and wash s a ion 10·3% 33·3% 35·4% 2 Ai pollu ion ·· ·· 100·0% 100·0% 100·0% 3 Ambien pa icula e ma e pollu ion Annual a e age daily exposu e o ou doo ai concen a ions o PM2·5 Uni o m dis ibu ion be ween 2·4 µg/m³ and 5·9 µg/m³ 23·1% 56·9% 78·0% 3 Household ai pollu ion om solid uels Indi idual exposu e o PM2·5 due o use o solid cooking uels No households a e exposed o excess indoo concen a ion o pa icles om solid uel use (assuming PM2·5 in no uel use is consis en wi h a TMREL o 2·4–5·9) 72·8% 59·5% 76·4% 3Ambien ozone pollu ion Seasonal (3 mon h) hou ly maximum ozone concen a ions, measu ed in ppb Uni o m dis ibu ion be ween 33·3 µg/m³ and 41·9 µg/m³, acco ding o minimum/5 h pe cen concen a ions 100·0% 100·0% 100·0% 2 O he en i onmen al isks ·· ·· 48·7% 26·2% 51·8% 3 Residen ial adon A e age daily exposu e o indoo ai adon le els measu ed in becque els ( adon disin eg a ions pe second) pe cubic me e (Bq/ m³) 10 Bq/m³, co esponding o he ou doo concen a ion o adon 39·0% 0·0% 39·0% 3 Lead exposu e Blood lead le els in µg/dL o blood, bone lead le els in µg/g o bone 2 ug/dL, co esponding o lead le els in p e-indus ial humans as na u al sou ces o lead p e en he easibili y o ze o exposu e 37·4% 26·2% 43·6% 2 Occupa ional isks ·· ·· 92·3% 90·8% 100·0% 3 Occupa ional ca cinogens ·· ·· 86·7% 85·6% 92·8% 4Occupa ional exposu e o asbes os P opo ion o he popula ion wi h cumula i e exposu e o asbes os No occupa ional exposu e o asbes os 82·6% 74·9% 87·2% 4Occupa ional exposu e o a senic P opo ion o he popula ion e e exposed o a senic a wo k o h ough hei occupa ion No occupa ional exposu e o a senic 82·6% 74·9% 87·2% 4Occupa ional exposu e o benzene P opo ion o he popula ion e e exposed o benzene a wo k o h ough hei occupa ion No occupa ional exposu e o benzene 82·6% 74·9% 87·2% 4Occupa ional exposu e o be yllium P opo ion o he popula ion e e exposed o be yllium a wo k o h ough hei occupa ion No occupa ional exposu e o be yllium 82·6% 74·9% 87·2% 4Occupa ional exposu e o cadmium P opo ion o he popula ion e e exposed o cadmium a wo k o h ough hei occupa ion No occupa ional exposu e o cadmium 82·6% 74·9% 87·2% 4Occupa ional exposu e o ch omium P opo ion o he popula ion e e exposed o ch omium a wo k o h ough hei occupa ion No occupa ional exposu e o ch omium 82·6% 74·9% 87·2% 4Occupa ional exposu e o diesel engine exhaus P opo ion o he popula ion e e exposed o diesel engine exhaus a wo k o h ough hei occupa ion No occupa ional exposu e o diesel engine exhaus 82·6% 74·9% 87·2% 4Occupa ional exposu e o second-hand smoke P opo ion o he popula ion e e exposed o second-hand smoke a wo k o h ough hei occupa ion No occupa ional exposu e o second- hand smoke 82·6% 74·9% 87·2% 4Occupa ional exposu e o o maldehyde P opo ion o he popula ion e e exposed o o maldehyde a wo k o h ough hei occupa ion No occupa ional exposu e o o maldehyde 82·6% 74·9% 87·2% 4Occupa ional exposu e o nickel P opo ion o he popula ion e e exposed o nickel a wo k o h ough hei occupa ion No occupa ional exposu e o nickel 82·6% 74·9% 87·2% 4Occupa ional exposu e o polycyclic a oma ic hyd oca bons P opo ion o he popula ion e e exposed o polycyclic a oma ic hyd oca bons a wo k o h ough hei occupa ion No occupa ional exposu e o polycyclic a oma ic hyd oca bons 82·6% 74·9% 87·2% (Table 2 con inues on nex page) Global Heal h Me ics 1362 www. helance .com Vol 390 Sep embe 16, 2017 Risk ac o s Exposu e de ini ion Theo e ical minimum isk exposu e le el Da a ep esen a i eness index <2006 2006–16 To al (Con inued om p e ious page) 4Occupa ional exposu e o silica P opo ion o he popula ion e e exposed o silica a wo k o h ough hei occupa ion No occupa ional exposu e o silica 82·6% 74·9% 87·2% 4Occupa ional exposu e o sul u ic acid P opo ion o he popula ion e e exposed o sul u ic acid a wo k o h ough hei occupa ion No occupa ional exposu e o sul u ic acid 80·5% 73·3% 85·1% 4Occupa ional exposu e o ichlo oe hylene P opo ion o he popula ion e e exposed o ichlo e hylene a wo k o h ough hei occupa ion No occupa ional exposu e o ichlo oe hylene 80·5% 73·3% 85·1% 3 Occupa ional as hmagens P opo ion o he popula ion cu en ly exposed o as hmagens a wo k o h ough hei occupa ion Backg ound as hmagen exposu es 82·6% 74·9% 87·2% 3 Occupa ional pa icula e ma e , gases, and umes P opo ion o he popula ion e e exposed o pa icula es, gases, o umes a wo k o h ough hei occupa ion No occupa ional exposu e o pa icula es, gases, o umes 83·6% 75·9% 88·2% 3 Occupa ional noise P opo ion o he popula ion e e exposed o noise g ea e han 85 dB a wo k o h ough hei occupa ion Backg ound noise exposu e 83·6% 75·9% 88·2% 3 Occupa ional inju ies P opo ion o he popula ion a isk o inju ies ela ed o wo k o h ough hei occupa ion The a e o inju y dea hs pe 100 000 pe son-yea s is ze o 82·6% 75·4% 87·2% 3 Occupa ional e gonomic ac o s P opo ion o he popula ion who a e exposed o e gonomic isk ac o s o low back pain a wo k o h ough hei occupa ion All indi iduals ha e he e gonomic ac o s o cle ical and ela ed wo ke s 82·6% 74·9% 87·2% 1 Beha iou al isks ·· ·· 100·0% 100·0% 100·0% 2 Child and ma e nal malnu i ion ·· ·· 100·0% 100·0% 100·0% 3 Subop imal b eas eeding ·· ·· 67·1% 54·6% 73·9% 4 Non-exclusi e b eas eeding P opo ion o child en younge han 6 mon hs who ecei e p edominan , pa ial, o no b eas eeding All child en a e exclusi ely b eas ed o i s 6 mon hs o li e 67·1% 54·6% 73·9% 4 Discon inued b eas eeding P opo ion o child en aged 6–23 mon hs who do no ecei e any b eas milk All child en con inue o ecei e b eas milk un il 2 yea s o age 68·1% 65·3% 79·2% 3 Child g ow h ailu e ·· ·· 5·6% 0·0% 5·6% 4Child unde weigh P opo ion o child en less han –3 SD, –3 o –2 SD, and –2 o –1 SDs o he WHO 2006 s anda d weigh - o -age cu e All child en a e abo e –1 SD o WHO 2006 s anda d weigh - o -age cu e 77·4% 65·1% 81·0% 4Child was ing P opo ion o child en less han –3 SD, –3 o –2 SDs, and –2 o –1 SD o he WHO 2006 s anda d weigh - o -leng h cu e All child en a e abo e –1 SD o WHO 2006 s anda d weigh - o -heigh cu e 78·0% 66·2% 82·1% 4 Child s un ing P opo ion o child en less han –3 SD, –3 o –2 SD, and –2 o –1 SD o he WHO 2006 s anda d heigh - o -age cu e All child en a e abo e –1 SD o WHO 2006 s anda d heigh - o -age cu e 78·0% 66·2% 82·1% 3 Low bi hweigh and sho ges a ion ·· ·· 3·6% 16·4% 18·0% 4 Sho ges a ion o bi hweigh P opo ion o bi hs occu ing in 2 week bands s a ing om <24 weeks o 39–40 weeks 40–41 weeks ges a ion 3·6% 16·4% 18·0% 4 Low bi hweigh o ges a ion P opo ion o bi hs occu ing in 500 g ca ego ies s a ing om <500 g o 4000–4499 g 4500–4999 g bi hweigh 3·6% 16·4% 18·0% 3I on de iciency Pe iphe al blood haemoglobin concen a ion in g/L Coun e ac ual haemoglobin concen a ion in he abscence o i on de iciency in g/L 81·5% 44·1% 85·1% 3Vi amin A de iciency P opo ion o child en aged 0–5 yea s wi h se um e inol concen a ion <0·7 µmol/L No childhood i amin A de iciency 54·9% 44·1% 56·4% 3Zinc de iciency P opo ion o he popula ion wi h inadequa e zinc in ake e sus loss No inadequa e zinc in ake 94·9% 93·3% 94·9% 2Tobacco ·· ·· 98·0% 100·0% 100·0% 3 Smoking Smoking Impac Ra io me hod: cumula i e exposu e o smoked obacco p oduc s, p oxied by excess lung cance mo ali y; di ec smoking: 5 yea lagged p opo ion o he popula ion who cu en ly smoke daily All indi iduals a e li elong non-smoke s 92·8% 96·9% 99·0% 3Smokeless obacco Cu en use o any smokeless obacco p oduc All indi iduals a e li elong non-use s o smokeless obacco p oduc s 34·4% 70·8% 73·3% 3 Second-hand smoke A e age daily exposu e o ai pa icula e ma e in he home om second-hand smoke wi h an ae odynamic diame e smalle han 2·5 µg, measu ed in µg/m3, among non-smoke s li ing wi h a cu en daily smoke No second-hand smoke exposu e 73·9% 67·7% 90·8% 2Alcohol and d ug use ·· ·· 54·9% 62·6% 79·0% (Table 2 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1363 Risk ac o s Exposu e de ini ion Theo e ical minimum isk exposu e le el Da a ep esen a i eness index <2006 2006–16 To al (Con inued om p e ious page) 3Alcohol use A e age daily alcohol consump ion o pu e alcohol (measu ed in g pe day) in cu en d inke s who had consumed alcohol du ing he pas 12 mon hs; binge d inking: p opo ion o he popula ion epo ing binge consump ion o a leas 60 g o males and 48 g o emales o pu e alcohol on a single occasion No alcohol consump ion 52·3% 45·6% 69·7% 3D ug use P opo ion o he popula ion dependen upon opioids, cannabis, cocaine, o amphe amines; p opo ion o he popula ion who ha e e e injec ed d ugs No d ug use 20·5% 37·4% 43·1% 2 Die a y isks ·· ·· 100·0% 100·0% 100·0% 3 Die low in ui s A e age daily consump ion o ui s ( esh, ozen, cooked, canned, o d ied ui s, excluding ui juices and sal ed o pickled ui s) Consump ion o ui be ween 200 g and 300 g pe day 94·9% 94·9% 94·9% 3 Die low in ege ables A e age daily consump ion o ege ables ( esh, ozen, cooked, canned, o d ied ege ables, excluding legumes and sal ed o pickled ege ables, juices, nu s, and seeds, and s a chy ege ables such as po a oes o co n) Consump ion o ege ables be ween 290 g and 430 g pe day 100·0% 100·0% 100·0% 3 Die low in legumes A e age daily consump ion o legumes ( esh, ozen, cooked, canned, o d ied legumes) Consump ion o legumes be ween 50 g and 70 g pe day 100·0% 100·0% 100·0% 3 Die low in whole g ains A e age daily consump ion o whole g ains (b an, ge m, and endospe m in hei na u al p opo ion) om b eak as ce eals, b ead, ice, pas a, biscui s, mu ins, o illas, pancakes, and o he sou ces Consump ion o whole g ains be ween 100 g and 150 g pe day 15·9% 13·9% 20·0% 3 Die low in nu s and seeds A e age daily consump ion o nu and seed oods Consump ion o nu s and seeds be ween 16 g and 25 g pe day 100·0% 100·0% 100·0% 3 Die low in milk A e age daily consump ion o milk including non- a , low- a , and ull- a milk, excluding soy milk and o he plan de i a i es Consump ion o milk be ween 350 g and 520 g pe day 100·0% 100·0% 100·0% 3 Die high in ed mea A e age daily consump ion o ed mea (bee , po k, lamb, and goa bu excluding poul y, ish, eggs, and all p ocessed mea s) Consump ion o ed mea be ween 18 g and 27 g pe day 100·0% 100·0% 100·0% 3 Die high in p ocessed mea A e age daily consump ion o mea p ese ed by smoking, cu ing, sal ing, o addi ion o chemical p ese a i es Consump ion o p ocessed mea be ween 0 g and 4 g pe day 100·0% 100·0% 100·0% 3 Die high in suga -swee ened be e ages A e age daily consump ion o be e ages wi h ≥50 kcal pe 226·8 g se ing, including ca bona ed be e ages, sodas, ene gy d inks, ui d inks, bu excluding 100% ui and ege able juices Consump ion o suga -swee ened be e ages be ween 0 g and 5 g pe day 34·9% 30·3% 36·9% 3 Die low in ib e A e age daily in ake o ib e om all sou ces including ui s, ege ables, g ains, legumes, and pulses Consump ion o ib e be ween 19 g and 28 g pe day 100·0% 100·0% 100·0% 3 Die low in calcium A e age daily in ake o calcium om all sou ces, including milk, yogu , and cheese Consump ion o calcium be ween 1·00 g and 1·50 g pe day 100·0% 100·0% 100·0% 3 Die low in sea ood omega 3 a y acids A e age daily in ake o eicosapen aenoic acid and docosahexaenoic acid Consump ion o sea ood omega 3 a y acids be ween 200 mg and 300 mg pe day 100·0% 100·0% 100·0% 3 Die low in polyunsa u a ed a y acids A e age daily in ake o omega 6 a y acids om all sou ces, mainly liquid ege able oils, including soybean oil, co n oil, and sa lowe oil Consump ion o polyunsa u a ed a y acids be ween 9% and 13% o o al daily ene gy 96·9% 94·9% 96·9% 3 Die high in ans a y acids A e age daily in ake o ans a om all sou ces, mainly pa ially hyd ogena ed ege able oils and uminan p oduc s Consump ion o ans a y acids be ween 0% and 1% o o al daily ene gy 37·4% 38·5% 38·5% 3 Die high in sodium 24 h u ina y sodium measu ed in g pe day 24 h u ina y sodium be ween 1 g and 5 g pe day 15·9% 21·5% 26·2% 2 Sexual abuse and iolence ·· ·· 68·2% 78·0% 87·2% 3 Childhood sexual abuse P opo ion o he popula ion e e ha ing had he expe ience o in e cou se o o he con ac abuse (ie, ondling and o he sexual ouching) when aged 15 yea s o younge , and he pe pe a o o pa ne was mo e han 5 yea s olde han he ic im No childhood sexual abuse 31·8% 18·5% 38·0% 3 In ima e pa ne iolence P opo ion o he popula ion who ha e e e expe ienced one o mo e ac s o physical o sexual iolence by a p esen o o me in ima e pa ne since age 15 yea s No in ima e pa ne iolence 67·2% 76·4% 86·2% 2 Unsa e sex P opo ion o he popula ion wi h exposu e o sexual encoun e s ha con ey he isk o disease No exposu e o a disease agen h ough sex 14·9% 51·3% 51·8% 2 Low physical ac i i y A e age weekly physical ac i i y a wo k, home, anspo - ela ed, and ec ea ional measu ed by MET min pe week All adul s expe ience 3000–4500 MET min pe week 52·3% 35·9% 67·2% (Table 2 con inues on nex page) Global Heal h Me ics 1364 www. helance .com Vol 390 Sep embe 16, 2017 We made se e al imp o emen s in he p ocess o es ima ing he bu den o disease a ibu able o die a y isks. To imp o e he quali y and co e age o ou die a y es ima es, we sys ema ically sea ched li e a u e o na ionally o subna ionally ep esen a i e s udies p o- iding in o ma ion on consump ion o each die a y ac o . We also made a sys ema ic e o o ob ain indi idual-le el da a o consump ion o die a y ac o s; e-ex ac ed da a om all a ailable sou ces; and s anda dised he de ini ion o die a y ac o s ac oss di e en sou ces. To cap u e ecen ends in consump ion, we used da a on sales o di e en esh and packaged oods o in o m ou es ima es. To add ess he conce ns o e wi hin-pe son a ia ion in in ake, we es ima ed usual in ake o each die a y ac o and used ha o es ima e he a ibu able disease bu den. To make he cu en and op imal le els o in ake mo e compa able, we used absolu e in ake o each die a y ac o ( a he han in ake s anda dised o 2000 kcal pe day). Fo mo e de ail, see appendix 1 (p 117). The e we e wo subs an ial changes in he es ima ion o second-hand smoke compa ed wi h GBD 2015. Fi s , we es ima ed he p opo ion o a popula ion exposed o second- hand smoke using in o ma ion abou household composi ion and smoking s a us om household su eys and censuses, a he han using ques ions ha ask di ec ly abou exposu e o second-hand smoke in su eys. Second, we modelled exposu e using spa io empo al Gaussian p ocess eg ession (ST-GPR), bo owing s eng h ac oss sexes and all ages, whe eas in GBD 2015 we an a DisMod model sepa a ely by sex and age. Fu he , we ound signi ican e idence o associa ions be ween second-hand smoke exposu e and wo addi ional ou comes: b eas cance and diabe es, which we e added o he lis o isk-ou come pai s o second-hand smoke. Mo e de ails on he es i- ma ion app oach a e p esen ed in appendix 1 (p 98). Fo he i s ime in he GBD s udy, we es ima ed exposu e o and bu den a ibu able o smokeless obacco, de ined as cu en use o any smokeless obacco p oduc . RR es ima es we e de i ed om p ospec i e coho s udies and case-con ol s udies and a y depending on he ype o p oduc used. Based on a ailable e idence, o chewing obacco RRs we e signi ican ly highe han one o o al cance and oesophageal cance , while o snus o snu we did no ind su icien e idence o a RR g ea e han one o any heal h ou come. Addi ional de ails on he es ima ion me hods and RRs a e p esen ed in appendix 1 (p 11, p 181). Low bi hweigh o ges a ion and sho ges a ion o bi hweigh a e included as new isk ac o s o GBD 2016. The es ima ion has been pa ame e ised o be poly omous by 500 g and 2 week ca ego ies. Low bi hweigh and ges a ional age a e highly co ela ed isks and hey a e es ima ed in a comple ely in e dependen manne . Fo each uni a ia e analysis, iden i ica ion o TMREL and calcula ion o PAFs is con ingen on he o he dimension. In o he wo ds, we ound he lowes isk bi hweigh ca ego y o each 2 week ges a ional age band and, co espondingly, he lowes isk ges a ional age o each 500 g bi hweigh band. RRs we e hen es ima ed o each 500 g pe 2 week bin. Exposu e o each bin was es ima ed in h ee s eps. Fi s , we es ima ed by gene a ing ensemble dis ibu ion es ima es using modelled mean and ca ego ical p e alence es ima es o each o bi hweigh (mean, % <2500 g) and ges a ional age (mean, % <37 weeks, % <28 weeks) o each loca ion, yea , and sex. Second, we e alua ed all mic oda a whe e bo h ges a ional age and bi hweigh we e a ailable and ound a high deg ee o consis ency in he co ela ion be ween hem. Thi d, we ook he pooled co ela ion coe icien om s ep 2 combined wi h uni a ia e ensemble dis ibu ions om s ep 1 and used a copula linking unc ion o simula e he join dis ibu ion which was hen summa ised in o each 500 g pe 2 week ca ego y. Join PAF calcula ion used a TMREL de ined as he lowes o e all isk o he en i e ma ix o bi hweigh and ges a ional age (see appendix1 p 77 o mo e de ails). Risk ac o s Exposu e de ini ion Theo e ical minimum isk exposu e le el Da a ep esen a i eness index <2006 2006–16 To al (Con inued om p e ious page) 1 Me abolic isks ·· ·· 100·0% 100·0% 100·0% 2 High as ing plasma glucose Se um as ing plasma glucose measu ed in mmol/L 4·8–5·4 mmol/L 51·8% 53·3% 69·7% 2High o al choles e ol Se um o al choles e ol, measu ed in mmol/L 2·78–3·38 mmol/L 59·0% 48·2% 78·0% 2 High sys olic blood p essu e Sys olic blood p essu e, measu ed in mmHg 110–115 mm Hg 64·1% 65·1% 83·6% 2 High body-mass index Body-mass index, measu ed in kg/m² 25 kg/m² 91·3% 100·0% 100·0% 2 Low bone mine al densi y S anda dised mean bone mine al densi y alues measu ed by dual x- ay abso p iome y a he emo al neck in g/cm² 99 h pe cen ile o NHANES 2005–14 by age and sex 33·3% 12·3% 35·9% 2 Impai ed kidney unc ion P opo ion o he popula ion wi h ACR >30 mg/g and/o GFR <60 mL/min pe 1·73m², excluding end-s age enal disease ACR <30 mg/g and GFR >60 mL/min pe 1·73m² 10·3% 0·0% 10·3% GBD=Global Bu den o Disease. MET=me abolic equi alen . NHANES=Na ional Heal h and Nu i ion Examina ion Su ey. PM2.5=pa icula e ma e wi h an ae odynamic diame e smalle han 2·5 µm, measu ed in μg/m³. TMREL= heo e ical minimum isk exposu e le el. ppb=pa s pe billion. ACR=albumin- o-c ea ine a io. GFR=glome ula il a ion a e. Table 2: GBD 2016 isk ac o hie a chy and accompanying exposu e de ini ions, heo e ical minimum isk exposu e le el, and da a ep esen a i eness index o each isk ac o , p e-2006, 2006–16, and o al (ac oss all yea s) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1365 Media ion In GBD 2016, we upda ed ou app oach o es ima ion o he join e ec s o combina ions o isk ac o s (appendix 1 p 23). Using indi idual-le el da a om p ospec i e coho s udies, we es ima ed he p opo ion o he e ec o beha iou al isks on ca diome abolic ou comes media ed h ough me abolic isk ac o s. We also es ima ed he p opo ion o he e ec o each me abolic isk ac o on ca diome abolic ou comes media ed h ough o he me abolic isks. Fo each media ion pa hway, we only included he media o s o which su icien e idence exis ed o hei causal ela ionship wi h he disease endpoin . Explaining he d i e s o ends in dea hs and DALYs As in GBD 2015, we unde ook a decomposi ion analysis o changes in DALYs o e he ime pe iod in o ou main componen s, namely, changes in DALYs due o changes in: (1) popula ion g ow h; (2) popula ion age s uc u e; (3) exposu e o all isks o a disease; and (4) all o he ac o s combined, app oxima ed as he isk-dele ed dea h and DALY a es. Risk-dele ed a es e e s o dea h and DALY a es ha would be obse ed i we emo ed all isk ac o s included in GBD 2016, es ima ed as DALY a es mul iplied by one minus he PAF o he se o isks. We used me hods de eloped by Das Gup a,19 bu as he me hods p esen ed he e do no esul in he decomposi ion esul s being linea agg ega es o e ime o isk, we adap ed hese me hods u he in GBD 2016. Ou decomposi ion analysis was unde aken o each 5 yea ime pe iod, a he all- isk le el, aking in o accoun isk media ion a he mos de ailed cause le el. The con ibu ion o changes in exposu e o he indi idual isks was scaled o he all- isk e ec a he mos de ailed ou come le el. The con ibu ion o isk exposu es o e longe ime pe iods—eg, 2000–16—o a highe cause agg ega es—eg, all cause—we e calcula ed as he linea agg ega e o he e ec o indi idual isks a he mos de ailed cause le el and ime pe iod. Risk ansi ion wi h de elopmen We explo ed how exposu e o isks a ies ac oss le els o de elopmen using he SDI, a composi e indica o o de elopmen s a us cons uc ed o GBD 2015 whose componen s a e s ongly co ela ed wi h heal h ou comes. I is he geome ic mean o 0 o 1 o indices o o al e ili y a e, mean educa ion o hose aged 15 yea s and olde , and lag-dis ibu ed income pe capi a. Mo e de ails on he es ima ion o SDI can be ound in appendix 1 (p 32). Role o he unding sou ce The unde s o he s udy had no ole in he s udy design, da a collec ion, da a analysis, da a in e p e a ion, o w i ing o he epo . The au ho s had ull access o all da a in he s udy and had inal esponsibili y o he decision o submi o publica ion. Resul s Global exposu e o isks F om 1990 o 2016, ends in SEVs a ied ac oss he se o isk ac o s included in GBD 2016. O no e, SEVs dec eased by mo e han 40% o h ee isks: die high in ans a y acids (51·3% [95% UI 34·1–70·1]), household ai pollu ion om solid uels (43·1% [40·7–45·6]), and unsa e sani a ion (40·3% [35·5–44·7]; able 3, appendix 2 p 1399). Du ing he same pe iod, SEVs inc eased by mo e han 40% o high body-mass index (BMI; 60·2% [45·1–79·1]), die high in suga -swee ened be e ages (44·7% [36·1–52·7]), occu- pa ional exposu e o diesel engine exhaus (41·8% [41·3–42·2]), and occupa ional exposu e o ichlo o- e hylene (40·6% [40·2–41·1]). Ac oss coun ies he e is subs an ial a ia ion in isk exposu e by le el o SDI. Some isk ac o s, such as high as ing plasma glucose (FPG) and high sys olic blood p essu e, show simila SEVs ac oss le els o SDI, while o he s, including household ai pollu ion and unsa e wa e sou ce, show ma ked ends wi h sociodemog aphic de elopmen . Figu e 1 shows he ela ionship be ween SEVs and SDI o he leading h ee me abolic, beha iou al, and en i onmen al and occupa ional isk ac o s and how ha changed be ween 1990 and 2016. Wi hin leading me abolic isks (high BMI, high FPG, and high sys olic blood p essu e [SBP]), isk-weigh ed exposu e shows an inc easing end wi h inc easing SDI o only high BMI. O e all, he SEV o high BMI has inc eased du ing he ime pe iod. Looking a he leading h ee en i onmen al isk ac o s (ambien ai pollu ion, household ai pollu ion, and unsa e wa e ), igu e 2 shows an in e se ela ionship wi h SDI o household ai pollu ion and unsa e wa e , wi h SEVs app oaching ze o a high le els o SDI, while he ela ionship is less consis en wi h ambien ai pollu ion. Finally, he ela ionship be ween SDI and he leading beha iou al isk ac o s is mo e he e ogeneous, wi h smoking and alcohol use ha ing a posi i e co ela ion wi h SDI, and sho ges a ion o bi hweigh ha ing a nega i e co ela ion wi h SDI. Global a ibu able bu den o all isk ac o s combined and hei o e lap Globally, 59·9% (58·4–61·3) o dea hs and 45·2% (43·2–47·3) o DALYs could be a ibu ed o he isk ac o s assessed in GBD 2016. Fo dea hs, non-communicable diseases (NCDs) show he la ges p opo ion a ibu able o measu ed isk ac o s, a 64·4% (62·6–66·2), wi h communicable, ma e nal, neona al, and nu i ional (CMNN) causes a 57·9% (55·4–61·0), and inju ies a 25·8% (23·7–27·8). The pic u e was di e en o DALYs, howe e , whe e we obse ed ha 58·2% (56·4–60·3) o DALYs in CMNN causes a e a ibu able o isk ac o s, compa ed wi h 43·5% (40·7–46·7) in NCDs and 21·0% (19·3–22·7) o inju ies. Leading causes o DALYs in CMNN causes, such as dia hoea and lowe espi a o y in ec ions (LRI), also showed mo e han 80% o DALYs can be a ibu ed o isk ac o s (appendix 2 p 1). Global Heal h Me ics 1366 www. helance .com Vol 390 Sep embe 16, 2017 Risk Male Female Combined pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 1 En i onmen al and occupa ional isks 2 Unsa e wa e , sani a ion, and handwashing 3Unsa e wa e sou ce 23·27 (15·57 o 26·55) 21·27 (14·30 o 24·21) 20·08 (13·47 o 22·83) –8·61 (–10·54 o –6·62)* –5·61 (–7·29 o –3·75)* –13·74 (–15·78 o –11·37)* 22·94 (15·32 o 26·19) 21·12 (14·19 o 24·03) 20·04 (13·45 o 22·79) –7·96 (–9·87 o –6·01)* –5·08 (–6·76 o –3·25)* –12·64 (–14·67 o –10·28)* –13·14 (–15·18 o –10·78)* 3 Unsa e sani a ion 56·46 (53·29 o 60·79) 42·29 (38·91 o 46·94) 33·26 (29·47 o 38·52) –25·10 (–28·04 o –22·10)* –21·36 (–25·52 o –17·53)* –41·10 (–45·39 o –36·37)* 55·13 (51·99 o 59·44) 41·91 (38·53 o 46·70) 33·34 (29·49 o 38·67) –23·97 (–27·05 o –20·77)* –20·45 (–24·51 o –16·63)* –39·51 (–44·05 o –34·59)* –40·28 (–44·73 o –35·47)* 3No access o handwashing acili y 36·22 (35·56 o 36·95) 34·57 (34·00 o 35·14) 33·13 (32·66 o 33·62) –4·57 (–6·31 o –2·72)* –4·15 (–5·29 o –2·89)* –8·53 (–10·53 o –6·29)* 35·82 (35·15 o 36·53) 34·54 (33·98 o 35·11) 33·34 (32·87 o 33·83) –3·57 (–5·34 o –1·69)* –3·46 (–4·64 o –2·22)* –6·91 (–8·94 o –4·61)* –7·67 (–9·69 o –5·40)* 2 Ai pollu ion 3 Ambien pa icula e ma e pollu ion 44·42 (37·19 o 53·39) 45·74 (38·10 o 54·89) 49·56 (41·42 o 58·71) 2·96 (1·88 o 3·97)* 8·37 (6·79 o 9·43)* 11·57 (9·47 o 13·51)* 43·79 (36·57 o 52·71) 45·00 (37·47 o 54·11) 48·87 (40·79 o 58·02) 2·76 (1·69 o 3·76)* 8·58 (6·98 o 9·69)* 11·58 (9·44 o 13·55)* 11·60 (9·48 o 13·56)* 3 Household ai pollu ion om solid uels 34·05 (27·33 o 41·50) 25·65 (20·30 o 31·36) 18·95 (14·97 o 23·48) –24·66 (–27·07 o –22·55)* –26·12 (–28·68 o –23·75)* –44·33 (–47·18 o –41·84)* 35·67 (30·59 o 40·81) 27·57 (23·56 o 31·88) 20·69 (17·54 o 24·11) –22·71 (–24·92 o –20·85)* –24·95 (–27·24 o –22·68)* –42·00 (–44·45 o –39·54)* –43·14 (–45·63 o –40·73)* 3Ambien ozone pollu ion 38·49 (13·87 o 68·02) 43·30 (15·71 o 74·16) 48·75 (18·05 o 78·30) 12·50 (8·84 o 14·03)* 12·57 (5·92 o 15·54)* 26·63 (15·49 o 31·29)* 38·22 (13·78 o 67·36) 42·66 (15·45 o 73·25) 47·94 (17·71 o 77·40) 11·61 (8·35 o 12·94)* 12·39 (5·99 o 15·22)* 25·44 (15·05 o 29·65)* 26·03 (15·27 o 30·47)* 2 O he en i onmen al isks 3 Residen ial adon 26·12 (22·17 o 30·31) 26·08 (22·09 o 30·34) 26·17 (22·17 o 30·54) –0·12 (–1·27 o 1·03) 0·34 (–0·24 o 0·98) 0·22 (–1·41 o 1·95) 26·27 (22·33 o 30·45) 26·23 (22·25 o 30·48) 26·34 (22·32 o 30·69) –0·12 (–1·32 o 1·09) 0·41 (–0·22 o 1·10) 0·29 (–1·45 o 2·12) 0·25 (–1·43 o 2·04) 3Lead exposu e 20·01 (8·93 o 33·97) 18·57 (8·35 o 31·87) 15·01 (6·28 o 27·06) –7·19 (–10·97 o –4·90)* –19·20 (–25·88 o –14·37)* –25·01 (–32·80 o –18·88)* 10·27 (2·82 o 21·64) 10·18 (3·19 o 21·15) 8·37 (2·47 o 18·17) –0·80 (–4·67 o 13·60) –17·86 (–24·00 o –13·50)* –18·52 (–24·51 o –10·29)* –22·68 (–30·06 o –17·08)* 2 Occupa ional isks 3 Occupa ional ca cinogens 4 Occupa ional exposu e o asbes os 4·11 (3·85 o 4·44) 4·00 (3·76 o 4·30) 3·90 (3·65 o 4·21) –2·68 (–5·60 o –0·17)* –2·41 (–3·52 o –1·46)* –5·03 (–7·49 o –2·85)* 1·47 (1·36 o 1·68) 1·25 (1·17 o 1·40) 1·19 (1·11 o 1·32) –14·74 (–16·66 o –13·21)* –4·97 (–6·27 o –3·53)* –18·98 (–21·23 o –17·53)* –6·91 (–8·97 o –5·07)* 4 Occupa ional exposu e o a senic 0·91 (0·00 o 3·12) 0·96 (0·00 o 3·46) 1·02 (0·00 o 3·75) 6·31 (0·18 o 10·99)* 6·23 (3·89 o 8·29)* 12·94 (4·14 o 20·24)* 0·72 (0·00 o 2·37) 0·81 (0·00 o 2·84) 0·88 (0·00 o 3·16) 11·83 (2·14 o 19·69)* 8·82 (5·35 o 11·33)* 21·70 (8·33 o 33·09)* 16·81 (6·00 o 25·80)* 4 Occupa ional exposu e o benzene 0·77 (0·36 o 1·59) 0·87 (0·44 o 1·74) 0·96 (0·51 o 1·88) 12·93 (9·26 o 21·67)* 10·25 (8·22 o 14·21)* 24·50 (18·21 o 38·83)* 0·65 (0·27 o 1·43) 0·80 (0·37 o 1·68) 0·94 (0·46 o 1·91) 22·92 (17·94 o 37·88)* 17·04 (13·69 o 24·74)* 43·86 (34·03 o 71·79)* 33·27 (25·56 o 52·63)* 4 Occupa ional exposu e o be yllium 0·09 (0·09 o 0·09) 0·10 (0·10 o 0·10) 0·11 (0·11 o 0·11) 10·33 (10·18 o 10·46)* 6·40 (6·30 o 6·51)* 17·39 (17·17 o 17·62)* 0·07 (0·07 o 0·07) 0·08 (0·08 o 0·08) 0·09 (0·09 o 0·09) 23·36 (23·14 o 23·58)* 13·48 (13·35 o 13·61)* 39·99 (39·65 o 40·30)* 26·78 (26·60 o 26·96)* 4 Occupa ional exposu e o cadmium 0·18 (0·18 o 0·18) 0·20 (0·20 o 0·20) 0·22 (0·22 o 0·22) 13·27 (12·96 o 13·59)* 9·35 (9·15 o 9·58)* 23·86 (23·39 o 24·33)* 0·13 (0·13 o 0·14) 0·16 (0·16 o 0·17) 0·19 (0·18 o 0·19) 22·86 (22·14 o 23·54)* 13·76 (13·16 o 14·47)* 39·76 (38·93 o 40·61)* 30·69 (30·23 o 31·19)* 4 Occupa ional exposu e o ch omium 0·38 (0·38 o 0·39) 0·45 (0·44 o 0·45) 0·50 (0·49 o 0·51) 17·37 (17·03 o 17·72)* 11·82 (11·59 o 12·06)* 31·24 (30·77 o 31·73)* 0·28 (0·28 o 0·29) 0·36 (0·35 o 0·37) 0·42 (0·41 o 0·43) 26·61 (25·62 o 27·46)* 16·00 (15·33 o 16·77)* 46·86 (45·96 o 47·74)* 37·94 (37·46 o 38·43)* 4 Occupa ional exposu e o diesel engine exhaus 2·29 (2·26 o 2·32) 2·78 (2·74 o 2·81) 3·11 (3·07 o 3·14) 21·41 (20·94 o 21·81)* 11·86 (11·60 o 12·11)* 35·80 (35·28 o 36·30)* 1·22 (1·20 o 1·23) 1·61 (1·59 o 1·64) 1·86 (1·83 o 1·89) 32·59 (32·10 o 33·07)* 15·19 (14·80 o 15·65)* 52·73 (51·97 o 53·59)* 41·78 (41·29 o 42·22)* (Table 3 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1367 Risk Male Female Combined pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 (Con inued om p e ious page) 4 Occupa ional exposu e o second-hand smoke 12·58 (5·66 o 21·95) 12·96 (5·67 o 22·91) 13·77 (6·00 o 24·44) 3·02 (0·61 o 4·26)* 6·23 (5·39 o 6·83)* 9·44 (6·25 o 11·25)* 10·65 (4·83 o 18·85) 11·47 (5·11 o 20·49) 12·18 (5·39 o 21·86) 7·69 (5·75 o 8·77)* 6·17 (5·33 o 6·69)* 14·33 (11·51 o 15·87)* 11·63 (8·77 o 13·29)* 4 Occupa ional exposu e o o maldehyde 0·79 (0·77 o 0·81) 0·91 (0·88 o 0·93) 1·01 (0·98 o 1·03) 14·91 (14·45 o 15·39)* 10·67 (10·41 o 10·94)* 27·17 (26·49 o 27·88)* 0·57 (0·55 o 0·58) 0·70 (0·67 o 0·72) 0·80 (0·77 o 0·82) 22·93 (21·84 o 23·99)* 14·63 (14·06 o 15·25)* 40·92 (39·83 o 42·05)* 32·87 (32·25 o 33·48)* 4 Occupa ional exposu e o nickel 1·60 (0·00 o 7·78) 1·67 (0·00 o 8·37) 1·75 (0·00 o 8·89) 4·62 (–3·15 o 7·54) 4·52 (1·26 o 6·14)* 9·36 (–1·85 o 14·13) 1·07 (0·00 o 4·86) 1·18 (0·00 o 5·65) 1·27 (0·00 o 6·20) 10·38 (–1·64 o 15·93) 7·75 (3·07 o 10·22)* 18·93 (1·74 o 27·60)* 13·25 (–0·43 o 19·36) 4 Occupa ional exposu e o polycyclic a oma ic hyd oca bons 0·80 (0·79 o 0·81) 0·93 (0·92 o 0·94) 1·05 (1·03 o 1·06) 17·04 (16·72 o 17·34)* 11·89 (11·71 o 12·09)* 30·96 (30·53 o 31·40)* 0·58 (0·58 o 0·59) 0·74 (0·73 o 0·75) 0·86 (0·85 o 0·88) 26·50 (25·77 o 27·17)* 16·77 (16·27 o 17·29)* 47·71 (46·91 o 48·49)* 38·08 (37·65 o 38·52)* 4 Occupa ional exposu e o silica 5·76 (2·34 o 14·58) 5·97 (2·59 o 14·73) 6·21 (2·78 o 15·06) 3·67 (0·97 o 10·72)* 4·05 (2·23 o 7·26)* 7·87 (3·25 o 18·79)* 3·11 (1·19 o 7·93) 3·16 (1·34 o 7·75) 3·29 (1·45 o 7·87) 1·62 (–2·33 o 12·08) 3·98 (1·53 o 8·05)* 5·66 (–0·80 o 21·02) 7·16 (1·90 o 19·77)* 4 Occupa ional exposu e o sul u ic acid 0·93 (0·56 o 1·94) 0·98 (0·63 o 1·95) 1·03 (0·67 o 2·00) 5·70 (0·98 o 11·50)* 4·63 (2·40 o 7·07)* 10·58 (3·34 o 19·35)* 0·68 (0·39 o 1·49) 0·77 (0·48 o 1·57) 0·83 (0·54 o 1·64) 12·54 (5·65 o 22·38)* 7·87 (4·54 o 11·75)* 21·39 (10·34 o 36·35)* 15·18 (6·51 o 26·46)* 4 Occupa ional exposu e o ichlo oe hylene 0·22 (0·22 o 0·22) 0·26 (0·26 o 0·27) 0·30 (0·29 o 0·30) 19·43 (19·07 o 19·87)* 11·90 (11·59 o 12·26)* 33·64 (33·15 o 34·20)* 0·16 (0·16 o 0·16) 0·21 (0·21 o 0·21) 0·24 (0·24 o 0·25) 29·39 (28·28 o 30·19)* 16·04 (15·52 o 16·69)* 50·15 (49·33 o 50·89)* 40·64 (40·23 o 41·07)* 3Occupa ional as hmagens 23·14 (19·26 o 27·93) 23·44 (19·61 o 28·24) 23·97 (20·12 o 28·88) 1·30 (0·28 o 2·38)* 2·28 (1·75 o 2·92)* 3·61 (2·17 o 5·17)* 10·70 (8·71 o 13·08) 12·42 (10·13 o 15·13) 13·39 (10·96 o 16·30) 16·04 (14·27 o 17·83)* 7·80 (7·01 o 8·74)* 25·09 (22·75 o 27·86)* 10·50 (8·62 o 12·32)* 3 Occupa ional pa icula e ma e , gases, and umes 12·28 (9·40 o 16·46) 12·53 (9·64 o 16·72) 12·60 (9·72 o 16·79) 1·99 (1·40 o 2·55)* 0·58 (0·19 o 0·97)* 2·59 (1·76 o 3·42)* 5·59 (4·29 o 7·66) 6·15 (4·78 o 8·35) 6·49 (5·05 o 8·81) 10·01 (8·28 o 11·78)* 5·44 (4·56 o 6·36)* 16·00 (13·53 o 18·35)* 7·30 (5·61 o 8·97)* 3 Occupa ional noise 16·38 (13·89 o 19·41) 16·38 (14·00 o 19·31) 16·21 (13·92 o 18·94) –0·01 (–0·92 o 0·79) –1·06 (–2·04 o –0·40)* –1·07 (–2·82 o 0·37) 7·11 (6·22 o 8·05) 7·94 (6·98 o 8·97) 8·45 (7·45 o 9·52) 11·69 (11·00 o 12·54)* 6·47 (6·09 o 6·87)* 18·92 (17·89 o 20·19)* 5·41 (3·83 o 6·85)* 3 Occupa ional e gonomic ac o s 24·56 (23·13 o 26·22) 24·62 (23·05 o 26·43) 23·44 (22·01 o 25·12) 0·27 (–0·72 o 1·19) –4·79 (–5·10 o –4·46)* –4·54 (–5·47 o –3·62)* 12·46 (11·73 o 13·36) 14·70 (13·80 o 15·80) 15·15 (14·21 o 16·25) 17·95 (16·56 o 19·42)* 3·06 (2·72 o 3·41)* 21·56 (19·97 o 23·25)* 4·31 (3·39 o 5·27)* 1 Beha iou al isks 2 Child and ma e nal malnu i ion 3 Subop imal b eas eeding 4 Non-exclusi e b eas eeding 24·03 (17·85 o 32·14) 22·62 (16·92 o 29·93) 22·72 (17·08 o 29·99) –5·85 (–7·72 o –3·89)* 0·43 (–1·59 o 2·60) –5·45 (–7·72 o –2·66)* 23·99 (17·82 o 32·11) 22·60 (16·88 o 29·95) 22·70 (17·05 o 30·00) –5·79 (–7·61 o –3·86)* 0·42 (–1·54 o 2·61) –5·39 (–7·63 o –2·63)* –5·42 (–7·68 o –2·65)* 4 Discon inued b eas eeding 12·15 (12·04 o 12·30) 11·93 (11·84 o 12·07) 12·75 (12·60 o 12·93) –1·80 (–3·03 o –0·46)* 6·86 (5·55 o 8·28)* 4·94 (3·15 o 6·70)* 12·15 (12·04 o 12·30) 11·89 (11·80 o 12·03) 12·69 (12·53 o 12·86) –2·12 (–3·35 o –0·80)* 6·71 (5·40 o 8·14)* 4·45 (2·68 o 6·18)* 4·70 (2·92 o 6·45)* 3 Child g ow h ailu e 4 Child unde weigh 14·90 (13·04 o 16·56) 12·52 (10·85 o 14·08) 9·19 (7·59 o 10·69) –15·99 (–19·77 o –12·69)* –26·61 (–30·36 o –23·72)* –38·34 (–43·20 o –34·46)* 14·04 (12·19 o 15·73) 11·14 (9·38 o 12·65) 8·41 (6·81 o 9·85) –20·62 (–24·29 o –17·36)* –24·50 (–28·14 o –21·50)* –40·06 (–44·66 o –35·98)* –39·14 (–43·61 o –35·50)* 4Child was ing 8·46 (7·11 o 9·72) 8·39 (7·08 o 9·60) 7·11 (5·84 o 8·33) –0·85 (–3·11 o 1·33) –15·26 (–18·20 o –12·78)* –15·98 (–19·31 o –13·01)* 8·24 (6·88 o 9·49) 7·57 (6·30 o 8·78) 6·54 (5·36 o 7·69) –8·16 (–10·86 o –5·59)* –13·56 (–15·99 o –11·39)* –20·61 (–24·15 o –17·18)* –18·19 (–21·38 o –15·64)* (Table 3 con inues on nex page) Global Heal h Me ics 1368 www. helance .com Vol 390 Sep embe 16, 2017 Risk Male Female Combined pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 (Con inued om p e ious page) 4 Child s un ing 24·71 (17·03 o 27·50) 21·31 (14·80 o 23·95) 17·07 (11·93 o 19·73) –13·77 (–16·16 o –11·88)* –19·86 (–23·55 o –17·01)* –30·90 (–35·38 o –27·56)* 23·49 (16·28 o 26·33) 19·53 (13·62 o 22·16) 15·48 (10·78 o 18·07) –16·82 (–19·62 o –14·76)* –20·77 (–24·47 o –17·65)* –34·10 (–38·80 o –30·53)* –32·40 (–36·66 o –29·30)* 3 Low bi hweigh and sho ges a ion 4 Sho ges a ion o bi hweigh 10·22 (9·52 o 11·09) 10·55 (9·81 o 11·50) 10·78 (10·00 o 11·81) 3·28 (2·71 o 3·92)* 2·16 (1·46 o 3·30)* 5·51 (4·37 o 7·01)* 10·26 (9·44 o 11·25) 10·67 (9·76 o 11·76) 10·92 (9·95 o 12·11) 3·95 (3·26 o 4·71)* 2·34 (1·67 o 3·41)* 6·39 (5·17 o 7·92)* 5·94 (4·95 o 7·21)* 4 Low bi hweigh o ges a ion 8·91 (7·92 o 10·06) 8·73 (7·80 o 9·80) 8·61 (7·71 o 9·64) –2·04 (–3·00 o –1·29)* –1·34 (–1·93 o –0·81)* –3·36 (–4·65 o –2·25)* 9·23 (8·23 o 10·59) 8·93 (8·04 o 10·16) 8·83 (7·96 o 10·03) –3·22 (–4·53 o –2·16)* –1·14 (–1·68 o –0·61)* –4·32 (–5·85 o –2·94)* –3·83 (–5·10 o –2·79)* 3I on de iciency ·· ·· ·· ·· ·· ·· 8·36 (6·25 o 10·98) 8·49 (6·35 o 11·11) 8·52 (6·38 o 11·16) 1·46 (1·27 o 1·69)* 0·39 (0·28 o 0·50)* 1·86 (1·65 o 2·09)* 1·87 (1·67 o 2·11)* 3Vi amin A de iciency 20·37 (16·63 o 24·22) 16·91 (13·58 o 20·19) 15·30 (12·25 o 18·41) –16·99 (–18·83 o –15·00)* –9·55 (–11·66 o –7·57)* –24·92 (–27·67 o –22·08)* 19·12 (15·60 o 22·93) 16·03 (13·04 o 19·14) 14·44 (11·43 o 17·54) –16·16 (–17·99 o –13·29)* –9·90 (–12·40 o –7·72)* –24·46 (–27·62 o –21·13)* –24·69 (–27·48 o –21·70)* 3Zinc de iciency 11·26 (3·33 o 21·64) 9·36 (2·93 o 18·11) 7·96 (2·45 o 15·87) –16·89 (–20·14 o –10·22)* –14·99 (–17·90 o –11·14)* –29·35 (–33·23 o –21·63)* 11·31 (3·29 o 21·72) 9·35 (2·90 o 18·12) 7·96 (2·46 o 15·92) –17·29 (–20·61 o –11·41)* –14·85 (–17·96 o –10·84)* –29·57 (–33·72 o –22·15)* –29·46 (–32·76 o –23·49)* 2 Tobacco 3 Smoking 35·72 (32·76 o 39·76) 30·16 (27·23 o 34·44) 25·14 (22·69 o 28·74) –15·57 (–18·63 o –12·33)* –16·63 (–20·29 o –12·87)* –29·61 (–33·96 o –24·13)* 11·11 (9·22 o 14·19) 9·65 (7·88 o 12·63) 7·93 (6·49 o 10·55) –13·15 (–16·68 o –7·93)* –17·83 (–23·41 o –12·38)* –28·63 (–34·48 o –20·87)* –28·99 (–33·00 o –24·33)* 3 Smokeless obacco 13·39 (12·68 o 14·11) 15·58 (15·10 o 16·07) 15·04 (14·34 o 15·80) 16·36 (9·65 o 23·26)* –3·46 (–8·38 o 2·17) 12·33 (4·70 o 20·89)* 8·34 (7·65 o 9·00) 9·31 (8·82 o 9·80) 8·61 (7·88 o 9·37) 11·55 (1·46 o 23·48)* –7·44 (–16·18 o 2·32) 3·25 (–8·03 o 16·93) 9·11 (2·16 o 16·49)* 3Second-hand smoke 23·11 (22·52 o 23·63) 19·73 (19·48 o 19·96) 18·96 (18·60 o 19·28) –14·62 (–16·80 o –12·40)* –3·91 (–4·99 o –2·82)* –17·96 (–20·68 o –15·11)* 43·29 (42·00 o 44·40) 35·87 (35·10 o 36·55) 33·32 (32·49 o 33·97) –17·13 (–18·78 o –15·25)* –7·11 (–8·22 o –6·01)* –23·03 (–25·21 o –20·59)* –21·39 (–23·64 o –18·82)* 2Alcohol and d ug use 3Alcohol use 13·82 (11·94 o 15·70) 14·27 (12·36 o 16·27) 14·05 (12·28 o 15·85) 3·26 (–1·07 o 8·20) –1·54 (–5·49 o 2·86) 1·68 (–3·97 o 8·77) 5·68 (4·57 o 6·78) 4·90 (3·97 o 5·88) 4·83 (3·93 o 5·78) –13·70 (–17·59 o –9·62)* –1·49 (–6·97 o 4·13) –14·98 (–20·47 o –8·98)* –2·84 (–8·09 o 3·36) 3D ug use 0·63 (0·32 o 1·13) 0·61 (0·31 o 1·09) 0·61 (0·31 o 1·10) –2·98 (–3·70 o –2·26)* 0·41 (–0·76 o 1·52) –2·58 (–4·08 o –0·98)* 0·38 (0·19 o 0·68) 0·35 (0·18 o 0·64) 0·36 (0·18 o 0·65) –7·43 (–8·40 o –6·57)* 1·19 (–0·04 o 2·29) –6·33 (–7·94 o –4·82)* –3·84 (–5·28 o –2·42)* 2 Die a y isks 3 Die low in ui s 74·84 (54·78 o 91·07) 67·49 (47·24 o 86·59) 61·77 (41·88 o 80·91) –9·81 (–13·94 o –4·92)* –8·49 (–11·37 o –6·45)* –17·47 (–23·57 o –11·01)* 72·47 (52·33 o 89·49) 63·10 (43·24 o 82·40) 56·95 (37·44 o 75·97) –12·92 (–17·54 o –7·87)* –9·75 (–12·98 o –7·61)* –21·41 (–28·12 o –15·01)* –19·41 (–25·83 o –13·02)* 3 Die low in ege ables 54·19 (36·90 o 71·51) 45·87 (29·62 o 62·63) 41·55 (26·41 o 57·44) –15·36 (–19·49 o –12·55)* –9·41 (–11·75 o –7·67)* –23·32 (–28·38 o –19·69)* 56·42 (38·74 o 74·29) 48·11 (31·55 o 64·93) 43·79 (28·06 o 60·10) –14·74 (–18·82 o –12·04)* –8·96 (–11·33 o –7·32)* –22·38 (–27·62 o –18·87)* –22·83 (–27·86 o –19·31)* 3 Die low in legumes 41·50 (28·42 o 54·90) 45·97 (33·03 o 58·84) 45·13 (32·40 o 57·73) 10·78 (6·42 o 17·21)* –1·83 (–3·69 o 0·03) 8·75 (4·50 o 14·83)* 47·78 (33·68 o 61·80) 52·23 (38·14 o 65·93) 51·61 (37·74 o 65·20) 9·33 (6·14 o 13·95)* –1·18 (–2·64 o 0·16) 8·04 (4·89 o 12·67)* 8·18 (4·89 o 13·01)* 3 Die low in whole g ains 64·83 (45·85 o 83·18) 58·75 (41·16 o 76·64) 58·64 (41·07 o 76·49) –9·37 (–10·53 o –7·87)* –0·20 (–0·52 o 0·11) –9·55 (–10·79 o –8·01)* 65·47 (46·12 o 83·94) 59·44 (41·30 o 77·68) 60·66 (42·41 o 78·76) –9·21 (–10·80 o –7·50)* 2·06 (1·26 o 2·80)* –7·34 (–8·50 o –6·19)* –8·44 (–9·57 o –7·11)* (Table 3 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1369 Risk Male Female Combined pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 1990 2006 2016 Pe cen change 1990–2006 Pe cen change 2006–16 Pe cen change 1990–2016 (Con inued om p e ious page) 3 Die low in nu s and seeds 88·83 (68·81 o 99·29) 83·75 (63·76 o 95·14) 81·39 (60·77 o 94·85) –5·72 (–7·32 o –4·13)* –2·82 (–4·85 o –0·31)* –8·38 (–11·67 o –4·50)* 89·01 (68·93 o 99·33) 84·32 (64·20 o 95·78) 81·94 (61·27 o 95·19) –5·27 (–6·94 o –3·53)* –2·82 (–4·65 o –0·54)* –7·94 (–11·18 o –4·16)* –8·16 (–11·38 o –4·33)* 3 Die low in milk 81·31 (63·75 o 93·81) 83·31 (65·78 o 95·69) 83·48 (65·88 o 95·94) 2·47 (1·94 o 3·09)* 0·20 (–0·23 o 0·59) 2·67 (2·11 o 3·25)* 81·43 (63·96 o 94·04) 83·40 (65·84 o 95·88) 83·62 (65·94 o 96·11) 2·42 (1·83 o 3·19)* 0·27 (–0·14 o 0·64) 2·70 (2·11 o 3·43)* 2·71 (2·19 o 3·22)* 3 Die high in ed mea 19·44 (16·17 o 22·95) 21·77 (18·13 o 25·66) 24·66 (21·03 o 28·64) 11·97 (6·60 o 17·58)* 13·28 (8·34 o 19·80)* 26·84 (20·66 o 34·20)* 8·50 (6·08 o 11·17) 8·96 (6·42 o 11·86) 10·84 (7·89 o 13·98) 5·35 (–2·82 o 16·00) 21·05 (10·94 o 34·59)* 27·53 (17·12 o 41·17)* 27·57 (21·74 o 34·70)* 3 Die high in p ocessed mea 7·84 (6·20 o 10·03) 7·62 (6·12 o 9·88) 6·19 (4·58 o 8·67) –2·79 (–8·00 o 1·77) –18·81 (–26·23 o –11·45)* –21·08 (–29·56 o –12·44)* 5·38 (3·82 o 7·35) 5·07 (3·69 o 7·09) 4·32 (2·95 o 6·49) –5·92 (–11·73 o 0·09) –14·62 (–22·25 o –7·62)* –19·68 (–27·67 o –10·91)* –20·45 (–27·41 o –12·36)* 3 Die high in suga -swee ened be e ages 12·19 (11·19 o 13·25) 15·70 (14·48 o 16·87) 17·90 (16·52 o 19·25) 28·79 (22·74 o 35·00)* 14·06 (11·40 o 16·81)* 46·89 (38·49 o 55·16)* 9·47 (8·47 o 10·53) 11·79 (10·79 o 12·82) 13·45 (12·28 o 14·59) 24·47 (17·25 o 31·99)* 14·10 (10·72 o 17·61)* 42·02 (31·42 o 52·44)* 44·73 (36·08 o 52·69)* 3 Die low in ib e 59·23 (38·47 o 80·17) 56·12 (35·61 o 76·88) 53·27 (33·15 o 73·95) –5·24 (–7·57 o –3·74)* –5·08 (–7·43 o –3·57)* –10·06 (–13·95 o –7·46)* 66·96 (45·54 o 87·29) 64·02 (42·94 o 84·48) 61·76 (40·67 o 82·64) –4·39 (–6·33 o –3·04)* –3·53 (–5·53 o –2·10)* –7·77 (–11·04 o –5·33)* –8·89 (–12·30 o –6·46)* 3 Die low in calcium 63·99 (44·32 o 82·99) 60·79 (41·37 o 80·23) 57·11 (37·87 o 76·76) –5·01 (–6·88 o –3·24)* –6·05 (–8·50 o –4·33)* –10·75 (–14·66 o –7·46)* 66·45 (46·60 o 85·13) 63·73 (43·96 o 83·09) 60·70 (41·09 o 80·49) –4·09 (–5·70 o –2·36)* –4·76 (–6·69 o –3·15)* –8·66 (–11·87 o –5·44)* –9·67 (–13·21 o –6·43)* 3Die low in sea ood omega 3 a y acids 80·95 (62·89 o 93·16) 78·84 (60·21 o 92·11) 76·66 (57·55 o 91·30) –2·61 (–4·24 o –1·11)* –2·76 (–4·41 o –0·86)* –5·31 (–8·41 o –1·95)* 82·50 (64·41 o 94·45) 81·01 (62·43 o 93·88) 79·29 (60·18 o 93·34) –1·81 (–3·21 o –0·60)* –2·12 (–3·59 o –0·53)* –3·89 (–6·61 o –1·16)* –4·59 (–7·46 o –1·59)* 3 Die low in polyunsa u a ed a y acids 45·06 (43·63 o 46·41) 42·75 (41·51 o 43·97) 39·59 (38·34 o 40·95) –5·12 (–8·80 o –1·13)* –7·39 (–10·43 o –4·14)* –12·13 (–15·52 o –8·13)* 42·88 (41·39 o 44·43) 42·13 (40·86 o 43·41) 39·01 (37·71 o 40·27) –1·75 (–6·01 o 2·86) –7·42 (–10·78 o –3·74)* –9·03 (–13·10 o –4·82)* –10·66 (–13·33 o –7·81)* 3 Die high in ans a y acids 7·64 (3·38 o 13·77) 4·95 (1·69 o 10·43) 3·65 (0·96 o 8·75) –35·13 (–52·63 o –22·20)* –26·21 (–45·06 o –14·67)* –52·13 (–72·97 o –33·77)* 10·53 (5·22 o 17·83) 7·03 (2·87 o 13·30) 5·21 (1·73 o 11·02) –33·22 (–46·91 o –21·80)* –25·92 (–42·55 o –15·38)* –50·53 (–68·52 o –34·00)* –51·32 (–70·08 o –34·10)* 3 Die high in sodium 44·14 (19·26 o 76·14) 40·66 (12·48 o 76·89) 39·77 (11·77 o 76·42) –7·89 (–35·22 o 1·07) –2·18 (–9·26 o –0·40)* –9·89 (–40·40 o 0·12) 43·80 (18·77 o 76·78) 37·98 (11·76 o 74·27) 36·22 (10·50 o 72·98) –13·29 (–38·80 o –2·86)* –4·64 (–12·09 o –1·57)* –17·32 (–44·79 o –4·79)* –13·63 (–42·22 o –2·33)* 2 Sexual abuse and iolence 3 Childhood sexual abuse 6·78 (5·66 o 8·02) 6·81 (5·72 o 7·98) 7·09 (5·94 o 8·33) 0·46 (–0·56 o 1·57) 4·10 (3·41 o 4·77)* 4·58 (3·92 o 5·29)* 7·78 (6·57 o 9·20) 7·51 (6·39 o 8·83) 7·68 (6·46 o 9·06) –3·44 (–4·40 o –2·36)* 2·23 (1·23 o 3·13)* –1·29 (–2·41 o 0·17) 1·46 (0·76 o 2·27)* 3 In ima e pa ne iolence ·· ·· ·· ·· ·· ·· 11·80 (10·05 o 13·42) 10·90 (9·40 o 12·26) 10·32 (8·88 o 11·63) –7·62 (–8·80 o –6·28)* –5·33 (–5·90 o –4·79)* –12·55 (–13·59 o –11·39)* –12·80 (–13·82 o –11·65)* 2 Low physical ac i i y 18·02 (9·66 o 28·42) 18·16 (9·81 o 28·87) 18·25 (9·81 o 28·80) 0·78 (–28·27 o 39·60) 0·51 (–27·42 o 41·11) 1·30 (0·94 o 1·72)* 15·32 (8·52 o 23·82) 15·12 (8·42 o 23·35) 15·05 (8·33 o 23·45) –1·28 (–30·22 o 37·56) –0·49 (–28·76 o 41·07) –1·77 (–2·31 o –1·28)* 0·07 (–0·32 o 0·38) 1 Me abolic isks 2 High as ing plasma glucose 2·87 (1·79 o 4·14) 3·68 (2·37 o 5·23) 3·70 (2·36 o 5·22) 28·39 (19·48 o 41·24)* 0·60 (–7·76 o 8·12) 29·17 (21·33 o 40·03)* 2·46 (1·48 o 3·73) 3·34 (2·14 o 4·76) 3·14 (1·97 o 4·55) 35·71 (20·73 o 59·93)* –5·93 (–15·95 o 1·66) 27·66 (18·53 o 42·31)* 28·77 (21·32 o 39·87)* 2High o al choles e ol 17·43 (13·61 o 21·82) 16·87 (13·07 o 21·24) 16·75 (12·96 o 21·12) –3·20 (–4·08 o –2·45)* –0·74 (–1·28 o –0·21)* –3·91 (–4·91 o –2·98)* 20·14 (16·16 o 24·66) 19·30 (15·40 o 23·74) 19·05 (15·10 o 23·49) –4·17 (–5·13 o –3·34)* –1·29 (–1·91 o –0·68)* –5·41 (–6·65 o –4·34)* –5·12 (–6·23 o –4·19)* (Table 3 con inues on nex page) Global Heal h Me ics 1376 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· A ial ib illa ion and lu e 1·76 (0·65 o 3·49) 2·45 (0·88 o 4·91) 39·22 (29·86 o 46·04)* 0·69 (–2·60 o 4·79) 69·13 (28·74 o 129·13) 83·64 (32·94 o 159·75) 20·99 (12·73 o 25·56)* –6·93 (–12·49 o –4·15)* ·· Ao ic aneu ysm 1·52 (0·54 o 2·93) 1·63 (0·55 o 3·25) 7·18 (–2·91 o 14·30) –17·85 (–24·53 o –13·48)* 32·04 (11·44 o 61·16) 32·04 (10·70 o 62·83) 0·01 (–9·81 o 6·58) –21·90 (–29·35 o –16·99)* ·· Pe iphe al ascula disease 0·16 (0·03 o 0·41) 0·20 (0·03 o 0·53) 19·84 (–2·64 o 35·45) –11·54 (–24·29 o –3·03)* 5·60 (1·52 o 12·98) 6·34 (1·62 o 15·16) 13·07 (2·26 o 20·57)* –13·53 (–21·26 o –9·06)* ·· Endoca di is 0·83 (0·29 o 1·74) 0·97 (0·32 o 2·09) 16·60 (4·99 o 26·41)* –9·45 (–17·23 o –4·25)* 20·69 (6·81 o 43·39) 21·53 (6·70 o 47·48) 4·04 (–6·57 o 13·03) –16·42 (–25·07 o –10·13)* ·· O he ca dio ascula and ci cula o y diseases 5·41 (1·95 o 10·17) 5·94 (1·95 o 11·38) 9·71 (–0·49 o 16·74) –16·12 (–23·01 o –11·62)* 152·85 (52·63 o 310·64) 153·78 (48·05 o 324·49) 0·60 (–9·13 o 6·44) –20·84 (–28·73 o –16·05)* ·· Idiopa hic de elopmen al in ellec ual disabili y ·· ·· ·· ·· 2916·48 (1228·14 o 5089·94) 2920·47 (1234·48 o 5155·20) 0·14 (–3·18 o 2·41) –8·99 (–12·03 o –6·90)* ·· Ch onic kidney disease due o diabe es melli us 10·10 (4·15 o 18·35) 12·65 (5·09 o 23·20) 25·28 (19·04 o 29·44)* –4·60 (–8·89 o –1·68)* 260·59 (102·04 o 495·91) 302·16 (113·45 o 584·15) 15·96 (9·37 o 20·09)* –10·04 (–15·36 o –6·87)* ·· Ch onic kidney disease due o hype ension 6·22 (2·72 o 11·32) 8·27 (3·62 o 15·14) 33·02 (27·46 o 37·34)* –2·02 (–5·80 o 0·78) 128·17 (54·29 o 242·87) 155·62 (64·33 o 297·32) 21·42 (15·72 o 25·19)* –6·97 (–11·22 o –4·21)* ·· Ch onic kidney disease due o glome uloneph i is 2·42 (0·93 o 4·54) 2·92 (1·08 o 5·50) 20·90 (15·70 o 26·39)* –7·48 (–11·06 o –4·04)* 65·59 (21·46 o 133·89) 70·02 (22·73 o 143·93) 6·76 (0·61 o 11·59)* –15·00 (–20·26 o –11·29)* ·· Ch onic kidney disease due o o he causes 4·42 (1·88 o 8·20) 5·69 (2·39 o 10·62) 28·68 (22·76 o 34·24)* –2·47 (–6·62 o 1·13) 111·53 (43·93 o 213·01) 126·74 (48·88 o 248·43) 13·63 (7·40 o 18·08)* –10·64 (–15·64 o –6·92)* 2 Occupa ional isks: all causes 1409·60 (1288·25 o 1539·63) 1528·02 (1383·55 o 1680·97) 8·40 (6·20 o 10·41)* –14·80 (–16·48 o –13·37)* 68 543·89 (60 461·38 o 77 147·09) 75 925·43 (66 060·97 o 86 257·10) 10·77 (8·84 o 12·62)* –8·98 (–10·61 o –7·49)* 3 Occupa ional ca cinogens: all causes 628·39 (529·77 o 733·38) 746·54 (624·13 o 874·38) 18·80 (16·21 o 21·35)* –8·62 (–10·42 o –6·83)* 17 462·68 (14 595·36 o 20 617·18) 20 682·73 (17 015·37 o 24 682·77) 18·44 (15·67 o 21·04)* –7·56 (–9·50 o –5·67)* 4 Occupa ional exposu e o asbes os: all causes 187·83 (142·94 o 233·46) 222·32 (168·96 o 277·92) 18·36 (15·32 o 21·47)* –10·30 (–12·67 o –7·98)* 3197·37 (2410·48 o 4019·53) 3640·71 (2743·34 o 4594·60) 13·87 (11·05 o 16·82)* –12·65 (–14·84 o –10·38)* ·· La ynx cance 3·25 (1·80 o 4·82) 3·74 (2·02 o 5·53) 15·08 (11·70 o 18·64)* –13·01 (–15·58 o –10·35)* 59·03 (32·22 o 89·00) 65·51 (35·04 o 99·12) 10·97 (7·31 o 14·61)* –15·26 (–18·03 o –12·51)* ·· T acheal, b onchus, and lung cance 155·24 (111·10 o 201·47) 181·45 (128·29 o 236·62) 16·88 (13·29 o 20·48)* –11·40 (–14·19 o –8·74)* 2539·55 (1770·09 o 3359·44) 2844·28 (1957·87 o 3803·22) 12·00 (8·53 o 15·59)* –14·15 (–16·73 o –11·42)* ·· O a ian cance 5·16 (2·58 o 7·94) 6·02 (2·98 o 9·40) 16·73 (9·65 o 23·13)* –13·33 (–18·64 o –8·71)* 82·25 (40·54 o 128·84) 93·12 (45·80 o 149·95) 13·21 (5·49 o 20·04)* –13·97 (–19·78 o –8·87)* ·· Meso helioma 21·29 (20·16 o 22·57) 27·61 (25·56 o 29·34) 29·68 (23·73 o 34·79)* –1·06 (–5·59 o 2·90) 443·53 (413·23 o 481·26) 553·97 (507·29 o 597·78) 24·90 (19·28 o 29·80)* –3·39 (–7·70 o 0·41) ·· Asbes osis 2·89 (1·92 o 3·56) 3·49 (2·43 o 4·06) 21·00 (13·33 o 30·87)* –7·91 (–13·67 o –0·40)* 73·00 (57·24 o 86·90) 83·83 (67·86 o 97·43) 14·83 (9·18 o 21·83)* –9·23 (–13·68 o –3·33)* 4 Occupa ional exposu e o a senic: all causes 6·55 (1·52 o 11·97) 8·07 (2·05 o 14·63) 23·27 (18·26 o 35·03)* –5·27 (–9·14 o 4·00) 182·17 (43·97 o 330·51) 219·22 (57·76 o 395·48) 20·34 (15·23 o 31·54)* –6·95 (–10·91 o 2·16) ·· T acheal, b onchus, and lung cance 6·55 (1·52 o 11·97) 8·07 (2·05 o 14·63) 23·27 (18·26 o 35·03)* –5·27 (–9·14 o 4·00) 182·17 (43·97 o 330·51) 219·22 (57·76 o 395·48) 20·34 (15·23 o 31·54)* –6·95 (–10·91 o 2·16) 4 Occupa ional exposu e o benzene: all causes 1·63 (0·52 o 2·67) 1·90 (0·60 o 3·12) 16·21 (11·28 o 21·54)* –1·47 (–6·03 o 3·50) 74·24 (23·12 o 121·81) 83·87 (25·51 o 138·49) 12·97 (8·01 o 18·09)* –2·29 (–6·92 o 2·56) ·· Leukaemia 1·63 (0·52 o 2·67) 1·90 (0·60 o 3·12) 16·21 (11·28 o 21·54)* –1·47 (–6·03 o 3·50) 74·24 (23·12 o 121·81) 83·87 (25·51 o 138·49) 12·97 (8·01 o 18·09)* –2·29 (–6·92 o 2·56) ·· Acu e lymphoid leukaemia 0·28 (0·09 o 0·46) 0·37 (0·11 o 0·62) 32·70 (19·53 o 41·21)* 14·39 (3·02 o 21·87)* 13·95 (4·29 o 22·85) 18·08 (5·39 o 29·97) 29·59 (16·43 o 37·84)* 13·73 (2·19 o 21·17)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1377 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ch onic lymphoid leukaemia 0·09 (0·03 o 0·15) 0·11 (0·04 o 0·19) 24·21 (16·84 o 35·39)* 0·43 (–6·33 o 10·47) 3·30 (1·12 o 5·43) 4·07 (1·35 o 6·69) 23·32 (15·50 o 33·93)* 1·98 (–5·31 o 11·94) ·· Acu e myeloid leukaemia 0·41 (0·14 o 0·67) 0·54 (0·18 o 0·90) 32·16 (24·33 o 41·56)* 11·07 (3·73 o 20·10)* 17·90 (6·04 o 29·37) 23·24 (7·47 o 38·33) 29·83 (21·43 o 39·32)* 11·51 (3·58 o 20·44)* ·· Ch onic myeloid leukaemia 0·15 (0·05 o 0·24) 0·15 (0·05 o 0·25) 4·79 (–3·59 o 14·00) –11·79 (–18·96 o –3·60)* 6·60 (2·12 o 10·80) 6·86 (2·14 o 11·39) 4·04 (–4·07 o 13·79) –10·84 (–18·16 o –2·42)* ·· O he leukaemia 0·70 (0·21 o 1·16) 0·71 (0·21 o 1·19) 1·61 (–4·21 o 7·56) –13·30 (–18·31 o –8·34)* 32·49 (9·76 o 53·35) 31·62 (9·61 o 52·92) –2·70 (–8·57 o 3·32) –15·49 (–20·60 o –10·44)* 4 Occupa ional exposu e o be yllium: all causes 0·20 (0·17 o 0·24) 0·26 (0·21 o 0·31) 28·93 (22·38 o 34·98)* –0·80 (–4·98 o 2·96) 5·76 (4·76 o 6·81) 7·22 (5·89 o 8·59) 25·48 (18·89 o 31·61)* –2·63 (–6·90 o 1·11) ·· T acheal, b onchus, and lung cance 0·20 (0·17 o 0·24) 0·26 (0·21 o 0·31) 28·93 (22·38 o 34·98)* –0·80 (–4·98 o 2·96) 5·76 (4·76 o 6·81) 7·22 (5·89 o 8·59) 25·48 (18·89 o 31·61)* –2·63 (–6·90 o 1·11) 4 Occupa ional exposu e o cadmium: all causes 0·46 (0·39 o 0·53) 0·61 (0·50 o 0·71) 31·38 (24·62 o 37·82)* 1·00 (–3·45 o 5·10) 13·15 (11·14 o 15·16) 16·83 (14·14 o 19·64) 28·00 (21·21 o 34·47)* –0·75 (–5·34 o 3·51) ·· T acheal, b onchus, and lung cance 0·46 (0·39 o 0·53) 0·61 (0·50 o 0·71) 31·38 (24·62 o 37·82)* 1·00 (–3·45 o 5·10) 13·15 (11·14 o 15·16) 16·83 (14·14 o 19·64) 28·00 (21·21 o 34·47)* –0·75 (–5·34 o 3·51) 4 Occupa ional exposu e o ch omium: all causes 0·96 (0·86 o 1·07) 1·28 (1·13 o 1·44) 33·02 (27·40 o 38·50)* 2·28 (–1·68 o 6·05) 27·33 (24·34 o 30·24) 35·45 (31·40 o 40·17) 29·71 (24·03 o 35·28)* 0·57 (–3·49 o 4·55) ·· T acheal, b onchus, and lung cance 0·96 (0·86 o 1·07) 1·28 (1·13 o 1·44) 33·02 (27·40 o 38·50)* 2·28 (–1·68 o 6·05) 27·33 (24·34 o 30·24) 35·45 (31·40 o 40·17) 29·71 (24·03 o 35·28)* 0·57 (–3·49 o 4·55) 4 Occupa ional exposu e o diesel engine exhaus : all causes 13·41 (11·85 o 15·17) 17·50 (15·20 o 20·06) 30·45 (24·63 o 35·78)* 0·26 (–3·89 o 3·78) 381·69 (337·43 o 428·72) 485·69 (426·18 o 553·93) 27·25 (21·26 o 32·75)* –1·40 (–5·65 o 2·19) ·· T acheal, b onchus, and lung cance 13·41 (11·85 o 15·17) 17·50 (15·20 o 20·06) 30·45 (24·63 o 35·78)* 0·26 (–3·89 o 3·78) 381·69 (337·43 o 428·72) 485·69 (426·18 o 553·93) 27·25 (21·26 o 32·75)* –1·40 (–5·65 o 2·19) 4 Occupa ional exposu e o second-hand smoke: all causes 364·05 (275·49 o 465·66) 433·15 (326·16 o 554·32) 18·98 (15·73 o 22·42)* –7·67 (–9·82 o –5·44)* 12 060·36 (9008·45 o 15 202·22) 14 474·34 (10 754·05 o 18 289·00) 20·02 (16·70 o 23·11)* –5·73 (–7·98 o –3·57)* ·· Lowe espi a o y in ec ions 25·22 (11·95 o 41·26) 31·03 (14·71 o 51·31) 23·07 (18·77 o 27·30)* –3·05 (–6·52 o 0·24) 754·30 (355·32 o 1235·87) 901·83 (424·90 o 1491·75) 19·56 (15·20 o 24·09)* –4·55 (–7·93 o –1·02)* ·· O i is media 0·00 (0·00 o 0·00) 0·00 (0·00 o 0·00) –51·34 (–68·17 o –26·94)* –53·19 (–69·51 o –29·77)* 0·00 (0·00 o 0·00) 0·00 (0·00 o 0·00) –0·26 (–3·00 o 2·10) –4·95 (–7·62 o –2·74)* ·· T acheal, b onchus, and lung cance 36·79 (17·19 o 62·63) 44·38 (20·66 o 75·46) 20·63 (16·93 o 23·85)* –7·23 (–10·03 o –4·78)* 1009·34 (472·19 o 1717·66) 1185·42 (551·75 o 2013·66) 17·45 (13·68 o 20·74)* –9·21 (–12·08 o –6·69)* ·· B eas cance 3·93 (0·93 o 6·85) 4·86 (1·19 o 8·40) 23·68 (16·23 o 31·66)* –3·23 (–9·07 o 2·90) 131·38 (30·86 o 228·23) 160·49 (39·88 o 276·83) 22·16 (14·48 o 30·64)* –3·10 (–9·13 o 3·41) ·· Ischaemic hea disease 145·11 (108·16 o 184·75) 177·23 (131·12 o 226·23) 22·13 (16·84 o 27·55)* –4·86 (–7·90 o –1·79)* 4427·58 (3270·63 o 5659·16) 5337·92 (3904·37 o 6856·49) 20·56 (15·58 o 25·71)* –4·76 (–7·77 o –1·66)* ·· Ischaemic s oke 24·76 (17·40 o 32·82) 28·32 (19·67 o 38·37) 14·40 (7·34 o 21·60)* –12·26 (–16·32 o –8·12)* 749·82 (529·06 o 995·24) 892·52 (616·96 o 1211·73) 19·03 (12·07 o 26·19)* –8·13 (–12·07 o –4·39)* ·· Haemo hagic s oke 52·38 (37·29 o 69·30) 56·78 (39·66 o 75·11) 8·39 (3·67 o 13·19)* –15·19 (–17·69 o –12·61)* 1679·51 (1187·37 o 2237·60) 1799·87 (1247·86 o 2400·70) 7·17 (2·54 o 11·92)* –14·80 (–17·22 o –12·28)* ·· Ch onic obs uc i e pulmona y disease 48·15 (22·29 o 85·80) 51·90 (23·79 o 91·43) 7·78 (4·30 o 11·52)* –17·01 (–19·72 o –14·14)* 1570·14 (727·09 o 2820·77) 1819·99 (831·20 o 3260·92) 15·91 (12·59 o 19·00)* –10·63 (–13·17 o –8·26)* ·· Diabe es melli us 27·71 (10·20 o 43·82) 38·64 (14·31 o 60·82) 39·45 (37·04 o 42·10)* 7·38 (5·52 o 9·33)* 1738·30 (616·68 o 2847·07) 2376·30 (847·55 o 3851·52) 36·70 (34·59 o 39·02)* 7·55 (5·95 o 9·37)* (Table 4 con inues on nex page) Global Heal h Me ics 1378 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) 4 Occupa ional exposu e o o maldehyde: all causes 0·95 (0·78 o 1·15) 1·09 (0·90 o 1·32) 13·89 (5·40 o 22·94)* –4·03 (–10·29 o 2·45) 42·70 (35·09 o 51·51) 46·93 (38·81 o 56·99) 9·90 (1·78 o 18·05)* –5·67 (–12·09 o 0·77) ·· Nasopha ynx cance 0·42 (0·29 o 0·58) 0·48 (0·33 o 0·68) 13·08 (–1·13 o 29·19) –6·37 (–16·69 o 4·83) 17·57 (11·88 o 24·10) 19·02 (12·99 o 27·09) 8·25 (–5·73 o 24·38) –8·78 (–19·03 o 3·13) ·· Acu e lymphoid leukaemia 0·09 (0·08 o 0·11) 0·13 (0·11 o 0·15) 34·88 (18·69 o 42·16)* 16·60 (3·46 o 22·11)* 4·72 (3·86 o 5·83) 6·21 (5·02 o 7·60) 31·43 (16·61 o 38·79)* 15·52 (2·59 o 21·35)* ·· Ch onic lymphoid leukaemia 0·02 (0·02 o 0·03) 0·03 (0·03 o 0·04) 30·39 (20·80 o 38·61)* 7·25 (0·20 o 13·50)* 0·95 (0·79 o 1·17) 1·22 (1·02 o 1·44) 27·96 (16·27 o 37·10)* 7·86 (–0·97 o 15·12) ·· Acu e myeloid leukaemia 0·11 (0·09 o 0·13) 0·15 (0·12 o 0·18) 35·38 (28·55 o 41·33)* 15·11 (9·74 o 19·69)* 5·06 (4·14 o 6·15) 6·70 (5·54 o 8·16) 32·57 (25·83 o 39·02)* 14·91 (9·32 o 20·00)* ·· Ch onic myeloid leukaemia 0·04 (0·04 o 0·05) 0·05 (0·04 o 0·06) 6·23 (0·31 o 13·49)* –9·89 (–14·91 o –4·16)* 2·05 (1·66 o 2·53) 2·15 (1·73 o 2·65) 4·77 (–1·61 o 12·57) –9·72 (–15·13 o –3·27)* ·· O he leukaemia 0·26 (0·21 o 0·31) 0·26 (0·21 o 0·31) –1·61 (–9·46 o 6·91) –15·64 (–21·92 o –9·05)* 12·35 (9·66 o 14·91) 11·64 (9·27 o 14·19) –5·80 (–13·73 o 2·60) –17·95 (–24·52 o –11·12)* 4 Occupa ional exposu e o nickel: all causes 6·68 (0·95 o 17·47) 8·10 (1·24 o 20·81) 21·35 (15·63 o 32·69)* –6·73 (–11·14 o 2·03) 187·01 (27·49 o 483·87) 221·35 (34·93 o 563·34) 18·37 (12·66 o 29·20)* –8·40 (–12·92 o 0·27) ·· T acheal, b onchus, and lung cance 6·68 (0·95 o 17·47) 8·10 (1·24 o 20·81) 21·35 (15·63 o 32·69)* –6·73 (–11·14 o 2·03) 187·01 (27·49 o 483·87) 221·35 (34·93 o 563·34) 18·37 (12·66 o 29·20)* –8·40 (–12·92 o 0·27) 4 Occupa ional exposu e o polycyclic a oma ic hyd oca bons: all causes 3·41 (2·89 o 3·92) 4·53 (3·83 o 5·29) 32·92 (26·40 o 39·18)* 2·21 (–2·06 o 6·07) 97·03 (82·37 o 111·83) 125·78 (105·37 o 145·87) 29·63 (22·78 o 35·89)* 0·51 (–4·05 o 4·55) ·· T acheal, b onchus, and lung cance 3·41 (2·89 o 3·92) 4·53 (3·83 o 5·29) 32·92 (26·40 o 39·18)* 2·21 (–2·06 o 6·07) 97·03 (82·37 o 111·83) 125·78 (105·37 o 145·87) 29·63 (22·78 o 35·89)* 0·51 (–4·05 o 4·55) 4 Occupa ional exposu e o silica: all causes 50·95 (28·57 o 73·67) 58·40 (31·42 o 86·00) 14·63 (8·41 o 19·51)* –12·09 (–16·90 o –8·34)* 1396·95 (774·36 o 2030·14) 1574·57 (860·21 o 2314·76) 12·71 (6·89 o 17·49)* –12·64 (–17·10 o –8·94)* ·· T acheal, b onchus, and lung cance 40·38 (17·91 o 63·22) 48·00 (21·24 o 75·45) 18·88 (13·37 o 24·69)* –8·64 (–12·83 o –4·21)* 1123·77 (503·32 o 1756·69) 1303·95 (576·29 o 2042·00) 16·03 (10·58 o 21·66)* –10·26 (–14·61 o –5·78)* ·· Silicosis 10·57 (9·77 o 12·23) 10·40 (9·57 o 11·68) –1·60 (–14·72 o 5·54) –24·35 (–34·05 o –18·99)* 273·19 (247·13 o 310·72) 270·62 (243·58 o 301·41) –0·94 (–14·17 o 5·65) –22·15 (–32·16 o –17·05)* 4 Occupa ional exposu e o sul u ic acid: all causes 2·96 (1·27 o 5·35) 3·54 (1·52 o 6·49) 19·47 (13·15 o 26·36)* –8·14 (–12·96 o –2·92)* 89·85 (38·68 o 161·94) 105·23 (45·84 o 192·42) 17·12 (10·83 o 23·79)* –9·04 (–13·97 o –3·84)* ·· La ynx cance 2·96 (1·27 o 5·35) 3·54 (1·52 o 6·49) 19·47 (13·15 o 26·36)* –8·14 (–12·96 o –2·92)* 89·85 (38·68 o 161·94) 105·23 (45·84 o 192·42) 17·12 (10·83 o 23·79)* –9·04 (–13·97 o –3·84)* 4 Occupa ional exposu e o ichlo oe hylene: all causes 0·04 (0·01 o 0·07) 0·06 (0·01 o 0·11) 48·91 (43·08 o 53·27)* 14·75 (10·28 o 18·08)* 1·17 (0·26 o 2·16) 1·72 (0·38 o 3·23) 47·21 (41·37 o 51·60)* 14·65 (10·09 o 17·96)* ·· Kidney cance 0·04 (0·01 o 0·07) 0·06 (0·01 o 0·11) 48·91 (43·08 o 53·27)* 14·75 (10·28 o 18·08)* 1·17 (0·26 o 2·16) 1·72 (0·38 o 3·23) 47·21 (41·37 o 51·60)* 14·65 (10·09 o 17·96)* 3 Occupa ional as hmagens: all causes 36·83 (26·75 o 47·73) 37·57 (28·36 o 47·94) 2·02 (–6·22 o 10·50) –19·40 (–25·79 o –12·65)* 2122·64 (1699·18 o 2619·54) 2339·48 (1860·90 o 2923·32) 10·22 (4·21 o 15·66)* –8·91 (–14·66 o –3·71)* ·· As hma 36·83 (26·75 o 47·73) 37·57 (28·36 o 47·94) 2·02 (–6·22 o 10·50) –19·40 (–25·79 o –12·65)* 2122·64 (1699·18 o 2619·54) 2339·48 (1860·90 o 2923·32) 10·22 (4·21 o 15·66)* –8·91 (–14·66 o –3·71)* 3 Occupa ional pa icula e ma e , gases, and umes: all causes 407·53 (338·66 o 479·12) 424·27 (349·98 o 507·55) 4·11 (–0·16 o 8·15) –21·37 (–23·97 o –18·61)* 8771·11 (7497·47 o 10 068·75) 9377·10 (7972·61 o 10 789·56) 6·91 (3·78 o 10·55)* –17·84 (–19·96 o –15·42)* ·· Ch onic obs uc i e pulmona y disease 399·93 (331·13 o 472·15) 416·68 (342·87 o 499·76) 4·19 (–0·04 o 8·27) –21·32 (–23·94 o –18·63)* 8557·06 (7276·89 o 9859·70) 9154·55 (7771·09 o 10 539·37) 6·98 (3·85 o 10·70)* –17·82 (–19·97 o –15·30)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1379 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Coal wo ke s pneumoconiosis 3·03 (1·91 o 3·49) 2·68 (1·79 o 3·07) –11·29 (–19·54 o 0·39) –32·63 (–38·84 o –23·91)* 87·45 (65·52 o 104·62) 89·05 (70·16 o 108·86) 1·83 (–6·81 o 12·73) –21·65 (–28·21 o –13·50)* ·· O he pneumoconiosis 4·57 (3·71 o 6·32) 4·91 (4·16 o 6·56) 7·27 (–1·26 o 15·86) –17·49 (–24·05 o –11·05)* 126·59 (104·34 o 161·76) 133·51 (112·07 o 165·88) 5·46 (–2·23 o 13·23) –16·68 (–22·73 o –10·63)* 3 Occupa ional noise: all causes ·· ·· ·· ·· 5865·39 (4107·31 o 8092·94) 7108·28 (4978·56 o 9802·69) 21·19 (19·01 o 22·96)* –0·74 (–2·21 o 0·56) ·· Age- ela ed and o he hea ing loss ·· ·· ·· ·· 5865·39 (4107·31 o 8092·94) 7108·28 (4978·56 o 9802·69) 21·19 (19·01 o 22·96)* –0·74 (–2·21 o 0·56) 3 Occupa ional inju ies: all causes 352·96 (344·63 o 360·98) 335·71 (328·64 o 343·27) –4·89 (–7·71 o –1·89)* –17·78 (–20·22 o –15·20)* 21 906·21 (20 353·14 o 23 776·95) 21 774·60 (19 810·66 o 24 090·16) –0·60 (–4·19 o 2·98) –12·95 (–15·95 o –9·94)* ·· Pedes ian oad inju ies 67·01 (62·03 o 73·85) 63·97 (59·35 o 69·72) –4·53 (–10·63 o 0·01) –18·09 (–23·28 o –14·24)* 3434·81 (3182·07 o 3771·04) 3278·98 (3037·91 o 3549·98) –4·54 (–10·46 o –0·04)* –16·52 (–21·66 o –12·63)* ·· Cyclis oad inju ies 10·32 (9·27 o 11·62) 9·99 (8·96 o 11·51) –3·16 (–8·97 o 5·60) –17·77 (–22·81 o –10·17)* 673·49 (580·35 o 787·54) 707·70 (596·26 o 850·17) 5·08 (–0·72 o 11·51) –9·29 (–14·16 o –3·79)* ·· Mo o cyclis oad inju ies 44·53 (40·17 o 49·15) 42·56 (38·79 o 46·82) –4·41 (–9·93 o 0·93) –15·65 (–20·46 o –10·89)* 2623·88 (2388·56 o 2894·57) 2549·86 (2330·54 o 2817·91) –2·82 (–8·29 o 2·44) –13·57 (–18·33 o –9·00)* ·· Mo o ehicle oad inju ies 74·30 (65·78 o 85·66) 73·17 (67·36 o 83·11) –1·51 (–6·37 o 7·20) –13·94 (–18·25 o –6·31)* 4091·59 (3653·03 o 4667·92) 4058·76 (3712·02 o 4590·12) –0·80 (–5·44 o 7·38) –12·17 (–16·25 o –4·94)* ·· O he oad inju ies 1·98 (1·74 o 2·43) 1·88 (1·68 o 2·28) –5·05 (–12·93 o 5·85) –18·33 (–25·07 o –8·69)* 167·13 (137·60 o 207·71) 198·25 (158·96 o 254·29) 18·62 (9·95 o 27·66)* 2·77 (–4·57 o 10·39) ·· O he anspo inju ies 14·25 (12·59 o 15·77) 13·71 (12·58 o 14·97) –3·74 (–11·07 o 5·18) –16·70 (–22·82 o –8·99)* 970·91 (855·69 o 1109·73) 969·10 (847·30 o 1119·40) –0·19 (–6·23 o 6·80) –12·66 (–17·77 o –6·62)* ·· Falls 38·58 (34·48 o 40·43) 39·52 (36·06 o 41·41) 2·42 (–3·75 o 8·20) –14·40 (–19·49 o –9·55)* 3253·95 (2718·82 o 3890·24) 3637·49 (3004·39 o 4424·49) 11·79 (6·86 o 16·48)* –4·69 (–8·77 o –0·73)* ·· D owning 29·91 (28·60 o 31·52) 26·74 (25·32 o 28·13) –10·60 (–14·16 o –6·83)* –21·41 (–24·53 o –18·10)* 1558·83 (1491·01 o 1643·06) 1365·42 (1294·39 o 1433·95) –12·41 (–15·98 o –8·51)* –21·39 (–24·55 o –17·92)* .. Fi e, hea , and ho subs ances 10·40 (9·05 o 11·29) 9·42 (8·02 o 10·46) –9·40 (–14·52 o –4·17)* –22·76 (–27·12 o –18·35)* 749·03 (646·32 o 879·73) 758·15 (626·89 o 922·03) 1·22 (–4·90 o 6·74) –11·99 (–17·27 o –7·18)* .. Poisonings 6·69 (5·21 o 7·55) 5·85 (4·37 o 6·54) –12·57 (–23·95 o 3·86) –24·93 (–34·60 o –11·05)* 351·08 (280·67 o 395·21) 313·70 (244·88 o 347·77) –10·65 (–20·53 o 3·82) –21·69 (–30·25 o –9·04)* .. Unin en ional i ea m inju ies 4·19 (3·23 o 4·60) 3·83 (2·80 o 4·20) –8·61 (–17·66 o 0·01) –19·38 (–27·38 o –11·76)* 253·51 (198·88 o 282·79) 240·12 (181·74 o 271·14) –5·28 (–13·02 o 2·95) –15·61 (–22·69 o –8·27)* ·· Unin en ional su oca ion 0·77 (0·68 o 0·90) 0·92 (0·67 o 1·04) 19·08 (–7·56 o 34·67) 4·58 (–18·86 o 18·24) 69·06 (56·28 o 86·36) 80·23 (63·30 o 101·14) 16·18 (1·23 o 25·85)* 2·43 (–10·54 o 10·82) ·· O he exposu e o mechanical o ces 17·58 (13·83 o 18·79) 15·29 (11·75 o 16·30) –13·04 (–17·93 o –8·65)* –24·91 (–29·14 o –21·17)* 1292·58 (1072·42 o 1512·50) 1290·07 (1044·64 o 1570·19) –0·19 (–5·99 o 5·81) –13·26 (–18·20 o –8·29)* ·· Venomous animal con ac 6·92 (6·26 o 7·56) 5·66 (5·21 o 6·27) –18·20 (–25·20 o –6·78)* –30·45 (–36·32 o –20·64)* 446·07 (390·64 o 500·68) 389·47 (338·03 o 449·59) –12·69 (–19·31 o –3·42)* –23·84 (–29·63 o –15·81)* ·· Non- enomous animal con ac 1·47 (1·09 o 1·80) 1·32 (0·99 o 1·71) –9·58 (–17·89 o 0·09) –23·14 (–30·13 o –14·72)* 122·37 (93·44 o 157·70) 116·27 (88·44 o 149·33) –4·98 (–11·38 o 1·81) –17·63 (–22·98 o –11·96)* ·· Pulmona y aspi a ion and o eign body in ai way 5·70 (5·08 o 6·60) 6·15 (5·50 o 7·31) 8·00 (0·69 o 17·21)* –8·88 (–15·06 o –1·29)* 368·39 (314·09 o 433·78) 400·88 (341·30 o 484·16) 8·82 (2·49 o 15·63)* –5·71 (–11·16 o 0·22) (Table 4 con inues on nex page) Global Heal h Me ics 1380 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Fo eign body in o he body pa 1·03 (0·70 o 1·32) 1·05 (0·76 o 1·32) 1·96 (–7·01 o 15·08) –11·39 (–19·07 o –0·51)* 123·60 (91·48 o 162·21) 136·41 (101·25 o 180·00) 10·37 (3·84 o 16·97)* –3·80 (–9·33 o 1·81) ·· O he unin en ional inju ies 17·35 (15·52 o 18·15) 14·67 (12·87 o 15·41) –15·45 (–19·85 o –11·30)* –26·15 (–30·00 o –22·53)* 1355·94 (1171·12 o 1583·40) 1283·74 (1074·02 o 1552·79) –5·32 (–10·48 o –0·38)* –17·08 (–21·56 o –12·93)* 3Occupa ional e gonomic ac o s: all causes ·· ·· ·· ·· 13 229·58 (9255·44 o 17 770·82) 15 479·93 (10 733·37 o 20 772·45) 17·01 (14·86 o 19·35)* –1·74 (–3·26 o –0·45)* ·· Low back pain ·· ·· ·· ·· 13 229·58 (9255·44 o 17 770·82) 15 479·93 (10 733·37 o 20 772·45) 17·01 (14·86 o 19·35)* –1·74 (–3·26 o –0·45)* 1 Beha iou al isks: all causes 22 393·17 (21 227·31 o 23 619·19) 21 830·19 (20 450·24 o 23 314·12) –2·51 (–4·89 o –0·13)* –21·55 (–23·25 o –19·81)* 910 996·12 (869 496·72 o 953 010·97) 781 103·69 (737 052·73 o 830 058·54) –14·26 (–16·59 o –11·83)* –25·18 (–27·08 o –23·22)* 2 Child and ma e nal malnu i ion: all causes 4301·09 (4107·68 o 4499·13) 2736·96 (2573·81 o 2904·34) –36·37 (–39·81 o –32·52)* –36·99 (–40·42 o –33·17)* 406 715·03 (385 244·16 o 429 424·87) 275 068·98 (255 117·96 o 296 600·82) –32·37 (–36·04 o –28·67)* –33·64 (–37·18 o –30·01)* 3 Subop imal b eas eeding: all causes 278·09 (223·03 o 332·55) 152·48 (124·06 o 183·65) –45·17 (–50·75 o –38·89)* –45·59 (–51·13 o –39·40)* 24 214·14 (19 400·12 o 28 949·80) 13 373·25 (10 878·18 o 16 087·13) –44·77 (–50·34 o –38·57)* –45·20 (–50·73 o –39·07)* 4 Non-exclusi e b eas eeding: all causes 264·19 (210·54 o 318·37) 144·11 (116·21 o 173·92) –45·45 (–51·08 o –39·34)* –45·79 (–51·39 o –39·70)* 22 971·14 (18 284·60 o 27 651·42) 12 598·41 (10 160·91 o 15 194·04) –45·16 (–50·76 o –39·06)* –45·49 (–51·07 o –39·43)* ·· Dia hoeal diseases 169·62 (132·18 o 206·77) 88·76 (68·74 o 111·24) –47·67 (–54·86 o –39·28)* –48·02 (–55·16 o –39·68)* 14 810·81 (11 518·55 o 18 077·32) 7821·54 (6057·18 o 9801·86) –47·19 (–54·37 o –38·91)* –47·54 (–54·67 o –39·31)* ·· Lowe espi a o y in ec ions 94·57 (62·35 o 130·16) 55·35 (35·96 o 75·66) –41·47 (–46·49 o –35·45)* –41·79 (–46·78 o –35·80)* 8160·33 (5381·55 o 11 233·53) 4776·87 (3103·20 o 6528·56) –41·46 (–46·48 o –35·45)* –41·78 (–46·77 o –35·80)* 4 Discon inued b eas eeding: all causes 16·70 (5·98 o 29·32) 10·04 (3·49 o 17·76) –39·90 (–48·41 o –29·27)* –41·77 (–50·01 o –31·40)* 1490·66 (534·34 o 2615·99) 924·29 (322·52 o 1634·92) –37·99 (–46·40 o –27·87)* –39·95 (–48·10 o –30·10)* ·· Dia hoeal diseases 16·70 (5·98 o 29·32) 10·04 (3·49 o 17·76) –39·90 (–48·41 o –29·27)* –41·77 (–50·01 o –31·40)* 1490·66 (534·34 o 2615·99) 924·29 (322·52 o 1634·92) –37·99 (–46·40 o –27·87)* –39·95 (–48·10 o –30·10)* 3 Child g ow h ailu e: all causes 1874·90 (1718·60 o 2023·15) 1010·58 (908·98 o 1119·90) –46·10 (–51·03 o –40·34)* –47·58 (–52·39 o –42·00)* 164 876·44 (151 738·69 o 177 603·01) 91 199·77 (82 272·24 o 100 948·47) –44·69 (–49·42 o –39·13)* –46·23 (–50·84 o –40·81)* 4Child unde weigh : all causes 615·18 (515·40 o 776·56) 312·61 (266·20 o 389·00) –49·18 (–55·81 o –41·66)* –50·76 (–57·23 o –43·44)* 55 627·11 (46 807·75 o 69 301·37) 30 009·75 (25 768·76 o 36 212·38) –46·05 (–52·86 o –37·94)* –47·77 (–54·35 o –39·88)* ·· Dia hoeal diseases 127·09 (100·36 o 161·58) 52·67 (40·79 o 66·71) –58·56 (–64·86 o –51·39)* –59·80 (–65·94 o –52·78)* 11 105·27 (8743·61 o 14 096·57) 4690·97 (3642·30 o 5935·54) –57·76 (–64·06 o –50·68)* –59·03 (–65·13 o –52·13)* ·· Lowe espi a o y in ec ions 163·67 (110·46 o 282·27) 74·94 (50·68 o 134·75) –54·21 (–59·84 o –48·26)* –55·36 (–60·85 o –49·50)* 14 008·04 (9452·95 o 24 153·07) 6422·64 (4342·77 o 11 542·06) –54·15 (–59·76 o –48·19)* –55·29 (–60·77 o –49·43)* ·· Measles 90·51 (19·16 o 218·56) 18·86 (3·38 o 49·55) –79·17 (–85·30 o –74·27)* –80·02 (–85·90 o –75·33)* 7705·27 (1633·01 o 18 583·17) 1607·04 (288·75 o 4213·11) –79·14 (–85·23 o –74·24)* –79·99 (–85·84 o –75·30)* ·· P o ein-ene gy malnu i ion 233·90 (206·48 o 265·01) 166·14 (141·84 o 197·87) –28·97 (–41·25 o –12·92)* –31·28 (–43·19 o –15·72)* 22 808·52 (20 316·73 o 25 669·57) 17 289·10 (14 869·06 o 20 449·39) –24·20 (–35·67 o –10·17)* –26·77 (–37·78 o –13·18)* 4 Child was ing: all causes 1734·23 (1516·43 o 1927·79) 952·40 (813·72 o 1,078·99) –45·08 (–50·29 o –39·28)* –46·57 (–51·63 o –40·95)* 152 812·32 (134 145·84 o 169 500·58) 86 165·42 (74 409·95 o 97 423·29) –43·61 (–48·72 o –37·94)* –45·17 (–50·15 o –39·64)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1381 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Dia hoeal diseases 681·26 (562·68 o 775·51) 358·50 (291·19 o 415·43) –47·38 (–54·62 o –38·82)* –48·84 (–55·87 o –40·50)* 59 883·01 (49 482·08 o 68 365·76) 32 202·36 (26 200·00 o 37 322·59) –46·22 (–53·39 o –38·04)* –47·73 (–54·71 o –39·75)* ·· Lowe espi a o y in ec ions 710·19 (548·14 o 830·75) 400·91 (298·47 o 479·06) –43·55 (–49·82 o –37·17)* –44·86 (–51·02 o –38·64)* 60 842·27 (46 968·94 o 71 152·73) 34 383·68 (25 595·42 o 41 070·89) –43·49 (–49·75 o –37·14)* –44·79 (–50·93 o –38·62)* ·· Measles 108·87 (22·88 o 295·48) 26·85 (4·48 o 77·75) –75·34 (–83·92 o –69·78)* –76·29 (–84·44 o –70·99)* 9278·52 (1953·33 o 25 167·82) 2290·28 (383·79 o 6620·03) –75·32 (–83·90 o –69·75)* –76·27 (–84·43 o –70·96)* ·· P o ein-ene gy malnu i ion 233·90 (206·48 o 265·01) 166·14 (141·84 o 197·87) –28·97 (–41·25 o –12·92)* –31·28 (–43·19 o –15·72)* 22 808·52 (20 316·73 o 25 669·57) 17 289·10 (14 869·06 o 20 449·39) –24·20 (–35·67 o –10·17)* –26·77 (–37·78 o –13·18)* 4 Child s un ing: all causes 366·43 (184·02 o 613·94) 162·19 (74·85 o 301·18) –55·74 (–63·28 o –48·78)* –57·10 (–64·53 o –50·28)* 31 579·40 (15 947·91 o 52 776·94) 14 114·74 (6609·85 o 26 162·13) –55·30 (–62·90 o –48·48)* –56·68 (–64·19 o –50·03)* ·· Dia hoeal diseases 133·15 (51·03 o 233·07) 60·15 (21·84 o 112·30) –54·83 (–61·70 o –45·79)* –56·28 (–62·91 o –47·53)* 11 661·60 (4481·93 o 20 495·06) 5381·00 (2025·40 o 10 118·70) –53·86 (–60·50 o –44·93)* –55·35 (–61·80 o –46·71)* ·· Lowe espi a o y in ec ions 173·89 (17·78 o 415·12) 88·31 (7·20 o 226·69) –49·22 (–56·08 o –37·47)* –50·59 (–57·26 o –39·05)* 14 868·01 (1516·40 o 35 518·80) 7564·20 (616·04 o 19 419·68) –49·12 (–55·96 o –37·42)* –50·49 (–57·14 o –38·99)* ·· Measles 59·38 (5·88 o 164·35) 13·73 (1·21 o 40·90) –76·87 (–82·40 o –71·74)* –77·86 (–83·16 o –72·91)* 5049·80 (506·57 o 13 966·03) 1169·54 (103·24 o 3473·72) –76·84 (–82·34 o –71·73)* –77·82 (–83·10 o –72·90)* 3 Low bi hweigh and sho ges a ion: all causes 2341·51 (2264·77 o 2427·94) 1673·60 (1589·23 o 1758·45) –28·52 (–31·98 o –24·88)* –28·19 (–31·66 o –24·53)* 202 783·89 (196 133·92 o 210 268·23) 144 947·75 (137 645·54 o 152 301·77) –28·52 (–31·97 o –24·88)* –28·19 (–31·66 o –24·53)* 4 Sho ges a ion o bi hweigh : all causes 2064·01 (1949·93 o 2171·84) 1485·61 (1392·05 o 1580·00) –28·02 (–31·59 o –24·49)* –27·69 (–31·27 o –24·14)* 178 754·75 (168 864·65 o 188 091·13) 128 668·91 (120 565·96 o 136 862·69) –28·02 (–31·58 o –24·49)* –27·69 (–31·27 o –24·14)* ·· Dia hoeal diseases 55·68 (50·20 o 61·51) 23·63 (20·92 o 26·58) –57·57 (–62·84 o –51·19)* –57·43 (–62·71 o –51·02)* 4820·28 (4345·76 o 5325·35) 2045·43 (1811·41 o 2301·28) –57·57 (–62·84 o –51·19)* –57·43 (–62·71 o –51·02)* ·· Lowe espi a o y in ec ions 183·79 (162·94 o 202·96) 104·40 (89·31 o 119·24) –43·20 (–48·74 o –37·39)* –42·98 (–48·54 o –37·15)* 15 913·47 (14 107·71 o 17 572·78) 9039·55 (7732·87 o 10 324·80) –43·20 (–48·74 o –37·39)* –42·97 (–48·54 o –37·15)* .. Uppe espi a o y in ec ions 0·09 (0·06 o 0·12) 0·05 (0·04 o 0·07) –41·66 (–60·35 o –14·21)* –41·40 (–60·16 o –13·83)* 7·54 (5·36 o 10·34) 4·40 (3·13 o 6·32) –41·66 (–60·35 o –14·21)* –41·40 (–60·16 o –13·82)* ·· O i is media 0·01 (0·01 o 0·02) 0·01 (0·00 o 0·01) –55·23 (–72·96 o –21·17)* –55·11 (–72·91 o –20·94)* 1·13 (0·78 o 1·72) 0·51 (0·33 o 0·83) –55·23 (–72·96 o –21·18)* –55·11 (–72·91 o –20·95)* ·· Pneumococcal meningi is 0·74 (0·51 o 1·02) 0·62 (0·40 o 0·93) –15·86 (–31·66 o 6·43) –15·56 (–31·41 o 6·80) 63·93 (43·85 o 87·89) 53·80 (35·00 o 80·84) –15·85 (–31·66 o 6·43) –15·56 (–31·41 o 6·80) ·· H in luenzae ype B meningi is 2·05 (1·48 o 2·68) 1·71 (1·22 o 2·40) –16·55 (–32·62 o 6·20) –16·25 (–32·37 o 6·59) 177·11 (127·74 o 231·69) 147·80 (105·37 o 207·64) –16·55 (–32·62 o 6·20) –16·25 (–32·37 o 6·59) ·· Meningococcal in ec ion 7·44 (5·63 o 9·42) 4·67 (3·45 o 6·41) –37·20 (–47·71 o –22·35)* –36·98 (–47·52 o –22·08)* 643·78 (487·60 o 815·98) 404·31 (298·70 o 555·31) –37·20 (–47·71 o –22·35)* –36·98 (–47·52 o –22·08)* ·· O he meningi is 5·57 (4·16 o 7·06) 5·57 (4·05 o 8·31) 0·08 (–17·80 o 26·45) 0·43 (–17·54 o 26·88) 481·88 (360·51 o 611·08) 482·25 (350·92 o 719·69) 0·08 (–17·80 o 26·45) 0·43 (–17·53 o 26·88) ·· Encephali is 1·34 (1·00 o 1·56) 1·00 (0·79 o 1·24) –24·98 (–43·32 o –2·82)* –24·73 (–43·13 o –2·52)* 115·89 (86·59 o 134·97) 86·95 (68·43 o 107·11) –24·98 (–43·32 o –2·82)* –24·73 (–43·13 o –2·52)* ·· Neona al p e e m bi h complica ions 819·36 (770·29 o 909·83) 590·38 (541·05 o 643·11) –27·95 (–33·72 o –22·15)* –27·60 (–33·41 o –21·78)* 70 980·50 (66 730·62 o 78 805·17) 51 151·21 (46 878·45 o 55 713·15) –27·94 (–33·70 o –22·14)* –27·59 (–33·39 o –21·77)* (Table 4 con inues on nex page) Global Heal h Me ics 1382 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Neona al encephalopa hy due o bi h asphyxia and auma 477·77 (426·69 o 525·03) 370·94 (322·96 o 419·15) –22·36 (–29·79 o –14·36)* –21·97 (–29·43 o –13·93)* 41 371·74 (36 949·03 o 45 464·08) 32 120·93 (27 966·29 o 36 295·65) –22·36 (–29·79 o –14·36)* –21·97 (–29·43 o –13·93)* ·· Neona al sepsis and o he neona al in ec ions 170·34 (138·61 o 217·43) 151·23 (126·64 o 206·06) –11·22 (–21·77 o 2·78) –10·86 (–21·43 o 3·20) 14 749·24 (12 001·55 o 18 826·29) 13 094·15 (10 964·91 o 17 842·59) –11·22 (–21·77 o 2·78) –10·86 (–21·44 o 3·20) ·· Haemoly ic disease and o he neona al jaundice 55·72 (48·90 o 64·54) 32·45 (27·90 o 38·04) –41·77 (–49·82 o –32·96)* –41·52 (–49·61 o –32·68)* 4824·42 (4234·14 o 5587·98) 2809·45 (2416·02 o 3293·80) –41·77 (–49·82 o –32·96)* –41·52 (–49·61 o –32·68)* ·· O he neona al diso de s 282·16 (250·52 o 317·48) 197·44 (173·31 o 220·92) –30·03 (–37·01 o –21·73)* –29·69 (–36·71 o –21·36)* 24 432·57 (21 692·72 o 27 491·34) 17 096·35 (15 006·94 o 19 130·02) –30·03 (–37·01 o –21·73)* –29·69 (–36·71 o –21·36)* ·· Sudden in an dea h synd ome 1·98 (1·47 o 2·54) 1·52 (1·16 o 1·87) –23·02 (–39·72 o –8·37)* –22·88 (–39·61 o –8·20)* 171·26 (127·36 o 219·51) 131·83 (100·77 o 161·72) –23·02 (–39·72 o –8·37)* –22·88 (–39·61 o –8·20)* 4 Low bi hweigh o ges a ion: all causes 1096·85 (1005·37 o 1207·52) 778·37 (705·63 o 864·12) –29·04 (–33·70 o –24·31)* –28·69 (–33·38 o –23·94)* 95 009·64 (87 086·08 o 104 596·97) 67 430·06 (61 121·27 o 74 855·14) –29·03 (–33·69 o –24·30)* –28·69 (–33·37 o –23·93)* ·· Dia hoeal diseases 8·81 (6·21 o 11·88) 3·44 (2·38 o 4·75) –60·94 (–66·12 o –55·24)* –60·78 (–65·99 o –55·07)* 762·62 (537·68 o 1028·73) 297·89 (206·10 o 411·47) –60·94 (–66·12 o –55·24)* –60·78 (–65·99 o –55·07)* ·· Lowe espi a o y in ec ions 35·74 (25·03 o 48·36) 19·19 (12·83 o 26·70) –46·30 (–52·21 o –39·99)* –46·06 (–51·99 o –39·72)* 3094·33 (2167·54 o 4187·61) 1661·65 (1111·03 o 2311·96) –46·30 (–52·21 o –39·99)* –46·06 (–51·99 o –39·71)* ·· Uppe espi a o y in ec ions 0·02 (0·01 o 0·03) 0·01 (0·01 o 0·02) –44·27 (–64·75 o –11·69)* –44·00 (–64·57 o –11·28)* 1·71 (1·05 o 2·67) 0·95 (0·56 o 1·55) –44·27 (–64·75 o –11·69)* –44·00 (–64·57 o –11·27)* ·· O i is media 0·00 (0·00 o 0·00) 0·00 (0·00 o 0·00) –55·15 (–71·15 o –26·78)* –55·00 (–71·08 o –26·52)* 0·16 (0·09 o 0·25) 0·07 (0·04 o 0·12) –55·15 (–71·15 o –26·78)* –55·00 (–71·08 o –26·52)* ·· Pneumococcal meningi is 0·13 (0·08 o 0·20) 0·11 (0·06 o 0·17) –19·39 (–35·79 o 2·80) –19·04 (–35·49 o 3·25) 11·42 (6·55 o 17·49) 9·20 (5·13 o 15·15) –19·39 (–35·79 o 2·80) –19·04 (–35·49 o 3·25) ·· H in luenzae ype B meningi is 0·36 (0·22 o 0·53) 0·29 (0·17 o 0·45) –20·05 (–36·17 o 2·27) –19·71 (–35·89 o 2·71) 31·35 (19·05 o 45·47) 25·07 (14·61 o 38·71) –20·05 (–36·16 o 2·27) –19·71 (–35·89 o 2·71) ·· Meningococcal in ec ion 1·30 (0·81 o 1·86) 0·80 (0·46 o 1·25) –38·84 (–50·93 o –23·22)* –38·58 (–50·72 o –22·88)* 112·69 (69·75 o 161·06) 68·92 (39·87 o 108·45) –38·84 (–50·93 o –23·22)* –38·58 (–50·72 o –22·88)* ·· O he meningi is 1·00 (0·62 o 1·44) 0·94 (0·55 o 1·48) –5·58 (–23·60 o 18·81) –5·19 (–23·30 o 19·32) 86·49 (53·37 o 124·38) 81·66 (47·91 o 127·74) –5·58 (–23·59 o 18·81) –5·18 (–23·29 o 19·32) ·· Encephali is 0·20 (0·13 o 0·28) 0·14 (0·10 o 0·21) –29·88 (–45·21 o –11·08)* –29·59 (–44·97 o –10·70)* 17·74 (11·22 o 24·41) 12·44 (8·28 o 17·83) –29·88 (–45·21 o –11·08)* –29·59 (–44·97 o –10·70)* ·· Neona al p e e m bi h complica ions 819·36 (770·29 o 909·83) 590·38 (541·05 o 643·11) –27·95 (–33·72 o –22·15)* –27·60 (–33·41 o –21·78)* 70 980·50 (66 730·62 o 78 805·17) 51 151·21 (46 878·45 o 55 713·15) –27·94 (–33·70 o –22·14)* –27·59 (–33·39 o –21·77)* ·· Neona al encephalopa hy due o bi h asphyxia and auma 117·60 (83·00 o 156·33) 84·68 (58·86 o 116·05) –27·99 (–35·44 o –20·42)* –27·62 (–35·10 o –20·01)* 10 183·45 (7187·60 o 13 537·45) 7332·98 (5096·63 o 10 049·16) –27·99 (–35·44 o –20·42)* –27·62 (–35·10 o –20·01)* ·· Neona al sepsis and o he neona al in ec ions 35·50 (23·71 o 50·81) 29·56 (19·65 o 43·87) –16·73 (–28·32 o –2·51)* –16·34 (–27·98 o –2·04)* 3073·99 (2053·27 o 4400·09) 2559·70 (1701·26 o 3798·68) –16·73 (–28·32 o –2·51)* –16·34 (–27·98 o –2·04)* ·· Haemoly ic disease and o he neona al jaundice 11·40 (7·99 o 15·92) 6·32 (4·34 o 9·07) –44·53 (–53·03 o –34·47)* –44·26 (–52·80 o –34·17)* 987·26 (692·04 o 1378·49) 547·68 (375·55 o 785·14) –44·52 (–53·03 o –34·47)* –44·26 (–52·80 o –34·17)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1383 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· O he neona al diso de s 65·24 (45·86 o 88·09) 42·37 (28·62 o 57·94) –35·06 (–42·81 o –26·85)* –34·73 (–42·52 o –26·48)* 5649·31 (3971·62 o 7628·08) 3668·67 (2478·27 o 5016·91) –35·06 (–42·81 o –26·85)* –34·73 (–42·52 o –26·48)* ·· Sudden in an dea h synd ome 0·19 (0·11 o 0·30) 0·14 (0·08 o 0·21) –28·09 (–43·32 o –14·05)* –27·96 (–43·22 o –13·89)* 16·64 (9·23 o 26·37) 11·97 (6·94 o 18·10) –28·09 (–43·32 o –14·05)* –27·96 (–43·22 o –13·89)* 3I on de iciency: all causes 27·52 (12·14 o 43·69) 20·95 (9·79 o 33·31) –23·88 (–30·25 o –15·97)* –31·14 (–36·96 o –24·17)* 33 835·12 (22 660·82 o 48 281·14) 35 849·87 (24 052·89 o 50 796·92) 5·95 (4·22 o 7·72)* –3·09 (–4·68 o –1·56)* ·· Ma e nal haemo hage 19·26 (7·33 o 32·35) 14·10 (5·33 o 24·29) –26·80 (–34·82 o –17·79)* –33·34 (–40·64 o –25·27)* 1105·24 (420·28 o 1854·49) 798·94 (301·29 o 1366·56) –27·71 (–35·87 o –18·55)* –33·84 (–41·20 o –25·64)* ·· Ma e nal sepsis and o he p egnancy ela ed in ec ions 5·54 (2·03 o 9·37) 3·89 (1·38 o 6·67) –29·86 (–38·95 o –20·14)* –35·83 (–44·10 o –26·86)* 325·54 (119·05 o 544·08) 227·22 (80·46 o 386·37) –30·20 (–38·96 o –20·38)* –35·70 (–43·84 o –27·13)* ·· I on-de iciency anaemia 2·72 (2·35 o 3·89) 2·96 (2·52 o 3·75) 8·94 (–9·11 o 27·26) –11·59 (–27·78 o 4·94) 32 404·33 (21 523·57 o 46 641·55) 34 823·71 (23 073·25 o 49 667·43) 7·47 (6·17 o 8·89)* –1·78 (–2·96 o –0·51)* 3Vi amin A de iciency: all causes 108·40 (62·61 o 166·64) 42·18 (24·16 o 65·39) –61·08 (–66·90 o –53·83)* –62·78 (–68·35 o –55·79)* 9600·08 (5604·44 o 14 578·34) 3979·05 (2357·30 o 6000·15) –58·55 (–64·51 o –51·19)* –60·47 (–66·15 o –53·43)* ·· Dia hoeal diseases 64·17 (32·47 o 96·79) 30·04 (14·54 o 46·71) –53·18 (–60·01 o –44·61)* –55·12 (–61·70 o –46·81)* 5620·97 (2833·29 o 8506·22) 2695·50 (1309·94 o 4149·27) –52·05 (–58·86 o –43·62)* –54·05 (–60·63 o –45·90)* ·· Measles 44·23 (13·84 o 96·01) 12·14 (3·73 o 28·13) –72·55 (–77·30 o –67·69)* –73·85 (–78·35 o –69·07)* 3753·95 (1185·75 o 8149·96) 1031·27 (318·97 o 2391·75) –72·53 (–77·21 o –67·68)* –73·83 (–78·30 o –69·05)* ·· Vi amin A de iciency ·· ·· ·· ·· 225·16 (139·62 o 348·12) 252·29 (158·71 o 388·09) 12·05 (8·70 o 15·49)* 2·64 (–0·33 o 5·60) 3Zinc de iciency: all causes 53·32 (2·85 o 141·73) 25·09 (1·32 o 69·47) –52·95 (–60·88 o –43·61)* –55·43 (–62·95 o –46·59)* 4651·43 (359·57 o 12 155·34) 2245·65 (213·63 o 5993·34) –51·72 (–59·17 o –38·63)* –54·27 (–61·32 o –41·88)* ·· Dia hoeal diseases 31·31 (0·00 o 87·89) 14·67 (0·00 o 42·50) ·· ·· 2785·75 (132·69 o 7615·90) 1359·88 (108·32 o 3778·60) –51·18 (–58·99 o –14·97)* –53·76 (–61·16 o –19·47)* .. Lowe espi a o y in ec ions 22·01 (0·00 o 86·72) 10·42 (0·00 o 42·20) .. .. 1865·68 (2·95 o 7331·05) 885·77 (2·26 o 3568·53) –52·52 (–60·86 o –18·33)* –55·03 (–62·93 o –22·65)* 2 Tobacco: all causes 6853·45 (6227·56 o 7447·85) 7131·38 (6503·23 o 7780·89) 4·06 (1·29 o 6·96)* –20·37 (–22·48 o –18·30)* 178 305·14 (163 133·82 o 194 298·17) 177 302·31 (162 327·84 o 194 250·39) –0·56 (–3·34 o 2·52) –21·31 (–23·35 o –19·05)* 3 Smoking: all causes 6081·95 (5443·81 o 6681·35) 6321·10 (5673·66 o 6962·35) 3·93 (0·87 o 7·06)* –20·68 (–22·98 o –18·31)* 153 365·37 (138 408·89 o 167 887·88) 155 065·75 (140 025·42 o 170 602·15) 1·11 (–1·79 o 4·20) –20·83 (–23·12 o –18·45)* ·· D ug-suscep ible ube culosis 129·07 (66·60 o 195·37) 90·24 (44·98 o 139·18) –30·08 (–34·42 o –26·43)* –44·49 (–48·00 o –41·50)* 4240·53 (2168·23 o 6389·84) 2934·12 (1440·35 o 4528·89) –30·81 (–34·75 o –27·37)* –43·68 (–47·17 o –40·93)* ·· Mul id ug- esis an ube culosis wi hou ex ensi e d ug esis ance 14·07 (7·18 o 21·44) 8·19 (4·00 o 12·82) –41·80 (–48·21 o –35·18)* –53·46 (–58·72 o –48·18)* 458·79 (234·16 o 698·87) 257·57 (126·48 o 404·28) –43·86 (–50·23 o –37·69)* –54·10 (–59·43 o –49·05)* ·· Ex ensi ely d ug- esis an ube culosis 0·92 (0·48 o 1·40) 1·33 (0·66 o 2·11) 44·76 (19·92 o 72·63)* 16·94 (–2·69 o 38·90) 31·47 (16·42 o 48·08) 43·78 (21·82 o 68·67) 39·10 (14·10 o 68·50)* 14·83 (–5·56 o 38·75) ·· Lowe espi a o y in ec ions 326·00 (257·89 o 397·51) 345·94 (270·42 o 426·72) 6·12 (0·26 o 10·80)* –19·55 (–23·91 o –16·10)* 7002·64 (5630·01 o 8415·41) 7022·96 (5529·91 o 8607·77) 0·29 (–5·31 o 5·35) –20·81 (–25·17 o –16·90)* (Table 4 con inues on nex page) Global Heal h Me ics 1384 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Lip and o al ca i y cance 51·72 (44·13 o 60·07) 64·11 (53·04 o 77·13) 23·95 (15·31 o 32·49)* –4·81 (–11·29 o 1·58) 1393·05 (1176·02 o 1627·58) 1658·72 (1362·64 o 2015·39) 19·07 (10·04 o 28·65)* –6·71 (–13·94 o 0·57) ·· Nasopha ynx cance 21·46 (15·13 o 28·44) 22·33 (16·02 o 30·03) 4·05 (–6·14 o 14·01) –18·25 (–25·96 o –10·94)* 635·38 (432·94 o 851·08) 618·24 (441·07 o 838·14) –2·70 (–13·59 o 9·00) –22·14 (–30·47 o –13·55)* ·· Oesophageal cance 144·04 (90·12 o 204·21) 144·40 (93·42 o 205·40) 0·25 (–5·55 o 8·89) –23·33 (–27·74 o –17·01)* 3249·88 (2072·43 o 4607·13) 3104·99 (2025·56 o 4431·70) –4·46 (–10·71 o 4·48) –25·91 (–30·69 o –19·11)* ·· S omach cance 86·47 (50·10 o 134·64) 78·50 (45·61 o 124·13) –9·21 (–15·82 o –2·65)* –30·05 (–34·90 o –25·17)* 1985·62 (1151·90 o 3061·29) 1668·26 (961·69 o 2631·19) –15·98 (–23·04 o –8·83)* –34·01 (–39·20 o –28·67)* ·· Colon and ec um cance 46·29 (32·90 o 59·71) 49·01 (33·90 o 64·52) 5·88 (–0·09 o 11·90) –19·96 (–24·42 o –15·55)* 973·58 (681·64 o 1272·87) 963·80 (667·18 o 1291·65) –1·00 (–7·15 o 5·34) –23·19 (–27·69 o –18·37)* ·· Li e cance due o hepa i is B 41·56 (18·21 o 77·66) 43·39 (19·66 o 81·96) 4·41 (–6·80 o 17·06) –17·17 (–24·98 o –8·46)* 1222·27 (522·08 o 2265·72) 1164·10 (521·30 o 2235·84) –4·76 (–17·66 o 10·74) –22·84 (–32·30 o –11·64)* ·· Li e cance due o hepa i is C 19·24 (10·53 o 28·42) 22·01 (12·01 o 32·79) 14·35 (7·81 o 21·02)* –12·81 (–17·64 o –8·10)* 414·97 (225·94 o 628·23) 448·80 (238·88 o 687·22) 8·15 (0·75 o 16·28)* –16·20 (–21·61 o –10·61)* ·· Li e cance due o alcohol use 14·69 (8·71 o 21·74) 16·71 (9·61 o 25·36) 13·74 (5·31 o 21·66)* –12·48 (–18·79 o –6·56)* 343·61 (201·26 o 506·60) 377·43 (217·22 o 566·00) 9·84 (0·81 o 18·67)* –14·44 (–20·97 o –7·97)* ·· Li e cance due o o he causes 24·71 (11·36 o 45·81) 26·42 (12·15 o 49·30) 6·90 (–4·05 o 18·94) –15·62 (–23·12 o –7·34)* 683·22 (286·75 o 1300·01) 662·38 (294·93 o 1262·06) –3·05 (–15·91 o 13·35) –21·80 (–31·15 o –10·21)* ·· Panc ea ic cance 61·47 (49·77 o 74·37) 70·90 (56·11 o 87·71) 15·34 (9·71 o 21·46)* –12·20 (–16·27 o –7·87)* 1315·34 (1059·48 o 1601·29) 1431·89 (1125·82 o 1797·72) 8·86 (2·52 o 15·73)* –15·66 (–20·48 o –10·57)* ·· La ynx cance 60·04 (50·50 o 68·78) 64·92 (53·57 o 76·19) 8·14 (2·92 o 13·33)* –17·06 (–21·01 o –13·10)* 1524·37 (1284·41 o 1751·12) 1596·46 (1320·70 o 1877·67) 4·73 (–0·81 o 10·00) –18·86 (–23·02 o –14·71)* ·· T acheal, b onchus, and lung cance 1014·39 (875·09 o 1123·75) 1144·75 (973·82 o 1299·87) 12·85 (7·75 o 17·44)* –13·53 (–17·47 o –10·01)* 22 094·05 (18 775·21 o 24 684·60) 23 701·45 (19 814·76 o 27 245·91) 7·28 (1·69 o 12·27)* –16·85 (–21·09 o –13·12)* ·· B eas cance 16·88 (5·04 o 30·02) 17·91 (5·25 o 31·90) 6·11 (–0·34 o 13·11) –18·14 (–22·76 o –13·09)* 457·80 (129·80 o 835·33) 452·41 (126·69 o 827·14) –1·18 (–8·24 o 6·76) –21·43 (–26·56 o –15·69)* ·· Ce ical cance 11·03 (3·91 o 19·39) 10·85 (3·81 o 18·98) –1·66 (–10·26 o 7·78) –22·54 (–28·68 o –15·43)* 331·91 (114·69 o 595·93) 306·32 (105·80 o 541·94) –7·71 (–17·35 o 2·77) –25·19 (–32·55 o –16·79)* ·· P os a e cance 15·29 (11·00 o 19·90) 16·68 (11·72 o 22·10) 9·09 (2·16 o 18·00)* –19·29 (–24·05 o –12·77)* 257·95 (186·43 o 331·39) 268·27 (190·32 o 355·74) 4·00 (–3·76 o 12·92) –21·25 (–26·88 o –14·50)* ·· Kidney cance 20·10 (13·46 o 26·02) 22·07 (14·53 o 29·44) 9·79 (1·71 o 18·14)* –16·07 (–21·91 o –9·92)* 464·77 (311·24 o 604·80) 480·06 (316·13 o 639·24) 3·29 (–5·41 o 12·59) –19·84 (–26·34 o –12·84)* ·· Bladde cance 44·33 (33·18 o 55·10) 49·84 (36·98 o 63·01) 12·42 (6·43 o 18·18)* –15·76 (–20·05 o –11·55)* 820·50 (616·52 o 1016·68) 867·04 (639·82 o 1098·93) 5·67 (–0·75 o 11·94) –19·01 (–23·71 o –14·36)* ·· Acu e lymphoid leukaemia 2·45 (1·19 o 3·88) 2·65 (1·26 o 4·39) 8·51 (–1·79 o 18·19) –14·18 (–21·95 o –6·75)* 74·37 (35·76 o 121·34) 77·25 (35·75 o 131·34) 3·87 (–8·05 o 15·59) –16·04 (–25·20 o –6·72)* ·· Ch onic lymphoid leukaemia 4·13 (2·06 o 6·30) 4·32 (2·09 o 6·76) 4·69 (–3·63 o 13·22) –21·24 (–27·22 o –15·09)* 81·77 (41·39 o 125·41) 81·18 (39·93 o 126·38) –0·73 (–9·78 o 8·35) –23·72 (–30·52 o –17·08)* ·· Acu e myeloid leukaemia 7·27 (3·54 o 11·03) 8·00 (3·82 o 12·46) 10·07 (2·74 o 16·47)* –14·79 (–20·27 o –10·13)* 174·17 (88·65 o 265·91) 182·46 (89·93 o 285·57) 4·76 (–3·79 o 12·31) –17·20 (–23·71 o –11·49)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1385 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ch onic myeloid leukaemia 2·27 (1·10 o 3·48) 1·92 (0·89 o 3·02) –15·62 (–22·48 o –8·88)* –34·65 (–39·76 o –29·68)* 56·81 (27·53 o 88·46) 45·30 (21·19 o 72·34) –20·26 (–27·97 o –13·34)* –36·45 (–42·56 o –30·76)* ·· O he leukaemia 8·73 (4·12 o 14·42) 8·74 (4·11 o 14·48) 0·05 (–8·87 o 8·12) –21·85 (–28·03 o –16·79)* 220·47 (100·95 o 372·96) 198·49 (92·02 o 332·58) –9·97 (–21·62 o 1·39) –27·29 (–35·24 o –19·78)* ·· Ischaemic hea disease 1346·04 (1125·86 o 1572·65) 1391·74 (1144·96 o 1649·56) 3·40 (–0·14 o 7·31) –20·16 (–22·96 o –17·24)* 36 051·24 (30 135·29 o 41 836·78) 36 302·60 (29 797·02 o 42 911·24) 0·70 (–2·92 o 4·82) –20·54 (–23·37 o –17·43)* ·· Ischaemic s oke 350·47 (292·23 o 407·20) 347·05 (290·43 o 408·73) –0·98 (–5·13 o 3·31) –24·72 (–27·99 o –21·50)* 8972·51 (7487·52 o 10 550·77) 9235·11 (7655·96 o 10 990·85) 2·93 (–1·37 o 6·94) –20·73 (–24·06 o –17·62)* ·· Haemo hagic s oke 574·87 (485·95 o 664·83) 535·26 (448·47 o 627·04) –6·89 (–10·16 o –3·66)* –27·91 (–30·41 o –25·36)* 16 024·57 (13 595·74 o 18 501·64) 14 873·84 (12 549·42 o 17 354·01) –7·18 (–10·27 o –4·08)* –26·69 (–29·11 o –24·28)* ·· Hype ensi e hea disease 92·58 (69·07 o 115·52) 104·36 (75·52 o 129·77) 12·72 (–0·81 o 23·61) –13·06 (–23·84 o –4·65)* 2418·95 (1818·67 o 3023·75) 2611·14 (1927·81 o 3211·98) 7·95 (–2·72 o 17·76) –14·97 (–23·65 o –7·28)* ·· A ial ib illa ion and lu e 11·78 (8·34 o 15·89) 14·23 (10·02 o 19·31) 20·80 (16·34 o 24·92)* –11·40 (–14·55 o –8·44)* 616·54 (429·29 o 846·49) 710·44 (488·75 o 984·65) 15·23 (12·91 o 17·40)* –10·95 (–12·66 o –9·34)* ·· Ao ic aneu ysm 22·06 (17·20 o 26·40) 22·71 (17·69 o 27·64) 2·92 (–2·08 o 9·42) –20·66 (–24·43 o –15·86)* 554·61 (435·81 o 658·02) 560·44 (442·97 o 678·22) 1·05 (–4·19 o 8·10) –20·47 (–24·50 o –15·10)* ·· Pe iphe al ascula disease 4·59 (3·26 o 5·98) 5·12 (3·60 o 6·91) 11·65 (–0·50 o 26·59) –15·97 (–24·80 o –5·05)* 148·14 (100·88 o 203·55) 163·17 (110·40 o 225·34) 10·14 (0·93 o 20·74)* –16·24 (–22·89 o –8·54)* ·· O he ca dio ascula and ci cula o y diseases 53·33 (40·77 o 70·74) 55·64 (41·83 o 73·98) 4·33 (–0·04 o 9·45) –19·15 (–22·65 o –15·27)* 1998·90 (1531·92 o 2560·68) 2084·86 (1574·17 o 2694·49) 4·30 (0·52 o 8·39)* –16·90 (–19·76 o –13·76)* ·· Ch onic obs uc i e pulmona y disease 1190·52 (889·10 o 1462·49) 1253·30 (989·51 o 1520·42) 5·27 (–0·57 o 14·11) –22·12 (–26·38 o –15·51)* 23 659·75 (18 550·88 o 28 461·63) 25 038·91 (20 395·51 o 29 918·00) 5·83 (–0·06 o 13·85) –19·26 (–23·63 o –13·01)* ·· As hma 65·36 (44·88 o 91·56) 56·81 (39·28 o 78·57) –13·08 (–20·43 o –5·24)* –32·94 (–38·71 o –26·92)* 2444·85 (1802·94 o 3242·52) 2291·51 (1694·45 o 2999·22) –6·27 (–12·71 o –0·11)* –25·66 (–30·95 o –20·73)* ·· O he ch onic espi a o y diseases 3·07 (2·06 o 4·10) 3·77 (2·53 o 5·06) 22·95 (13·58 o 33·14)* –5·85 (–12·82 o 1·88) 103·01 (73·48 o 140·16) 126·04 (88·32 o 176·23) 22·36 (12·41 o 32·01)* –1·70 (–9·84 o 6·67) ·· Pep ic ulce disease 43·27 (31·46 o 55·50) 36·14 (26·26 o 47·09) –16·48 (–21·32 o –12·20)* –35·23 (–39·05 o –31·93)* 1202·60 (882·23 o 1539·63) 1008·27 (740·13 o 1308·30) –16·16 (–20·61 o –11·83)* –33·35 (–36·87 o –30·04)* ·· Gallbladde and bilia y diseases 2·22 (1·49 o 2·91) 2·32 (1·55 o 3·09) 4·66 (–1·51 o 10·83) –20·29 (–25·11 o –15·43)* 54·26 (36·94 o 71·95) 55·54 (36·83 o 74·21) 2·36 (–2·84 o 7·48) –19·57 (–23·79 o –15·50)* ·· Alzheime ’s disease and o he demen ias 67·57 (33·10 o 106·19) 82·80 (39·50 o 132·02) 22·55 (15·91 o 27·45)* –11·65 (–17·20 o –7·77)* 1062·73 (491·18 o 1670·22) 1256·05 (555·38 o 1982·80) 18·19 (12·39 o 22·10)* –11·38 (–16·39 o –8·22)* ·· Pa kinson’s disease –20·15 (–26·54 o –14·37) –23·16 (–30·39 o –16·44) 14·93 (10·72 o 19·10)* –12·99 (–16·05 o –9·98)* –403·98 (–525·52 o –283·21) –461·19 (–599·84 o –324·73) 14·16 (10·52 o 17·80)* –12·22 (–14·86 o –9·59)* ·· Mul iple scle osis 1·70 (1·11 o 2·36) 1·68 (1·09 o 2·33) –0·89 (–9·77 o 5·59) –21·16 (–28·03 o –16·17)* 98·79 (62·61 o 138·27) 99·08 (62·16 o 140·65) 0·29 (–5·43 o 4·75) –18·13 (–22·71 o –14·62)* ·· Diabe es melli us 56·47 (17·07 o 99·11) 66·30 (19·12 o 117·72) 17·40 (11·86 o 21·43)* –9·78 (–14·35 o –6·53)* 2881·41 (847·72 o 5096·99) 3192·65 (911·95 o 5662·02) 10·80 (7·07 o 13·63)* –12·37 (–15·58 o –10·13)* ·· Rheuma oid a h i is 1·45 (0·58 o 2·38) 1·37 (0·54 o 2·27) –6·01 (–10·76 o –0·77)* –28·01 (–31·59 o –24·03)* 224·49 (88·79 o 401·57) 241·06 (94·19 o 434·89) 7·38 (4·34 o 9·93)* –14·89 (–17·34 o –12·89)* (Table 4 con inues on nex page) Global Heal h Me ics 1392 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Diabe es melli us 10·29 (1·45 o 18·98) 14·00 (1·98 o 25·60) 36·00 (29·34 o 43·64)* 4·40 (–0·81 o 10·51) 624·65 (87·34 o 1153·77) 869·55 (120·69 o 1598·30) 39·21 (32·22 o 47·76)* 10·89 (5·38 o 17·71)* 3 Die high in p ocessed mea : all causes 146·70 (29·93 o 269·63) 139·62 (29·84 o 271·40) –4·83 (–15·30 o 5·01) –28·85 (–36·31 o –21·48)* 3499·30 (1121·42 o 6024·02) 3196·04 (1091·35 o 5836·23) –8·67 (–19·23 o 2·16) –28·87 (–36·93 o –20·27)* ·· Colon and ec um cance 9·84 (5·09 o 15·48) 10·28 (5·24 o 16·68) 4·45 (–3·10 o 11·58) –21·45 (–26·99 o –16·30)* 196·63 (102·18 o 308·02) 194·85 (98·50 o 321·61) –0·90 (–8·58 o 6·64) –23·50 (–29·34 o –17·79)* ·· Ischaemic hea disease 121·78 (5·27 o 240·19) 114·54 (4·50 o 238·06) –5·94 (–17·54 o 5·48) –29·84 (–38·03 o –21·64)* 2421·47 (107·64 o 4745·93) 2116·23 (82·94 o 4522·45) –12·61 (–24·84 o 0·05) –32·11 (–41·45 o –22·48)* ·· Diabe es melli us 15·09 (7·05 o 24·10) 14·80 (6·45 o 25·75) –1·89 (–13·21 o 10·00) –25·27 (–33·73 o –16·41)* 881·20 (420·66 o 1466·58) 884·96 (395·86 o 1583·28) 0·43 (–9·91 o 10·71) –20·75 (–28·79 o –12·62)* 3 Die high in suga -swee ened be e ages: all causes 17·80 (11·49 o 29·39) 22·56 (15·33 o 33·36) 26·77 (–20·93 o 56·21) –4·36 (–40·34 o 19·43) 605·81 (401·43 o 932·96) 779·51 (523·90 o 1145·18) 28·67 (–13·65 o 50·53) 1·96 (–32·16 o 19·85) ·· Oesophageal cance 0·29 (0·09 o 0·55) 0·37 (0·11 o 0·70) 28·96 (–25·95 o 56·82) –1·48 (–44·00 o 19·43) 7·08 (2·10 o 13·48) 8·90 (2·55 o 17·04) 25·73 (–26·29 o 51·70) –2·25 (–41·60 o 17·56) ·· Colon and ec um cance 0·36 (0·21 o 0·69) 0·43 (0·27 o 0·65) 20·23 (–39·42 o 72·88) –9·20 (–53·49 o 29·91) 8·10 (4·86 o 15·13) 9·67 (6·13 o 14·54) 19·38 (–40·62 o 73·22) –7·22 (–53·29 o 33·26) ·· Li e cance due o hepa i is B 0·11 (0·04 o 0·31) 0·16 (0·07 o 0·29) 46·97 (–48·94 o 107·46) 15·78 (–61·11 o 65·31) 3·43 (1·25 o 9·32) 4·91 (2·09 o 9·01) 43·11 (–47·86 o 105·26) 15·74 (–58·01 o 66·01) ·· Li e cance due o hepa i is C 0·09 (0·04 o 0·17) 0·13 (0·06 o 0·22) 35·33 (–26·26 o 72·90) 2·46 (–42·04 o 30·86) 2·08 (0·95 o 3·96) 2·77 (1·23 o 4·80) 32·68 (–26·61 o 69·83) 2·19 (–45·21 o 30·56) ·· Li e cance due o alcohol use 0·07 (0·03 o 0·14) 0·09 (0·04 o 0·15) 38·16 (–35·40 o 78·76) 5·72 (–51·04 o 33·84) 1·56 (0·67 o 3·18) 2·15 (0·98 o 3·68) 37·92 (–31·88 o 72·80) 7·05 (–47·30 o 34·90) ·· Li e cance due o o he causes 0·07 (0·03 o 0·22) 0·11 (0·05 o 0·19) 47·23 (–49·13 o 98·67) 14·78 (–59·69 o 53·95) 2·05 (0·74 o 5·72) 2·93 (1·22 o 5·21) 42·72 (–40·63 o 97·68) 14·45 (–56·86 o 57·63) ·· Gallbladde and bilia y ac cance 0·10 (0·06 o 0·17) 0·12 (0·07 o 0·20) 21·19 (–26·26 o 53·17) –8·78 (–44·49 o 16·53) 2·17 (1·19 o 3·59) 2·56 (1·49 o 4·06) 18·44 (–25·82 o 54·57) –8·47 (–43·46 o 17·51) ·· Panc ea ic cance 0·12 (0·04 o 0·25) 0·15 (0·05 o 0·27) 20·30 (–51·55 o 98·90) –9·06 (–63·71 o 47·86) 2·64 (0·91 o 6·08) 3·12 (1·12 o 5·98) 18·12 (–53·72 o 96·56) –8·66 (–65·03 o 47·86) ·· B eas cance 0·15 (0·06 o 0·38) 0·17 (0·08 o 0·32) 14·33 (–56·82 o 109·36) –14·46 (–67·38 o 58·17) 3·61 (1·40 o 9·75) 4·14 (1·92 o 7·86) 14·87 (–62·30 o 129·42) –12·26 (–69·56 o 74·33) ·· U e ine cance 0·10 (0·07 o 0·16) 0·13 (0·09 o 0·20) 31·24 (–14·19 o 56·34) –1·19 (–31·40 o 16·65) 2·50 (1·60 o 3·91) 3·32 (2·20 o 4·84) 32·82 (–12·54 o 58·57) 2·48 (–32·80 o 21·96) ·· O a ian cance 0·03 (0·00 o 0·11) 0·03 (0·00 o 0·07) –5·42 (–97·18 o 231·08) –27·30 (–97·63 o 169·46) 0·81 (0·06 o 2·86) 0·75 (0·00 o 1·90) –7·10 (–97·19 o 231·03) –26·75 (–97·31 o 156·14) ·· Kidney cance 0·13 (0·08 o 0·20) 0·17 (0·11 o 0·26) 34·51 (–0·86 o 60·98) 2·17 (–24·86 o 21·78) 3·08 (1·96 o 4·80) 4·06 (2·61 o 6·04) 31·80 (–2·65 o 56·85) 2·54 (–25·05 o 22·42) ·· Thy oid cance 0·02 (0·01 o 0·03) 0·02 (0·01 o 0·04) 23·74 (–45·68 o 71·02) –5·05 (–56·07 o 32·19) 0·48 (0·23 o 0·95) 0·58 (0·31 o 0·95) 22·78 (–42·37 o 72·84) –2·72 (–53·99 o 35·78) ·· Non-Hodgkin lymphoma 0·07 (0·03 o 0·14) 0·08 (0·04 o 0·14) 14·80 (–48·12 o 89·49) –11·36 (–59·15 o 44·86) 1·93 (0·88 o 3·84) 2·17 (1·02 o 3·70) 12·11 (–53·36 o 89·82) –9·92 (–61·71 o 50·34) ·· Mul iple myeloma 0·04 (0·02 o 0·07) 0·04 (0·02 o 0·08) 20·90 (–36·98 o 86·20) –8·58 (–52·81 o 40·23) 0·80 (0·33 o 1·52) 0·96 (0·43 o 1·68) 19·88 (–41·55 o 79·48) –7·25 (–53·09 o 39·99) ·· Acu e lymphoid leukaemia 0·01 (0·01 o 0·03) 0·02 (0·01 o 0·03) 21·67 (–42·96 o 84·50) –0·50 (–52·49 o 49·86) 0·60 (0·33 o 1·16) 0·72 (0·44 o 1·15) 20·31 (–42·71 o 77·73) 2·35 (–50·81 o 53·90) (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1393 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ch onic lymphoid leukaemia 0·02 (0·01 o 0·03) 0·02 (0·01 o 0·03) 11·87 (–40·76 o 59·76) –17·04 (–56·19 o 17·59) 0·31 (0·17 o 0·60) 0·34 (0·20 o 0·57) 9·98 (–47·66 o 65·06) –15·46 (–59·33 o 28·08) ·· Acu e myeloid leukaemia 0·04 (0·02 o 0·06) 0·04 (0·03 o 0·07) 20·64 (–33·37 o 72·72) –5·40 (–47·60 o 32·17) 1·08 (0·62 o 1·88) 1·27 (0·79 o 2·04) 17·65 (–34·43 o 64·82) –3·94 (–45·68 o 33·05) ·· Ch onic myeloid leukaemia 0·01 (0·01 o 0·02) 0·01 (0·01 o 0·02) –11·77 (–55·23 o 31·96) –31·15 (–64·52 o 1·81) 0·31 (0·17 o 0·64) 0·26 (0·16 o 0·42) –15·95 (–62·20 o 24·58) –31·30 (–68·51 o 2·27) ·· O he leukaemia 0·04 (0·02 o 0·10) 0·04 (0·02 o 0·07) 7·12 (–62·16 o 97·24) –16·02 (–65·44 o 48·79) 1·08 (0·54 o 3·48) 1·09 (0·64 o 1·86) 1·35 (–70·91 o 82·39) –16·40 (–73·68 o 53·84) ·· Ischaemic hea disease 5·98 (3·78 o 9·98) 7·03 (4·58 o 10·61) 17·56 (–29·12 o 52·55) –11·34 (–46·57 o 15·33) 150·69 (97·37 o 229·60) 176·63 (116·37 o 263·07) 17·21 (–23·17 o 43·80) –7·75 (–40·83 o 13·00) ·· Ischaemic s oke 1·09 (0·61 o 2·32) 1·17 (0·73 o 1·80) 7·45 (–54·16 o 58·69) –19·02 (–66·03 o 20·18) 31·26 (19·20 o 57·90) 36·59 (24·19 o 54·00) 17·06 (–40·45 o 50·57) –9·27 (–55·99 o 17·68) ·· Haemo hagic s oke 2·14 (1·36 o 3·88) 2·47 (1·65 o 3·69) 15·27 (–38·70 o 39·47) –9·12 (–52·40 o 11·93) 72·43 (47·51 o 116·88) 84·66 (57·32 o 122·05) 16·90 (–28·03 o 35·60) –4·88 (–42·13 o 11·16) ·· Hype ensi e hea disease 0·94 (0·53 o 1·57) 1·33 (0·73 o 2·21) 41·34 (1·13 o 61·93)* 5·33 (–25·08 o 21·50) 22·35 (14·24 o 34·30) 30·09 (18·45 o 46·26) 34·67 (1·67 o 50·99)* 5·72 (–20·06 o 18·87) ·· A ial ib illa ion and lu e 0·18 (0·10 o 0·30) 0·25 (0·15 o 0·39) 44·03 (–1·62 o 70·54) –0·79 (–32·88 o 17·51) 5·37 (3·13 o 8·88) 7·33 (4·22 o 11·54) 36·35 (0·50 o 59·28)* 2·11 (–24·17 o 18·00) ·· As hma 0·15 (0·08 o 0·36) 0·14 (0·09 o 0·23) –3·48 (–64·53 o 42·11) –25·38 (–72·46 o 10·94) 15·00 (8·45 o 25·64) 17·32 (10·00 o 28·61) 15·47 (–28·42 o 40·68) –3·65 (–40·85 o 18·12) ·· Gallbladde and bilia y diseases 0·13 (0·08 o 0·21) 0·19 (0·12 o 0·28) 45·16 (5·28 o 65·76)* 7·18 (–20·39 o 22·76) 3·01 (1·95 o 4·61) 4·24 (2·75 o 6·19) 40·81 (3·82 o 57·89)* 10·74 (–18·83 o 24·22) .. Alzheime ’s disease and o he demen ias 1·09 (0·44 o 2·12) 1·57 (0·66 o 2·80) 43·79 (–31·20 o 81·61) –1·32 (–48·85 o 25·19) 13·62 (5·90 o 27·29) 18·90 (7·82 o 34·07) 38·78 (–28·85 o 85·48) 0·35 (–48·69 o 32·06) .. Diabe es melli us 2·68 (1·80 o 3·83) 3·72 (2·50 o 5·30) 38·65 (13·79 o 51·31)* 6·23 (–14·28 o 15·85) 160·49 (104·01 o 235·77) 228·01 (146·36 o 338·55) 42·07 (24·20 o 52·10)* 14·03 (–0·94 o 22·21) ·· Ch onic kidney disease due o diabe es melli us 0·69 (0·34 o 1·18) 1·05 (0·53 o 1·79) 51·91 (15·47 o 70·56)* 14·19 (–12·15 o 27·71) 21·91 (9·80 o 37·27) 32·96 (15·37 o 55·88) 50·42 (16·36 o 69·24)* 15·99 (–9·49 o 29·45) ·· Ch onic kidney disease due o hype ension 0·28 (0·12 o 0·51) 0·43 (0·18 o 0·78) 52·70 (–0·59 o 74·23) 10·13 (–27·47 o 28·35) 6·42 (3·12 o 10·98) 9·82 (4·86 o 16·38) 52·91 (2·60 o 73·37)* 15·09 (–21·34 o 31·55) ·· Ch onic kidney disease due o glome uloneph i is 0·29 (0·14 o 0·50) 0·43 (0·20 o 0·73) 46·29 (22·10 o 61·05)* 11·21 (–7·71 o 21·11) 9·59 (3·88 o 17·35) 13·85 (5·67 o 24·73) 44·51 (18·51 o 60·36)* 13·38 (–7·28 o 24·40) ·· Ch onic kidney disease due o o he causes 0·30 (0·14 o 0·52) 0·45 (0·21 o 0·78) 51·23 (14·95 o 70·98)* 13·60 (–11·31 o 26·17) 9·12 (3·96 o 16·64) 13·55 (5·90 o 24·85) 48·59 (10·10 o 67·56)* 15·55 (–13·97 o 28·71) ·· Os eoa h i is ·· ·· ·· ·· 12·25 (6·32 o 21·91) 17·50 (9·15 o 29·79) 42·81 (–10·75 o 77·51) 12·04 (–30·98 o 38·72) ·· Low back pain ·· ·· ·· ·· 23·67 (12·74 o 49·51) 27·62 (16·04 o 44·45) 16·69 (–41·75 o 83·77) –2·98 (–51·67 o 51·38) ·· Gou ·· ·· ·· ·· 1·82 (0·94 o 3·25) 2·48 (1·29 o 4·40) 36·03 (8·43 o 49·14)* 9·54 (–13·22 o 20·02) ·· Ca a ac ·· ·· ·· ·· 1·12 (0·43 o 3·45) 1·27 (0·64 o 2·43) 13·37 (–69·99 o 140·46) –13·50 (–77·20 o 81·95) 3 Die low in ib e: all causes 769·74 (446·50 o 1159·77) 877·85 (502·37 o 1337·53) 14·05 (10·69 o 17·13)* –13·93 (–16·34 o –11·62)* 18 522·14 (10 865·99 o 27 596·25) 20 119·47 (11 653·46 o 30 430·15) 8·62 (5·17 o 11·61)* –14·06 (–16·63 o –11·74)* ·· Colon and ec um cance 77·72 (39·53 o 121·45) 92·53 (46·61 o 146·52) 19·05 (13·44 o 23·86)* –10·11 (–14·25 o –6·60)* 1658·67 (852·86 o 2584·40) 1905·91 (965·68 o 3008·24) 14·91 (8·93 o 19·90)* –10·61 (–15·08 o –6·81)* (Table 4 con inues on nex page) Global Heal h Me ics 1394 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ischaemic hea disease 692·02 (395·74 o 1063·40) 785·32 (440·85 o 1225·40) 13·48 (9·90 o 16·76)* –14·36 (–16·96 o –11·96)* 16 863·47 (9820·85 o 25 673·28) 18 213·56 (10 409·47 o 28 118·37) 8·01 (4·25 o 11·19)* –14·42 (–17·20 o –11·94)* 3 Die low in calcium: all causes 135·49 (86·00 o 194·76) 159·88 (101·07 o 232·62) 18·00 (11·94 o 22·51)* –10·61 (–15·09 o –7·34)* 2935·65 (1882·89 o 4176·04) 3353·07 (2127·08 o 4832·47) 14·22 (7·84 o 18·84)* –11·07 (–15·93 o –7·61)* ·· Colon and ec um cance 135·49 (86·00 o 194·76) 159·88 (101·07 o 232·62) 18·00 (11·94 o 22·51)* –10·61 (–15·09 o –7·34)* 2935·65 (1882·89 o 4176·04) 3353·07 (2127·08 o 4832·47) 14·22 (7·84 o 18·84)* –11·07 (–15·93 o –7·61)* 3 Die low in sea ood omega 3 a y acids: all causes 1347·53 (575·06 o 2186·21) 1538·76 (641·93 o 2518·12) 14·19 (11·23 o 17·24)* –13·43 (–15·57 o –11·15)* 30 245·39 (13 187·67 o 48 313·74) 33 347·84 (14 222·64 o 53 678·05) 10·26 (7·23 o 13·38)* –13·56 (–15·86 o –11·20)* ·· Ischaemic hea disease 1347·53 (575·06 o 2186·21) 1538·76 (641·93 o 2518·12) 14·19 (11·23 o 17·24)* –13·43 (–15·57 o –11·15)* 30 245·39 (13 187·67 o 48 313·74) 33 347·84 (14 222·64 o 53 678·05) 10·26 (7·23 o 13·38)* –13·56 (–15·86 o –11·20)* 3 Die low in polyunsa u a ed a y acids: all causes 373·71 (152·88 o 579·39) 404·13 (167·80 o 628·84) 8·14 (1·10 o 15·92)* –18·99 (–24·21 o –13·07)* 8077·08 (3337·50 o 12 512·69) 8351·81 (3443·29 o 12 916·37) 3·40 (–2·82 o 10·23) –18·99 (–23·72 o –13·61)* ·· Ischaemic hea disease 373·71 (152·88 o 579·39) 404·13 (167·80 o 628·84) 8·14 (1·10 o 15·92)* –18·99 (–24·21 o –13·07)* 8077·08 (3337·50 o 12 512·69) 8351·81 (3443·29 o 12 916·37) 3·40 (–2·82 o 10·23) –18·99 (–23·72 o –13·61)* 3 Die high in ans a y acids: all causes 236·27 (80·11 o 490·84) 223·64 (62·82 o 513·16) –5·34 (–25·31 o 5·65) –29·61 (–44·81 o –21·00)* 5426·02 (1751·02 o 11 428·66) 5111·02 (1348·61 o 11 683·02) –5·81 (–24·90 o 4·01) –26·47 (–41·85 o –18·49)* ·· Ischaemic hea disease 236·27 (80·11 o 490·84) 223·64 (62·82 o 513·16) –5·34 (–25·31 o 5·65) –29·61 (–44·81 o –21·00)* 5426·02 (1751·02 o 11 428·66) 5111·02 (1348·61 o 11 683·02) –5·81 (–24·90 o 4·01) –26·47 (–41·85 o –18·49)* 3 Die high in sodium: all causes 2093·86 (641·82 o 4027·16) 2310·47 (654·70 o 4498·83) 10·35 (1·14 o 14·18)* –17·24 (–23·87 o –14·54)* 44 080·70 (14 013·37 o 84 853·20) 47 567·08 (14 436·69 o 92 411·61) 7·91 (0·83 o 11·33)* –16·81 (–22·41 o –14·20)* ·· S omach cance 87·78 (29·91 o 169·46) 82·00 (25·89 o 164·38) –6·58 (–19·18 o 0·49) –28·70 (–37·72 o –24·32)* 1858·76 (665·42 o 3570·13) 1677·96 (551·88 o 3313·52) –9·73 (–21·11 o –2·91)* –30·26 (–38·59 o –25·91)* ·· Rheuma ic hea disease 18·85 (5·42 o 40·97) 16·56 (4·21 o 36·93) –12·11 (–24·41 o –3·58)* –32·10 (–41·39 o –26·32)* 508·22 (141·81 o 1117·27) 433·72 (110·18 o 999·89) –14·66 (–26·19 o –7·04)* –31·92 (–41·31 o –26·21)* ·· Ischaemic hea disease 933·02 (228·66 o 1899·86) 1097·91 (271·71 o 2220·51) 17·67 (12·33 o 22·92)* –12·43 (–16·13 o –8·54)* 18 024·31 (4595·42 o 37 082·96) 20 494·46 (5230·42 o 41 448·18) 13·70 (9·53 o 19·27)* –12·58 (–15·65 o –8·42)* ·· Ischaemic s oke 298·64 (87·80 o 607·24) 312·00 (88·62 o 643·83) 4·48 (–3·00 o 9·19) –21·85 (–27·22 o –18·72)* 6331·08 (2048·13 o 12 479·99) 6939·12 (2243·57 o 13 630·21) 9·60 (4·34 o 14·91)* –16·53 (–20·56 o –12·41)* ·· Haemo hagic s oke 462·49 (172·54 o 842·63) 432·53 (147·88 o 808·61) –6·48 (–16·08 o –1·80)* –29·05 (–36·48 o –25·70)* 10 650·45 (3995·11 o 19 583·09) 9962·38 (3520·25 o 18 774·49) –6·46 (–14·68 o –2·50)* –27·53 (–34·08 o –24·41)* ·· Hype ensi e hea disease 142·05 (27·30 o 351·99) 181·96 (33·21 o 464·61) 28·10 (2·03 o 45·37)* –5·27 (–24·95 o 6·83) 2731·43 (670·95 o 6388·79) 3298·57 (730·16 o 7748·68) 20·76 (1·85 o 35·50)* –7·33 (–22·43 o 3·79) ·· O he ca diomyopa hy 10·66 (2·22 o 23·96) 12·52 (2·32 o 28·86) 17·39 (–3·70 o 28·91) –11·88 (–28·39 o –2·67)* 242·84 (51·24 o 538·45) 270·46 (53·89 o 606·34) 11·38 (–5·12 o 20·11) –12·68 (–26·01 o –5·61)* ·· A ial ib illa ion and lu e 11·26 (2·54 o 25·22) 15·56 (3·33 o 35·44) 38·19 (25·76 o 43·79)* –1·98 (–9·57 o 1·66) 382·36 (95·58 o 800·54) 501·90 (124·45 o 1052·73) 31·26 (25·19 o 34·93)* –0·58 (–4·89 o 2·57) ·· Ao ic aneu ysm 9·57 (2·18 o 20·52) 11·02 (2·31 o 24·08) 15·18 (2·55 o 21·25)* –13·17 (–22·38 o –9·02)* 184·54 (43·83 o 391·55) 204·79 (44·97 o 436·91) 10·97 (–0·89 o 17·09) –14·32 (–23·42 o –9·77)* ·· Pe iphe al ascula disease 1·88 (0·25 o 4·56) 2·51 (0·34 o 6·25) 33·19 (16·18 o 51·41)* –3·46 (–14·44 o 10·20) 50·71 (9·14 o 121·19) 62·48 (10·88 o 148·77) 23·20 (11·72 o 32·25)* –7·07 (–15·48 o –0·73)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1395 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Endoca di is 4·12 (0·77 o 9·81) 5·16 (0·90 o 12·34) 25·41 (14·57 o 30·73)* –5·45 (–13·78 o –1·43)* 92·56 (16·37 o 222·32) 111·10 (18·80 o 270·10) 20·04 (11·39 o 25·25)* –5·37 (–13·40 o –1·59)* ·· O he ca dio ascula and ci cula o y diseases 29·97 (6·67 o 64·98) 34·19 (7·06 o 77·30) 14·10 (–1·52 o 21·18) –14·37 (–25·64 o –9·26)* 866·90 (215·87 o 1874·08) 970·65 (226·05 o 2134·15) 11·97 (0·73 o 17·31)* –12·89 (–21·61 o –8·68)* ·· Ch onic kidney disease due o diabe es melli us 38·25 (9·51 o 82·81) 47·89 (10·61 o 105·42) 25·21 (10·95 o 29·75)* –5·22 (–15·38 o –2·14)* 1047·19 (279·10 o 2297·95) 1269·79 (302·82 o 2829·29) 21·26 (8·49 o 25·52)* –5·96 (–15·38 o –2·85)* ·· Ch onic kidney disease due o hype ension 23·28 (5·93 o 50·23) 30·37 (7·11 o 66·16) 30·44 (17·26 o 35·06)* –4·36 (–12·78 o –1·54)* 497·97 (135·51 o 1054·49) 626·30 (162·35 o 1355·19) 25·77 (15·42 o 29·65)* –4·23 (–11·72 o –1·41)* ·· Ch onic kidney disease due o glome uloneph i is 8·03 (1·35 o 19·34) 9·84 (1·48 o 24·04) 22·57 (8·58 o 26·59)* –6·75 (–16·15 o –4·18)* 241·64 (42·80 o 581·91) 282·61 (47·47 o 682·09) 16·95 (5·24 o 20·87)* –7·52 (–15·54 o –5·01)* ·· Ch onic kidney disease due o o he causes 14·03 (2·72 o 33·20) 18·43 (3·17 o 44·06) 31·38 (15·39 o 36·18)* –1·84 (–13·73 o 1·01) 369·73 (73·40 o 902·50) 460·78 (84·25 o 1145·85) 24·62 (11·02 o 28·56)* –2·97 (–13·68 o –0·33)* 2 Sexual abuse and iolence: all causes 149·42 (94·83 o 204·16) 73·83 (53·79 o 94·09) –50·59 (–54·93 o –41·98)* –57·82 (–61·57 o –50·49)* 11 095·59 (8127·52 o 13 985·73) 8201·58 (6354·86 o 10 332·83) –26·08 (–34·79 o –15·42)* –36·15 (–43·53 o –27·22)* 3 Childhood sexual abuse: all causes 8·98 (6·58 o 11·81) 8·74 (6·40 o 11·74) –2·66 (–13·60 o 10·23) –20·18 (–28·78 o –10·11)* 2495·64 (1766·89 o 3377·91) 2748·30 (1920·53 o 3735·79) 10·12 (7·71 o 12·41)* –6·09 (–8·31 o –4·17)* ·· Alcohol use diso de s 8·98 (6·58 o 11·81) 8·74 (6·40 o 11·74) –2·66 (–13·60 o 10·23) –20·18 (–28·78 o –10·11)* 814·13 (574·56 o 1131·70) 854·71 (596·52 o 1200·17) 4·98 (–1·17 o 10·82) –10·40 (–15·87 o –5·29)* ·· Majo dep essi e diso de ·· ·· ·· ·· 1681·51 (1101·62 o 2354·77) 1893·59 (1235·31 o 2667·57) 12·61 (11·02 o 14·30)* –4·04 (–5·26 o –2·80)* 3 In ima e pa ne iolence: all causes 140·45 (86·78 o 194·82) 65·09 (44·85 o 85·84) –53·65 (–57·43 o –45·90)* –60·39 (–63·74 o –53·55)* 8702·76 (6067·70 o 11 437·85) 5575·29 (4224·54 o 7079·58) –35·94 (–43·21 o –25·04)* –44·53 (–50·72 o –35·17)* ·· D ug-suscep ible HIV/ AIDS– ube culosis 26·36 (12·66 o 43·52) 9·23 (4·43 o 14·96) –64·97 (–67·40 o –62·15)* –70·87 (–72·90 o –68·73)* 1146·54 (540·62 o 1916·16) 423·59 (203·21 o 687·99) –63·05 (–65·77 o –59·57)* –68·63 (–70·89 o –65·77)* ·· Mul id ug- esis an HIV/AIDS– ube culosis wi hou ex ensi e d ug esis ance 2·07 (0·93 o 3·52) 0·71 (0·32 o 1·22) –65·82 (–72·96 o –56·64)* –71·63 (–77·56 o –64·16)* 88·64 (39·75 o 152·39) 31·67 (14·10 o 54·75) –64·27 (–71·71 o –54·47)* –69·71 (–75·98 o –61·51)* ·· Ex ensi ely d ug- esis an HIV/AIDS – ube culosis 0·02 (0·01 o 0·04) 0·02 (0·01 o 0·04) 13·96 (–2·84 o 32·78) –4·23 (–18·41 o 11·39) 0·96 (0·42 o 1·70) 1·12 (0·48 o 1·97) 16·38 (–0·88 o 36·31) –0·47 (–15·26 o 16·38) ·· HIV/AIDS esul ing in o he diseases 84·54 (43·40 o 129·36) 31·10 (16·08 o 47·65) –63·22 (–66·05 o –59·87)* –68·71 (–71·09 o –65·93)* 4027·09 (2046·13 o 6160·95) 1584·24 (814·13 o 2425·13) –60·66 (–63·52 o –57·44)* –66·07 (–68·50 o –63·31)* ·· Ma e nal abo ion, misca iage, and ec opic p egnancy 4·11 (2·45 o 6·19) 3·00 (1·75 o 4·79) –27·02 (–36·19 o –17·03)* –34·53 (–42·83 o –25·55)* 233·81 (137·40 o 351·12) 170·68 (97·12 o 270·75) –27·00 (–35·84 o –17·85)* –34·18 (–42·23 o –25·85)* ·· Majo dep essi e diso de ·· ·· ·· ·· 1582·91 (966·13 o 2381·34) 1870·82 (1146·94 o 2801·23) 18·19 (15·62 o 21·12)* –1·74 (–3·69 o 0·18) ·· Assaul by i ea m 4·73 (3·09 o 5·60) 4·77 (3·13 o 6·06) 0·75 (–8·07 o 24·07) –10·75 (–18·39 o 9·61) 250·39 (163·69 o 295·57) 246·14 (163·72 o 308·71) –1·70 (–10·63 o 22·32) –10·98 (–19·00 o 10·46) ·· Assaul by sha p objec 6·88 (4·69 o 8·17) 6·00 (4·41 o 7·87) –12·69 (–23·31 o 21·78) –23·39 (–32·53 o 6·30) 367·54 (255·41 o 435·61) 314·12 (235·32 o 404·00) –14·54 (–24·84 o 18·52) –23·58 (–32·59 o 5·48) ·· Sexual iolence ·· ·· ·· ·· 291·29 (191·88 o 418·18) 298·83 (195·75 o 428·19) 2·59 (0·69 o 4·22)* –6·63 (–7·90 o –5·72)* (Table 4 con inues on nex page) Global Heal h Me ics 1396 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Assaul by o he means 11·73 (8·71 o 14·49) 10·26 (8·02 o 13·17) –12·56 (–24·54 o 5·66) –23·23 (–33·65 o –7·28)* 713·59 (558·79 o 866·06) 634·08 (509·27 o 793·77) –11·14 (–22·12 o 4·98) –20·79 (–30·38 o –7·10)* 2 Unsa e sex: all causes 1799·64 (1709·98 o 1892·29) 1100·90 (1048·42 o 1148·40) –38·83 (–40·96 o –36·41)* –47·76 (–49·54 o –45·78)* 86 860·81 (81 591·84 o 92 234·51) 54 603·03 (51 340·06 o 58 075·62) –37·14 (–39·35 o –34·64)* –45·34 (–47·21 o –43·21)* ·· D ug-suscep ible HIV/ AIDS– ube culosis 363·54 (244·52 o 481·15) 177·41 (121·51 o 236·50) –51·20 (–54·00 o –48·03)* –58·56 (–60·94 o –56·00)* 17 186·87 (11 569·46 o 22 809·50) 8948·63 (6232·62 o 11 865·25) –47·93 (–50·95 o –44·18)* –54·73 (–57·35 o –51·55)* ·· Mul id ug- esis an HIV/AIDS– ube culosis wi hou ex ensi e d ug esis ance 30·65 (18·73 o 45·88) 14·52 (8·81 o 21·68) –52·62 (–61·10 o –42·60)* –59·80 (–67·03 o –51·32)* 1423·49 (866·21 o 2131·53) 714·22 (433·23 o 1064·03) –49·83 (–58·78 o –39·15)* –56·42 (–64·22 o –47·18)* ·· Ex ensi ely d ug- esis an HIV/AIDS– ube culosis 0·52 (0·33 o 0·79) 0·77 (0·47 o 1·20) 48·49 (29·74 o 70·40)* 27·46 (11·27 o 46·30)* 24·64 (15·40 o 37·14) 36·82 (22·60 o 56·99) 49·44 (30·40 o 72·32)* 30·37 (13·77 o 50·30)* ·· HIV/AIDS esul ing in o he diseases 1165·31 (1020·87 o 1330·03) 652·04 (578·82 o 729·70) –44·05 (–46·83 o –40·95)* –51·77 (–54·17 o –49·13)* 58 595·06 (51 311·35 o 66 970·36) 34 615·61 (30 661·75 o 38 960·02) –40·92 (–43·71 o –37·90)* –48·30 (–50·71 o –45·70)* ·· Syphilis 3·31 (2·85 o 3·91) 3·02 (2·55 o 3·44) –8·89 (–18·77 o 9·37) –24·89 (–33·13 o –9·95)* 277·24 (229·80 o 328·03) 305·18 (247·07 o 367·04) 10·08 (1·88 o 18·96)* –8·03 (–14·11 o –0·79)* ·· Chlamydial in ec ion 1·24 (0·99 o 1·37) 1·19 (0·98 o 1·33) –4·51 (–11·73 o 12·18) –20·70 (–26·52 o –7·57)* 519·31 (341·24 o 781·67) 562·13 (370·06 o 850·69) 8·25 (5·89 o 10·42)* –3·33 (–5·56 o –1·40)* ·· Gonococcal in ec ion 3·51 (2·81 o 3·85) 3·37 (2·76 o 3·80) –4·05 (–11·10 o 12·51) –20·87 (–26·48 o –7·90)* 581·90 (412·15 o 823·83) 674·77 (467·35 o 974·12) 15·96 (10·35 o 21·76)* 2·68 (–2·71 o 7·83) ·· T ichomoniasis ·· ·· ·· ·· 170·83 (65·10 o 361·77) 198·07 (75·83 o 420·49) 15·95 (14·84 o 17·09)* 1·82 (0·94 o 2·72)* ·· Geni al he pes ·· ·· ·· ·· 187·73 (60·91 o 427·68) 221·21 (71·15 o 506·61) 17·84 (15·47 o 19·69)* –0·16 (–1·64 o 1·54) ·· O he sexually ansmi ed diseases 1·73 (1·40 o 1·90) 1·63 (1·35 o 1·83) –5·92 (–12·96 o 11·16) –21·03 (–26·82 o –7·18)* 858·99 (589·04 o 1221·09) 942·39 (643·29 o 1348·57) 9·71 (7·38 o 12·17)* –2·62 (–4·83 o –0·42)* ·· Ce ical cance 229·83 (195·46 o 245·84) 246·95 (203·95 o 263·27) 7·45 (1·21 o 15·47)* –15·99 (–20·69 o –9·78)* 7034·76 (5873·55 o 7509·99) 7384·00 (6014·77 o 7862·78) 4·96 (–1·30 o 13·23) –15·71 (–20·76 o –9·21)* 2 Low physical ac i i y: all causes 1159·60 (607·84 o 1790·07) 1373·34 (717·65 o 2084·16) 18·43 (–7·89 o 55·46) –12·88 (–31·98 o 13·86) 21 078·75 (11 156·78 o 32 368·81) 24 315·86 (12 811·32 o 36 604·69) 15·36 (–12·15 o 55·44) –11·79 (–32·55 o 18·47) ·· Colon and ec um cance 20·87 (1·07 o 50·40) 25·51 (1·28 o 61·93) 22·21 (–46·00 o 212·87) –8·42 (–59·11 o 136·31) 411·01 (23·10 o 991·31) 488·61 (26·82 o 1183·40) 18·88 (–48·29 o 205·64) –8·33 (–59·81 o 136·94) ·· B eas cance 6·71 (0·04 o 14·74) 7·85 (0·03 o 17·15) 16·97 (–19·98 o 88·93) –10·88 (–38·58 o 44·86) 175·07 (1·05 o 388·06) 200·14 (0·80 o 440·98) 14·33 (–24·10 o 90·78) –10·01 (–39·82 o 49·21) ·· Ischaemic hea disease 835·44 (347·97 o 1353·66) 1005·58 (425·31 o 1640·08) 20·37 (–6·38 o 58·30) –11·49 (–30·93 o 15·93) 14 658·37 (6114·10 o 23 953·87) 16 943·23 (7260·81 o 27 786·10) 15·59 (–11·49 o 54·73) –11·42 (–31·91 o 18·08) ·· Ischaemic s oke 267·12 (53·52 o 511·96) 295·28 (49·52 o 562·19) 10·54 (–19·06 o 49·40) –18·82 (–40·33 o 9·53) 4725·12 (1026·32 o 9141·81) 5268·62 (938·08 o 10 006·35) 11·50 (–18·88 o 54·06) –15·63 (–38·34 o 16·18) ·· Diabe es melli us 29·46 (7·36 o 52·61) 39·12 (8·65 o 71·86) 32·80 (–11·95 o 104·74) –0·40 (–33·63 o 52·78) 1109·18 (248·01 o 2082·98) 1415·26 (312·14 o 2604·08) 27·59 (–17·68 o 104·26) –0·58 (–35·47 o 58·06) (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1397 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) 1 Me abolic isks: all causes 14 834·47 (13 966·55 o 15 690·95) 17 493·53 (16 427·65 o 18 524·26) 17·92 (15·73 o 20·58)* –11·86 (–13·47 o –9·94)* 348 438·17 (324 520·78 o 374 936·88) 401 813·92 (372 407·65 o 434 394·06) 15·32 (13·16 o 17·52)* –10·29 (–11·98 o –8·60)* 2 High as ing plasma glucose: all causes 4700·40 (3722·99 o 5906·04) 5612·45 (4457·29 o 6987·54) 19·40 (15·54 o 23·19)* –10·32 (–13·29 o –7·61)* 123 096·04 (102 887·96 o 146 660·95) 144 088·58 (119 872·60 o 171 585·77) 17·05 (13·94 o 19·89)* –8·83 (–11·35 o –6·55)* ·· D ug-suscep ible ube culosis 125·08 (78·55 o 175·35) 99·60 (62·39 o 140·59) –20·36 (–24·38 o –16·57)* –37·14 (–40·10 o –34·46)* 4013·77 (2581·12 o 5546·25) 3126·64 (2002·75 o 4288·46) –22·10 (–25·60 o –18·55)* –37·09 (–39·78 o –34·65)* ·· Mul id ug- esis an ube culosis wi hou ex ensi e d ug esis ance 12·50 (7·74 o 18·06) 8·80 (5·32 o 12·83) –29·61 (–36·56 o –22·33)* –44·21 (–49·66 o –38·40)* 394·88 (253·40 o 557·02) 266·97 (168·75 o 375·02) –32·39 (–38·90 o –25·48)* –45·28 (–50·42 o –39·77)* ·· Ex ensi ely d ug- esis an ube culosis 0·54 (0·33 o 0·79) 0·94 (0·58 o 1·39) 73·66 (50·32 o 101·15)* 37·94 (20·01 o 59·36)* 17·18 (10·63 o 24·33) 28·42 (17·68 o 40·36) 65·41 (42·36 o 90·02)* 34·13 (15·91 o 54·00)* ·· Colon and ec um cance 46·54 (11·36 o 101·41) 56·18 (13·51 o 122·80) 20·70 (15·48 o 25·34)* –9·50 (–13·53 o –5·91)* 884·79 (208·91 o 1926·46) 1047·94 (242·88 o 2300·07) 18·44 (13·03 o 23·15)* –9·42 (–13·57 o –5·78)* ·· Li e cance due o o he causes 10·01 (2·06 o 23·07) 11·82 (2·44 o 26·96) 18·12 (13·22 o 22·67)* –8·69 (–12·24 o –5·26)* 247·67 (51·70 o 571·25) 279·35 (58·20 o 649·12) 12·79 (7·38 o 17·65)* –11·62 (–15·55 o –7·90)* ·· Panc ea ic cance 21·37 (4·71 o 46·72) 27·75 (6·10 o 60·79) 29·86 (26·27 o 33·12)* –2·11 (–4·96 o 0·48) 406·22 (90·54 o 891·18) 518·70 (115·69 o 1142·16) 27·69 (24·05 o 30·83)* –2·46 (–5·20 o 0·04) ·· T acheal, b onchus, and lung cance 100·11 (22·74 o 219·56) 117·06 (26·22 o 256·14) 16·93 (13·75 o 19·76)* –10·83 (–13·19 o –8·64)* 2028·69 (457·34 o 4483·59) 2304·26 (517·29 o 5093·70) 13·58 (10·25 o 16·54)* –12·74 (–15·22 o –10·53)* ·· B eas cance 26·09 (4·93 o 59·11) 31·03 (5·96 o 69·25) 18·94 (11·73 o 26·02)* –10·02 (–15·31 o –4·93)* 637·43 (120·29 o 1460·33) 749·77 (144·08 o 1694·69) 17·62 (9·76 o 25·72)* –8·95 (–14·91 o –2·97)* ·· O a ian cance 8·11 (1·53 o 19·32) 10·01 (1·88 o 23·94) 23·40 (18·12 o 28·40)* –6·84 (–10·75 o –3·13)* 182·64 (34·17 o 438·11) 226·27 (41·63 o 545·49) 23·89 (18·46 o 29·09)* –5·00 (–9·13 o –1·10)* ·· Bladde cance 10·79 (2·22 o 23·92) 13·47 (2·80 o 29·79) 24·87 (20·66 o 28·68)* –6·86 (–10·10 o –3·96)* 185·65 (37·01 o 413·28) 225·37 (45·96 o 501·26) 21·39 (16·66 o 25·27)* –7·62 (–11·16 o –4·73)* ·· Ischaemic hea disease 1576·70 (935·55 o 2479·20) 1883·33 (1104·82 o 2942·53) 19·45 (13·37 o 25·39)* –11·29 (–15·21 o –7·64)* 29 401·46 (18 681·34 o 45 481·26) 33 937·53 (21 184·55 o 51 236·60) 15·43 (10·21 o 20·56)* –11·40 (–15·50 o –7·55)* ·· Ischaemic s oke 449·06 (229·48 o 849·74) 472·53 (246·22 o 879·04) 5·23 (–1·90 o 12·75) –21·44 (–26·20 o –17·05)* 8810·40 (4539·51 o 14 964·85) 9467·73 (5021·42 o 15 876·46) 7·46 (0·60 o 13·96)* –18·27 (–23·34 o –13·54)* ·· Haemo hagic s oke 484·34 (304·87 o 745·37) 473·30 (301·08 o 720·04) –2·28 (–8·77 o 3·28) –25·71 (–30·75 o –21·17)* 10 790·83 (6746·12 o 15 844·21) 10 638·08 (6692·27 o 15 613·04) –1·42 (–7·28 o 3·80) –23·88 (–28·89 o –19·71)* ·· Pe iphe al ascula disease 8·67 (6·23 o 12·26) 11·73 (8·71 o 17·62) 35·33 (24·67 o 48·64)* –2·51 (–9·98 o 6·88) 213·89 (150·72 o 302·55) 271·68 (195·01 o 383·83) 27·02 (21·52 o 34·82)* –4·49 (–8·52 o 1·11) ·· Alzheime ’s disease and o he demen ias 123·02 (26·35 o 274·89) 174·35 (37·30 o 388·04) 41·73 (38·26 o 45·05)* –1·20 (–3·44 o 1·60) 1584·88 (330·04 o 3563·61) 2138·24 (445·48 o 4857·92) 34·92 (32·10 o 37·60)* –1·28 (–3·30 o 1·10) ·· Diabe es melli us 1095·53 (1065·39 o 1121·32) 1436·26 (1401·25 o 1469·57) 31·10 (28·92 o 33·39)* –0·87 (–2·52 o 0·84) 45 947·41 (38 659·07 o 54 662·94) 57 175·71 (47 919·49 o 68 211·91) 24·44 (22·70 o 26·24)* –1·66 (–3·03 o –0·22)* ·· Ch onic kidney disease due o diabe es melli us 384·78 (349·87 o 418·93) 500·41 (452·11 o 543·57) 30·05 (26·18 o 32·84)* –0·63 (–3·43 o 1·30) 11 723·50 (10 608·16 o 12 883·32) 14 649·82 (13 196·95 o 16 191·89) 24·96 (21·91 o 27·57)* –1·37 (–3·51 o 0·51) (Table 4 con inues on nex page) Global Heal h Me ics 1398 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ch onic kidney disease due o hype ension 103·23 (70·71 o 134·57) 135·31 (92·80 o 176·80) 31·08 (24·95 o 37·33)* –3·63 (–7·93 o 0·57) 2165·18 (1452·61 o 2857·87) 2724·97 (1827·82 o 3615·75) 25·85 (20·11 o 31·49)* –4·20 (–8·66 o 0·03) ·· Ch onic kidney disease due o glome uloneph i is 42·94 (28·57 o 57·82) 54·38 (36·92 o 73·20) 26·63 (21·53 o 31·75)* –3·73 (–7·53 o 0·00) 1251·76 (815·12 o 1731·15) 1519·82 (1004·85 o 2100·93) 21·42 (17·17 o 25·92)* –4·39 (–7·34 o –1·01)* ·· Ch onic kidney disease due o o he causes 71·01 (48·20 o 94·44) 94·20 (63·89 o 125·10) 32·66 (26·70 o 38·48)* –0·15 (–4·43 o 3·81) 1866·69 (1234·98 o 2533·02) 2346·56 (1566·99 o 3183·01) 25·71 (20·33 o 30·88)* –2·03 (–6·05 o 1·77) ·· Glaucoma ·· ·· ·· ·· 25·15 (5·71 o 58·51) 33·85 (7·75 o 78·65) 34·62 (31·92 o 37·57)* 1·52 (–0·42 o 3·66) ·· Ca a ac ·· ·· ·· ·· 315·98 (65·93 o 735·41) 410·89 (85·82 o 961·77) 30·04 (27·58 o 32·78)* –1·16 (–3·06 o 1·06) 2High o al choles e ol: all causes 3802·10 (2971·09 o 4832·93) 4392·51 (3374·22 o 5619·87) 15·53 (11·51 o 19·77)* –14·14 (–16·62 o –11·41)* 83 976·46 (70 004·69 o 98 804·76) 93 844·03 (78 027·31 o 111 266·48) 11·75 (8·59 o 15·13)* –13·29 (–15·68 o –10·73)* ·· Ischaemic hea disease 3343·63 (2597·25 o 4187·22) 3896·10 (2982·29 o 4940·40) 16·52 (12·29 o 20·89)* –13·22 (–15·68 o –10·56)* 73 403·57 (61 220·12 o 86 047·11) 82 187·03 (68 385·19 o 96 854·44) 11·97 (8·76 o 15·47)* –12·88 (–15·33 o –10·24)* ·· Ischaemic s oke 458·46 (185·09 o 924·24) 496·40 (196·69 o 990·11) 8·28 (1·92 o 14·44)* –20·63 (–23·82 o –17·08)* 10 572·88 (6206·10 o 17 681·57) 11 657·00 (6791·38 o 19 428·74) 10·25 (6·20 o 14·39)* –16·02 (–19·10 o –12·79)* 2 High sys olic blood p essu e: all causes 9083·07 (8209·73 o 9963·14) 10 455·86 (9381·88 o 11 507·49) 15·11 (12·53 o 18·15)* –14·05 (–15·90 o –11·81)* 188 635·23 (171 004·50 o 205 178·38) 212 105·09 (191 466·22 o 230 661·27) 12·44 (10·03 o 15·07)* –13·27 (–15·09 o –11·25)* ·· Rheuma ic hea disease 85·51 (58·24 o 126·10) 80·86 (55·41 o 124·17) –5·43 (–12·76 o 3·81) –26·92 (–32·20 o –20·72)* 2412·32 (1643·79 o 3500·44) 2234·54 (1547·75 o 3250·51) –7·37 (–13·42 o 0·51) –25·82 (–30·59 o –19·76)* ·· Ischaemic hea disease 4476·47 (3732·81 o 5193·76) 5261·72 (4374·30 o 6188·35) 17·54 (14·19 o 21·12)* –12·69 (–14·94 o –10·11)* 85 975·47 (74 665·22 o 97 205·97) 97 886·68 (84 378·88 o 110 500·79) 13·85 (10·72 o 17·14)* –12·44 (–14·77 o –9·97)* ·· Ischaemic s oke 1283·00 (989·81 o 1551·76) 1372·51 (1053·44 o 1670·88) 6·98 (3·05 o 11·54)* –20·42 (–23·09 o –17·59)* 25 564·17 (20 155·09 o 29 832·63) 28 119·95 (21 993·71 o 32 960·56) 10·00 (6·27 o 13·81)* –16·42 (–19·14 o –13·56)* ·· Haemo hagic s oke 1636·18 (1343·27 o 1897·92) 1672·64 (1375·89 o 1947·04) 2·23 (–0·33 o 4·87) –22·45 (–24·32 o –20·60)* 37 920·74 (31 833·70 o 43 655·27) 38 611·64 (32 491·61 o 44 204·86) 1·82 (–0·41 o 4·22) –20·91 (–22·79 o –19·01)* ·· Hype ensi e hea disease 694·18 (579·81 o 760·86) 893·14 (698·18 o 982·33) 28·66 (14·46 o 42·90)* –4·39 (–14·79 o 5·66) 13 562·97 (11 596·54 o 15 040·61) 16 323·95 (13 447·14 o 17 832·20) 20·36 (10·19 o 32·88)* –6·60 (–14·56 o 2·76) ·· O he ca diomyopa hy 60·64 (44·14 o 77·33) 74·93 (54·83 o 95·99) 23·56 (16·20 o 31·99)* –7·84 (–13·17 o –1·67)* 1352·53 (1021·85 o 1642·20) 1599·77 (1242·11 o 1935·40) 18·28 (11·07 o 26·29)* –7·37 (–12·73 o –1·09)* ·· A ial ib illa ion and lu e 61·68 (45·24 o 81·70) 85·31 (62·06 o 113·83) 38·31 (33·98 o 42·56)* –2·78 (–5·10 o –0·60)* 1865·37 (1396·49 o 2444·60) 2439·54 (1822·85 o 3211·02) 30·78 (28·89 o 32·53)* –1·52 (–2·73 o –0·44)* ·· Ao ic aneu ysm 51·01 (40·98 o 60·67) 60·10 (48·02 o 72·42) 17·81 (13·84 o 22·53)* –11·62 (–14·32 o –8·15)* 961·55 (799·00 o 1113·52) 1100·81 (930·12 o 1274·73) 14·48 (10·15 o 19·96)* –11·71 (–14·92 o –7·65)* ·· Pe iphe al ascula disease 12·49 (8·26 o 18·74) 16·55 (10·89 o 25·60) 32·49 (20·21 o 47·35)* –4·83 (–12·82 o 5·05) 290·81 (199·85 o 436·13) 360·60 (246·52 o 530·75) 24·00 (17·02 o 32·57)* –6·80 (–11·75 o –0·54)* ·· Endoca di is 25·33 (19·02 o 32·47) 33·12 (24·85 o 42·80) 30·76 (25·24 o 36·10)* –1·38 (–5·39 o 2·95) 589·46 (447·95 o 744·37) 745·71 (570·49 o 942·16) 26·51 (21·03 o 31·79)* 0·16 (–4·21 o 4·17) ·· O he ca dio ascula and ci cula o y diseases 174·04 (148·57 o 214·23) 208·84 (177·87 o 255·72) 20·00 (15·44 o 25·66)* –10·49 (–13·75 o –6·47)* 4740·48 (3978·63 o 5703·94) 5577·83 (4690·60 o 6705·53) 17·66 (14·21 o 22·09)* –8·60 (–11·32 o –5·34)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1399 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Ch onic kidney disease due o diabe es melli us 176·23 (128·84 o 227·68) 233·70 (170·75 o 301·63) 32·61 (29·00 o 35·48)* –0·06 (–2·77 o 1·94) 4755·11 (3375·01 o 6163·36) 6154·78 (4359·36 o 7973·15) 29·44 (26·62 o 32·07)* –0·01 (–2·10 o 1·78) ·· Ch onic kidney disease due o hype ension 222·32 (199·99 o 248·86) 299·48 (268·03 o 335·26) 34·71 (30·47 o 38·02)* –0·96 (–3·95 o 1·00) 5166·00 (4517·97 o 5842·00) 6602·34 (5756·41 o 7488·87) 27·80 (24·67 o 30·62)* –1·02 (–3·31 o 0·87) ·· Ch onic kidney disease due o glome uloneph i is 47·82 (34·20 o 62·17) 60·17 (42·74 o 78·14) 25·83 (22·33 o 29·04)* –4·69 (–6·90 o –2·70)* 1443·70 (1010·81 o 1931·01) 1739·55 (1207·79 o 2320·30) 20·49 (17·59 o 23·37)* –4·97 (–6·98 o –2·95)* ·· Ch onic kidney disease due o o he causes 76·17 (51·67 o 99·57) 102·79 (69·50 o 135·39) 34·95 (30·99 o 38·74)* 0·84 (–1·83 o 3·10) 2034·56 (1366·91 o 2688·13) 2607·39 (1738·64 o 3467·30) 28·16 (25·16 o 31·01)* –0·11 (–2·27 o 1·77) 2 High body-mass index: all causes 3519·12 (2136·48 o 5165·34) 4525·10 (2867·22 o 6434·24) 28·59 (23·43 o 35·93)* –2·71 (–6·52 o 2·81) 105 257·57 (65 833·95 o 150 547·40) 135 381·33 (88 608·73 o 187 363·70) 28·62 (23·09 o 36·63)* 0·88 (–3·40 o 7·02) ·· Oesophageal cance 57·66 (18·86 o 112·99) 70·33 (22·52 o 133·63) 21·97 (11·96 o 36·08)* –6·97 (–14·64 o 3·67) 1357·91 (431·31 o 2647·91) 1622·45 (516·51 o 3060·94) 19·48 (9·83 o 33·83)* –7·80 (–15·24 o 3·26) ·· Colon and ec um cance 49·63 (26·72 o 79·41) 65·11 (35·86 o 102·02) 31·19 (25·23 o 38·71)* –0·94 (–5·50 o 4·74) 1075·85 (579·66 o 1714·70) 1394·02 (775·82 o 2160·04) 29·57 (22·96 o 37·66)* –0·04 (–4·94 o 6·05) ·· Li e cance due o hepa i is B 26·37 (8·91 o 55·20) 37·72 (13·44 o 74·28) 43·05 (31·18 o 64·94)* 11·96 (2·72 o 28·75)* 782·13 (261·88 o 1631·20) 1078·26 (379·06 o 2124·71) 37·86 (25·99 o 60·04)* 10·01 (0·61 o 27·39)* ·· Li e cance due o hepa i is C 15·00 (6·11 o 28·01) 21·21 (8·95 o 38·36) 41·40 (33·58 o 52·25)* 6·97 (1·14 o 15·12)* 328·28 (134·34 o 602·47) 459·82 (197·62 o 813·07) 40·07 (31·65 o 52·24)* 7·44 (1·26 o 16·40)* ·· Li e cance due o alcohol use 11·43 (4·52 o 21·77) 16·59 (6·67 o 31·05) 45·18 (35·92 o 58·24)* 10·99 (3·90 o 20·62)* 265·54 (104·88 o 498·00) 383·17 (157·32 o 707·88) 44·30 (34·95 o 57·95)* 11·45 (4·17 o 21·82)* ·· Li e cance due o o he causes 14·98 (4·98 o 31·65) 21·93 (7·78 o 43·51) 46·36 (35·51 o 64·87)* 13·85 (5·45 o 27·54)* 415·44 (136·60 o 884·65) 586·63 (208·44 o 1183·29) 41·21 (29·77 o 61·17)* 12·10 (3·36 o 27·26)* ·· Gallbladde and bilia y ac cance 19·19 (10·00 o 31·40) 24·23 (12·96 o 38·93) 26·31 (20·46 o 33·91)* –5·19 (–9·47 o 0·48) 398·83 (206·71 o 659·38) 501·99 (271·35 o 804·62) 25·87 (19·54 o 33·96)* –3·50 (–8·43 o 2·52) ·· Panc ea ic cance 17·09 (6·73 o 32·72) 23·80 (9·45 o 45·36) 39·31 (33·12 o 46·65)* 5·04 (0·00 o 10·77) 355·53 (132·75 o 689·18) 488·30 (185·48 o 937·58) 37·34 (31·04 o 44·82)* 5·41 (0·50 o 11·10)* ·· B eas cance 24·50 (9·01 o 45·25) 34·14 (14·17 o 61·44) 39·33 (26·71 o 66·63)* 1·49 (–7·17 o 17·88) 478·48 (134·90 o 931·31) 696·82 (241·06 o 1278·23) 45·63 (28·58 o 100·78)* 4·33 (–6·57 o 30·51) ·· U e ine cance 25·33 (16·84 o 34·86) 31·98 (22·02 o 42·77) 26·29 (17·00 o 39·60)* –4·35 (–11·15 o 5·40) 616·37 (406·52 o 852·11) 777·06 (534·09 o 1037·37) 26·07 (16·24 o 39·81)* –2·75 (–10·14 o 7·44) ·· O a ian cance 3·96 (–0·06 o 8·73) 5·16 (–0·08 o 11·22) 30·36 (21·79 o 40·84)* –0·87 (–7·38 o 6·92) 100·08 (–1·45 o 221·53) 130·91 (–2·01 o 284·65) 30·81 (22·13 o 41·76)* 1·63 (–5·03 o 10·00) ·· Kidney cance 18·46 (10·70 o 28·15) 24·80 (14·55 o 37·29) 34·35 (28·83 o 41·33)* 1·72 (–2·45 o 6·95) 414·68 (240·63 o 629·90) 545·45 (324·36 o 818·33) 31·53 (25·96 o 38·50)* 1·48 (–2·72 o 6·69) ·· Thy oid cance 2·91 (1·43 o 5·04) 3·99 (2·04 o 6·86) 37·08 (28·94 o 47·41)* 4·67 (–1·57 o 12·41) 75·91 (37·37 o 132·41) 104·28 (53·14 o 180·08) 37·39 (29·21 o 48·00)* 7·53 (1·34 o 15·42)* ·· Non-Hodgkin lymphoma 8·76 (3·45 o 15·95) 12·11 (4·73 o 21·66) 38·22 (32·55 o 44·75)* 5·46 (1·16 o 10·68)* 214·81 (83·04 o 391·23) 295·53 (117·37 o 532·38) 37·58 (31·28 o 43·90)* 8·27 (3·38 o 13·37)* ·· Mul iple myeloma 4·86 (2·10 o 8·71) 6·66 (2·89 o 11·78) 37·06 (31·43 o 44·71)* 3·30 (–1·17 o 9·24) 103·69 (45·00 o 186·13) 142·21 (62·40 o 249·59) 37·15 (31·41 o 45·43)* 5·30 (0·94 o 11·53)* (Table 4 con inues on nex page) Global Heal h Me ics 1400 www. helance .com Vol 390 Sep embe 16, 2017 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Acu e lymphoid leukaemia 1·59 (0·75 o 2·73) 2·22 (1·11 o 3·78) 39·14 (29·44 o 48·47)* 10·63 (3·24 o 17·88)* 53·85 (25·63 o 93·15) 73·29 (36·49 o 125·61) 36·10 (26·03 o 46·07)* 12·10 (3·94 o 19·97)* ·· Ch onic lymphoid leukaemia 2·36 (1·18 o 3·92) 2·92 (1·50 o 4·80) 23·58 (17·80 o 31·41)* –8·23 (–13·00 o –2·59)* 45·52 (22·50 o 75·54) 55·53 (28·44 o 89·89) 21·98 (15·87 o 30·42)* –6·69 (–11·35 o –0·57)* ·· Acu e myeloid leukaemia 4·65 (2·33 o 7·66) 6·22 (3·15 o 10·05) 33·79 (28·67 o 40·45)* 3·44 (–0·54 o 8·61) 119·03 (59·43 o 197·90) 156·14 (79·64 o 253·37) 31·17 (26·04 o 38·42)* 4·62 (0·50 o 10·33)* ·· Ch onic myeloid leukaemia 1·50 (0·74 o 2·54) 1·56 (0·79 o 2·62) 3·86 (–0·97 o 9·84) –20·41 (–24·02 o –15·73)* 38·75 (18·95 o 66·00) 39·64 (20·22 o 66·66) 2·32 (–2·78 o 8·83) –18·45 (–22·36 o –13·42)* ·· O he leukaemia 5·65 (2·63 o 9·91) 6·91 (3·43 o 11·92) 22·36 (13·74 o 33·25)* –5·39 (–11·58 o 2·67) 150·74 (68·70 o 270·44) 175·88 (86·80 o 306·17) 16·67 (6·35 o 30·31)* –6·03 (–13·63 o 3·83) ·· Ischaemic hea disease 1288·03 (750·54 o 1915·37) 1592·33 (949·29 o 2325·60) 23·62 (18·28 o 31·01)* –6·63 (–10·33 o –1·34)* 30 281·04 (18 069·07 o 44 440·56) 36 991·70 (22 899·69 o 52 749·96) 22·16 (17·05 o 29·82)* –4·63 (–8·58 o 1·24) ·· Ischaemic s oke 283·31 (157·87 o 446·42) 318·39 (179·56 o 494·72) 12·38 (6·06 o 21·03)* –14·52 (–19·22 o –8·07)* 7636·97 (4439·93 o 11 465·75) 9139·16 (5520·94 o 13 559·93) 19·67 (13·90 o 27·73)* –7·74 (–12·19 o –1·69)* ·· Haemo hagic s oke 517·26 (299·18 o 797·22) 592·91 (364·88 o 872·03) 14·63 (7·65 o 24·31)* –10·40 (–15·68 o –2·82)* 15 913·88 (9447·13 o 23 465·66) 18 284·39 (11 769·74 o 25 665·62) 14·90 (7·94 o 24·58)* –8·36 (–13·89 o –0·19)* ·· Hype ensi e hea disease 215·62 (115·71 o 340·33) 300·81 (162·11 o 482·35) 39·51 (23·49 o 54·97)* 4·14 (–6·93 o 14·90) 4745·65 (2865·31 o 6909·68) 6328·03 (3954·75 o 8998·62) 33·34 (20·77 o 46·93)* 3·67 (–6·03 o 13·90) ·· A ial ib illa ion and lu e 30·66 (15·59 o 50·28) 46·15 (23·86 o 74·25) 50·50 (44·68 o 57·96)* 4·01 (0·15 o 9·07)* 847·22 (424·79 o 1434·95) 1206·94 (614·35 o 2008·58) 42·46 (38·94 o 47·40)* 6·27 (3·63 o 10·00)* ·· As hma 50·50 (26·16 o 85·76) 60·27 (33·27 o 99·29) 19·33 (9·60 o 32·81)* –7·72 (–15·43 o 2·78) 3096·98 (1685·64 o 5065·91) 3888·00 (2214·88 o 6203·97) 25·54 (19·00 o 34·22)* 4·23 (–2·03 o 11·64) ·· Gallbladde and bilia y diseases 22·65 (14·01 o 33·32) 31·11 (20·15 o 44·30) 37·32 (30·32 o 47·23)* 1·35 (–3·54 o 8·56) 478·24 (295·15 o 708·79) 634·28 (413·77 o 904·27) 32·63 (25·47 o 42·16)* 3·09 (–2·47 o 10·47) ·· Alzheime ’s disease and o he demen ias 185·54 (67·16 o 358·86) 286·44 (106·50 o 545·02) 54·38 (48·77 o 62·72)* 6·35 (2·04 o 13·00)* 2357·11 (900·89 o 4607·68) 3493·12 (1387·03 o 6739·85) 48·20 (43·46 o 55·36)* 7·68 (4·04 o 13·61)* ·· Diabe es melli us 390·47 (263·53 o 530·40) 553·44 (386·74 o 727·93) 41·74 (35·95 o 49·03)* 8·24 (3·84 o 14·15)* 20 585·42 (13 617·44 o 29 152·97) 28 645·74 (19 660·88 o 39 287·38) 39·16 (33·19 o 47·36)* 10·31 (5·57 o 16·73)* ·· Ch onic kidney disease due o diabe es melli us 98·46 (43·76 o 164·31) 146·40 (65·81 o 237·24) 48·69 (39·03 o 60·84)* 12·65 (7·32 o 19·88)* 3124·61 (1338·04 o 5247·93) 4566·00 (2050·51 o 7410·10) 46·13 (38·14 o 58·53)* 13·04 (7·74 o 20·08)* ·· Ch onic kidney disease due o hype ension 47·69 (18·11 o 89·54) 73·45 (26·32 o 135·91) 54·03 (38·50 o 66·89)* 12·85 (7·10 o 23·44)* 1176·40 (503·88 o 2012·81) 1785·47 (805·84 o 2934·09) 51·77 (41·13 o 65·00)* 15·47 (9·33 o 24·63)* ·· Ch onic kidney disease due o glome uloneph i is 30·93 (13·32 o 52·67) 41·71 (18·41 o 69·06) 34·87 (25·53 o 45·01)* 2·81 (–1·47 o 7·98) 1032·52 (417·03 o 1809·69) 1358·82 (567·29 o 2326·03) 31·60 (25·38 o 40·49)* 3·51 (–0·63 o 8·87) ·· Ch onic kidney disease due o o he causes 42·14 (18·81 o 71·07) 62·11 (26·60 o 104·77) 47·39 (32·26 o 59·95)* 11·26 (5·17 o 18·01)* 1301·30 (581·61 o 2232·05) 1867·87 (883·35 o 3113·60) 43·54 (35·86 o 54·17)* 11·97 (7·12 o 18·59)* ·· Os eoa h i is ·· ·· ·· ·· 2173·98 (1045·13 o 3867·70) 3225·98 (1624·93 o 5586·80) 48·39 (42·88 o 57·06)* 15·18 (11·04 o 21·86)* ·· Low back pain ·· ·· ·· ·· 2684·27 (1366·73 o 4685·98) 3630·51 (1919·27 o 6254·44) 35·25 (30·07 o 42·46)* 9·39 (5·70 o 14·83)* (Table 4 con inues on nex page) Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1401 2006 dea hs (in housands) 2016 dea hs (in housands) Pe cen age change o dea hs 2006–16 Pe cen age change o age- s anda dised dea hs a e 2006–16 2006 DALYs (in housands) 2016 DALYs (in housands) Pe cen age change o DALYs 2006–16 Pe cen age change o age- s anda dised DALYs a e 2006–16 (Con inued om p e ious page) ·· Gou ·· ·· ·· ·· 229·32 (105·94 o 410·88) 321·88 (154·53 o 568·22) 40·37 (35·33 o 47·42)* 10·69 (6·98 o 16·07)* ·· Ca a ac ·· ·· ·· ·· 201·26 (82·62 o 397·74) 306·06 (132·21 o 586·28) 52·08 (45·72 o 61·98)* 15·83 (10·93 o 23·62)* 2 Low bone mine al densi y: all causes 341·07 (288·70 o 360·77) 441·23 (374·93 o 466·70) 29·37 (24·07 o 34·07)* –5·78 (–9·63 o –2·34)* 9412·32 (8030·50 o 11 131·37) 11 955·49 (10 090·79 o 14 196·27) 27·02 (23·65 o 29·65)* –3·07 (–5·68 o –1·03)* ·· Pedes ian oad inju ies 40·74 (38·39 o 43·41) 46·93 (44·13 o 49·88) 15·20 (9·02 o 18·80)* –13·11 (–17·62 o –10·45)* 1094·99 (979·92 o 1226·14) 1293·53 (1143·70 o 1463·75) 18·13 (12·36 o 21·58)* –8·69 (–12·96 o –6·11)* ·· Cyclis oad inju ies 5·17 (4·64 o 5·66) 6·03 (5·44 o 6·73) 16·64 (11·21 o 23·63)* –10·21 (–14·32 o –5·00)* 343·04 (267·55 o 438·99) 447·83 (343·84 o 583·35) 30·55 (26·30 o 34·15)* 1·26 (–1·80 o 3·89) ·· Mo o cyclis oad inju ies 8·60 (7·58 o 9·40) 10·61 (9·08 o 11·55) 23·37 (16·31 o 29·85)* –3·30 (–8·74 o 1·71) 516·37 (422·92 o 630·17) 665·90 (537·39 o 824·92) 28·96 (24·64 o 32·55)* 1·63 (–1·65 o 4·24) ·· Mo o ehicle oad inju ies 29·15 (26·52 o 32·31) 33·42 (30·60 o 37·18) 14·65 (10·86 o 20·30)* –12·30 (–15·19 o –8·05)* 1053·30 (916·84 o 1212·20) 1227·50 (1055·45 o 1420·62) 16·54 (13·17 o 21·00)* –9·15 (–11·70 o –5·87)* ·· O he oad inju ies 1·11 (0·97 o 1·42) 1·34 (1·19 o 1·71) 20·66 (10·56 o 35·98)* –10·20 (–17·75 o 1·23) 85·10 (62·48 o 115·48) 129·35 (92·12 o 178·79) 51·99 (46·52 o 56·32)* 16·84 (12·28 o 20·37)* ·· O he anspo inju ies 7·41 (6·74 o 7·98) 8·91 (8·22 o 10·00) 20·29 (13·83 o 28·79)* –8·50 (–13·44 o –2·28)* 330·22 (273·06 o 402·51) 394·33 (321·20 o 482·74) 19·41 (15·51 o 24·18)* –7·29 (–10·26 o –3·74)* ·· Falls 237·28 (186·55 o 254·10) 321·08 (254·50 o 344·23) 35·32 (28·08 o 41·49)* –3·51 (–8·60 o 0·81) 5306·53 (4397·57 o 6284·03) 6968·79 (5750·97 o 8276·40) 31·32 (26·75 o 34·67)* –1·34 (–4·93 o 1·31) ·· O he exposu e o mechanical o ces 6·42 (5·21 o 6·94) 7·62 (5·85 o 8·28) 18·75 (11·69 o 23·63)* –11·15 (–16·26 o –7·33)* 401·92 (305·39 o 523·87) 513·05 (380·93 o 681·19) 27·65 (23·66 o 30·49)* –1·40 (–4·33 o 0·74) ·· Non- enomous animal con ac 0·68 (0·53 o 0·88) 0·76 (0·59 o 1·02) 12·06 (4·71 o 23·04)* –15·81 (–21·13 o –7·87)* 21·55 (16·66 o 27·50) 23·45 (18·15 o 30·34) 8·80 (3·65 o 14·68)* –15·77 (–19·71 o –11·18)* ·· Assaul by o he means 3·91 (3·13 o 4·64) 4·14 (3·51 o 5·31) 5·95 (–3·67 o 21·09) –18·19 (–25·57 o –7·12)* 236·94 (182·44 o 304·08) 268·81 (204·14 o 351·16) 13·45 (7·54 o 19·57)* –11·45 (–15·88 o –6·82)* ·· Fo ces o na u e, con lic and e o ism, and s a e ac o iolence 0·60 (0·40 o 0·81) 0·37 (0·21 o 0·57) –38·05 (–56·98 o –20·83)* –51·96 (–66·57 o –38·70)* 22·35 (13·90 o 36·70) 22·95 (10·58 o 47·82) 2·68 (–28·79 o 30·32) –19·58 (–43·89 o 1·64) 2 Impai ed kidney unc ion: all causes 2108·45 (1943·12 o 2277·00) 2554·21 (2346·59 o 2766·51) 21·14 (18·37 o 23·96)* –9·08 (–10·89 o –7·16)* 52 009·54 (48 088·99 o 55 861·74) 60 482·18 (55 678·63 o 65 319·35) 16·29 (13·87 o 18·61)* –8·10 (–9·94 o –6·30)* ·· Ischaemic hea disease 753·35 (627·96 o 868·81) 906·02 (749·80 o 1056·12) 20·27 (15·84 o 24·87)* –11·91 (–14·40 o –9·02)* 13 095·90 (11 202·99 o 14 872·74) 15 068·46 (12 896·50 o 17 267·64) 15·06 (11·42 o 18·84)* –11·75 (–14·21 o –9·06)* ·· Ischaemic s oke 201·59 (153·59 o 247·89) 219·00 (164·95 o 274·84) 8·63 (2·78 o 14·64)* –19·04 (–22·23 o –15·40)* 4041·29 (3235·99 o 4810·89) 4478·73 (3577·63 o 5417·18) 10·82 (6·20 o 15·37)* –15·45 (–18·71 o –12·11)* ·· Haemo hagic s oke 227·29 (185·54 o 269·78) 236·16 (191·40 o 283·30) 3·91 (0·62 o 7·40)* –20·50 (–22·52 o –18·46)* 5431·74 (4452·60 o 6455·91) 5578·78 (4537·14 o 6686·22) 2·71 (–0·10 o 5·74) –19·77 (–21·70 o –17·83)* ·· Pe iphe al ascula disease 5·64 (3·81 o 8·18) 7·32 (4·82 o 11·42) 29·76 (16·19 o 45·98)* –4·33 (–12·92 o 6·28) 170·24 (121·08 o 237·00) 210·83 (147·41 o 296·25) 23·84 (16·07 o 32·93)* –5·65 (–11·04 o 0·58) ·· Ch onic kidney disease due o diabe es melli us 384·78 (349·87 o 418·93) 500·41 (452·11 o 543·57) 30·05 (26·18 o 32·84)* –0·63 (–3·43 o 1·30) 11 723·50 (10 608·16 o 12 883·32) 14 649·82 (13 196·95 o 16 191·89) 24·96 (21·91 o 27·57)* –1·37 (–3·51 o 0·51) (Table 4 con inues on nex page) Global Heal h Me ics 1408 www. helance .com Vol 390 Sep embe 16, 2017 a e la ge, inc easing, and a iable ac oss coun ies a he same le el o de elopmen likely wa an pa icula policy a en ion. Ou analysis showed ha componen s o die , obesi y, FPG, and SBP a e he mos p ominen global isks ul illing hese c i e ia. Because o he s ong in e - ela ionships be ween hese isks, he ue d i e o his clus e is likely die , he isk in BMI, o bo h, wi h knock- on consequences o FPG and SBP. The ise o obesi y and he associa ed inc eases in FPG and SBP wa an con- side able global policy a en ion. O he majo isks ha should con inue o ecei e a en ion—e en in ensi ied a en ion in some loca ions—such as smoking, a e ne e - heless declining a he global le el. The unique combina ion o la ge cu en e ec and inc easing exposu e pu s obesi y in a special ca ego y o isks. Obesi y is likely o no only in luence u u e popula ion heal h in many loca ions, bu will ha e conside able inancial implica ions o heal h sys ems, gi en wha we know abou ea men cos s o he associa ed diseases. Since impo an d i e s o obesi y such as physical ac i i y and die pa e ns a e adop ed in childhood and adolescence, mo e wo k is needed o p oac i ely add ess he adop ion o hese isks in hese younge age g oups. Fo he i s ime, we assess he con ibu ion o changes o isk exposu es o he o e all global end o dea hs and DALYs; o example, in he pas 10 yea s, changes in all isk exposu es con ibu ed o an 10·8% (8·3–13·1) decline in DALYs, while o he ac o s con ibu ed o a 16·5% (14·1–18·8) dec ease in DALYs. Mo e de ailed assessmen s show la ge declines in CMNN causes and inc eases in inju ies and non-communicable DALYs. In each case, he con ibu ion o o he ac o s was subs an ially la ge han he con ibu ion o isk educ ion. Ou indings o he ela i ely small con ibu ion o isk educ ion o he declines in NCDs a e no a odds wi h published s udies o he UK and he USA,20–22 because we a e epo ing a he global le el; ou esul s a he na ional le el sugges a la ge ole o isk educ ion in some high-SDI loca ions. These obse a ions lead o wo di ec ions o u he analysis. Fi s , wha is he explana ion o he declines d i en by o he ac o s? Some o his e ec migh be social policy wo king h ough a ious causal channels, and some is likely due o imp o emen s in access o high-quali y heal h ca e. This is pa icula ly ue o condi ions such as selec ed cance s, ischaemic hea disease, ce eb o ascula disease, ch onic kidney diseases, HIV/AIDS, ube culosis, and ma e nal mo ali y, o which heal h ca e is known o ha e la ge e ec s. Second, in iew o he eno mous po en ial o isk educ ion o change heal h ou comes as documen ed in his and many o he s udies, why has p og ess on many isks been compa a i ely slow? Fo example, e en hough global obacco consump ion is declining in e ms o a es, he pace o decline has been ema kably slow on a e age, despi e mo e han 50 yea s o good e idence on he ha ms o obacco. The ela i ely poo ack eco d o global isk educ ion migh in pa e lec he low a e o in es men in isk educ ion compa ed wi h cu a i e heal h ca e. I migh also e lec he con inuing challenge o changing many isky beha iou s. Rela i ely li le unding o esea ch on changing beha iou s compa ed wi h new diagnos ics and he apeu ics migh also be pa o he explana ion o he p e en ion pa adox.23,24 Changing beha iou al isks could also equi e mo e han go e nmen ac ion; ha nessing he p i a e sec o o acili a e beha iou al change migh also be c ucial. Impo an changes in GBD 2016 compa ed wi h in GBD 2015 ( isks o de ed by global ank) Sys olic blood p essu e Inc eased SBP emains he leading global isk a Le el 3 in he GBD isk hie a chy. Highly e ec i e in e en ions exis o manage blood p essu e a he p ima y ca e le el, as do a ange o public heal h in e en ions, so i is qui e ema kable ha global exposu e o inc eased SBP is inc easing. Pa o his inc ease migh be ied o he global ise in high BMI, bu he inc ease in SBP ep esen s signi ican missed oppo uni y o he wo ld’s heal h sys ems. In 54 coun ies high SBP is ac ually declining, while i s inc ease in China is now well documen ed in a se ies o popula ion-based su eys.25–27 Tackling ising SBP is a global conce n, bu his is pa icula ly impo an in hose loca ions whe e a es a e inc easing. In iew o he e ec o he isk and he la ge a ay o a ailable, e ec i e in e en ions, heal h sys ems and he global heal h communi y need o mobilise inc eased esou ces and policy a en ion o ackle his p oblem. I migh be necessa y o design a a ie y o public policies including ood e o mula ion o educe sodium con en and e o s o incen i ise p ima y ca e p o ide s o gi e p io i y o he managemen o SBP.28–30 Tobacco In mo ing owa d de eloping a comp ehensi e pic u e o obacco use globally, in GBD 2016, we ha e o he i s ime included smokeless obacco use as a isk ac o . While he bu den o smokeless obacco is minimal in he majo i y o coun ies, i is o huge impo ance in sou h Asia, whe e he highes isk-weigh ed exposu e is obse ed in Bangladesh ( isk-weigh ed exposu e o 0·75 [0·61–0·87]), Bhu an (0·53 [0·44–0·62]), Myanma (0·50 [0·42–0·59]), Nepal (0·50 [0·42–0·58]), and India (0·45 [0·43–0·47]). In hese coun ies mo e women use smokeless obacco p oduc s han smoked obacco p oduc s, and we ind ha use o any obacco p oduc s, smoked o smokeless, con inuously inc eases wi h age, a egional age pa e n ha di e s om he global and male egional age pa e n. The combina ion o high exposu e and la ge popula ion esul s in a majo i y o global dea hs a ibu able o smokeless obacco in 2016 occu ing in India, whe e i is also he leading isk ac o o o al cance . In GBD 2016, we also imp o ed he es ima ion o bu den a ibu able o second-hand smoke. A he global le el, while he bu den o second-hand smoke emains sub- s an ial, exposu e o second-hand smoke has been declining signi ican ly a an annualised a e o change o Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1409 1·9% (1·5–2·4). These educ ions a e likely a ibu able o a wide ange o public heal h measu es o con ol obacco, which ha e accele a ed in a la ge numbe o coun ies since he implemen a ion o he F amewo k Con en ion on Tobacco Con ol (FCTC).31 P og ess comba ing he obacco epidemic has esul ed in global declines in p e alence o obacco use and second- hand smoke exposu e, ye he numbe o dea hs and DALYs a ibu able o obacco has inc eased since 1990. Inc eases in bu den we e d i en by a combina ion o popula ion g ow h and popula ion ageing, along wi h pe sis en ly high smoking p e alence in some o he mos populous coun ies o he wo ld. Taken oge he , we can expec he bu den o obacco o emain high in yea s o come, unless he a e o p og ess is signi ican ly accele a ed. Many coun ies wi h pe sis en ly high le els o daily smoking eco ded ma ginal p og ess in he pas decade, and smoking emains a leading isk ac o in mos coun ies. The ac ha obacco use pa e ns di e ge by loca ion, le el o de elopmen , and sex highligh s he need o mo e ailo ed app oaches o change smoking beha iou s in he u u e. Pa icula ly wo isome a e he ends among young men and women. Fo example, in Indonesia, a coun y ha has no ye a i ied he FCTC,31 mo e han hal o men aged 20–24 yea s a e daily smoke s. Unde s anding wha wo ks—and wha does no — o obacco con ol ac oss con ex s and wi hin subpopula ions (ie, men and women, younge and olde indi iduals, a ious socioeconomic g oups) is o g owing p io i y. To signi ican ly and pe manen ly change he oll o obacco, a enewed and sus ained ocus is needed on comp ehensi e obacco con ol policies a ound he wo ld. Fas ing plasma glucose The global inc ease in FPG is likely ied o he inc ease in BMI. While exposu e is inc easing, age-s anda dised a ibu able mo aliy a e is no ; a ela ed pa e n is ha he p e alence o diabe es is inc easing, bu dea hs om diabe es ha e been declining, likely because clinical managemen o he mac o ascula complica ions o diabe es has imp o ed in many (bu no all) loca ions. P e en ion ials show ha wi h in ensi e esou ces de o ed o weigh loss and physical ac i i y, educ ions in FPG can be achie ed; howe e , hese in e en ions ha e no been implemen ed a a na ional scale and adhe ence in he long un is challenging. Sys ema ic e o s o sc een o high FPG implemen ed in some coun ies may inc ease awa eness and ac ion in mo e pa ien s bu can be esou ce- in ensi e. Clinical in e en ions o educe FPG can be e ec i e, al hough he e a e mo e ecen deba es on he app op ia e a ge s o ea men in some cases. Wi h FPG inc easing in many se ings, i is di icul o de e mine he popula ion e ec o ea men o blood suga on popula ion FPG. FPG emains one o he isk ac o s ha is mos likely in luenced a he p ima y heal h-ca e le el, emphasising he ole o uni e sal co e age o p ima y ca e in a mul ip onged esponse o his inc easing p oblem. Body-mass index One o he mos ala ming isks in he analysis is inc eased BMI, because i s bu den is la ge and inc easing, and i is p e alen ac oss all le els o SDI.32,33 The po en ial d i e s o his global epidemic include changes in ood indus ies and sys ems, which inc ease a ailabili y, accessibili y, and a o dabili y o ene gy-dense oods, along wi h in ense ma ke ing o such oods, as well as educed oppo uni ies o physical ac i i y.34 A ange o in e en ions ha e been p oposed o educe obesi y, including es ic ing he ad e isemen o unheal hy oods o child en, imp o ing school meals, axa ion o suga -swee ened be e ages, and axa ion o educe consump ion o o he unheal hy oods and subsidies o inc ease in ake o heal hy oods, and using supply-chain incen i es o inc ease p oduc ion o heal hy oods.35 Howe e , he e idence base ha many o hese in e en ions can a ec ends in obesi y a scale is cu en ly weak.36 Wha we know wi hou a doub is ha obesi y a es con inue o inc ease in almos all loca ions. Low-SDI and middle-SDI coun ies gene ally ha e li le inancial esou ces o nu i ion p og ams and mos ly ely on ex e nal dono s whose p og ammes o en p e e en ially a ge unde nu i ion.37 The inc ease in exposu e o high BMI is g ea e han he inc ease in a ibu able bu den la gely because ca dio ascula disease dea h a es con inue o decline because o o he changes, pa icula ly imp o e- men s in ea men and declines in smoking and high choles e ol. P oposed policies, e en i ully imple men ed, a e unlikely o apidly educe he p e alence o obesi y. While no a solu ion o he ise o o e weigh and obesi y, clinical in e en ions ha con ol high SBP, choles e ol, and FPG ( he majo isk ac o s o ca dio ascula disease) can be used o mi iga e some o he ca dio ascula ill- e ec s.20 Expanded use o such in e en ions among obese people could e ec i ely educe he disease bu den o high BMI. Sus ained p og ess, howe e , will equi e policies ha e ec i ely con ol weigh in childhood and in young and middle-aged adul s. Die In GBD 2016, poo die a y habi s we e he second leading isk ac o a Le el 2 o he hie a chy o mo ali y globally, accoun ing o nea ly one in e e y i e dea hs. The o e all bu den o die a y isks a he global le el was 14·8% (11·7–18·5) lowe han in GBD 2015. Addi ionally, impo an di e ences we e obse ed in he a ibu able bu den and he anking o indi idual die a y isks. Mul iple ac o s ha e con ibu ed o hese di e ences, including using mo e da a sou ces, as well as imp o ing he me hod o es ima ion o he mean and dis ibu ion o in ake o each die a y ac o . In GBD 2016, o he i s ime, we used sales da a o in o m ou es ima es o consump ion o mos die a y ac o s. Using sales da a, in addi ion o imp o ing ou o e all da a co e age, allowed us o cap u e ecen ends in consump ion. This was pa icula ly impo an o speci ic die a y ac o s, such as suga -swee ened be e ages, which ha e been he a ge o die a y policies in se e al Global Heal h Me ics 1410 www. helance .com Vol 390 Sep embe 16, 2017 coun ies.38–43 Addi ionally, o imp o e he consis ency o de ini ions o die a y isk ac o s ac oss su eys, we made a sys ema ic e o o ob ain and e-ex ac indi idual-le el da a om nu i ion su eys. To make he cu en le el o in ake and op imal le el o in ake mo e compa able, we used he absolu e le el o in ake ( a he han he in ake s anda dised o 2000 kcal pe day) as he p ima y exposu e in GBD 2016. We also co ec ed ou es ima ed daily in ake o each indi idual die a y ac o o wi hin-pe son a ia ion and cha ac e ised he usual in ake a he popula ion le el. Finally, gi en he di e ences in he heal h e ec s and pa e ns o in ake o legumes and ege ables, we es ima ed he bu den o disease a ibu able o low in ake o legumes and low in ake o ege ables sepa a ely. The decade o 2016–25 has been decla ed as he Decade o Ac ion on Nu i ion by he Uni ed Na ions Gene al Assembly.44 GBD 2016 p o ides a comp ehensi e pic u e o a ious o ms o malnu i ion (ie, unde nu i ion, o e weigh o obesi y, and poo die a y habi s) ac oss all coun ies a he s a o he Decade o Ac ion on Nu i ion and can in o m p io i ies o e idence-based in e en ions in each coun y. GBD also p o ides an independen a enue o annually moni o he p og ess o coun ies owa d achie ing hei nu i ion- ela ed goals in a compa able and consis en manne . Ou esul s show ha among all o ms o malnu i ion, poo die a y habi s, pa icula ly low in ake o heal hy oods, is he leading isk ac o o mo ali y. This inding has impo an implica ions o na ional go e n- men s and in e na ional o ganisa ions aiming a ending malnu i ion o e he nex decade, highligh ing he need o comp ehensi e ood sys em in e en ions o p omo e he p oduc ion, dis ibu ion, and consump ion o heal hy oods ac oss na ions. Low bi hweigh and sho ges a ion Low bi hweigh and sho ges a ion ha e been added o GBD 2016; hey a e he hi d-leading global isk a Le el 3 in he GBD isk hie a chy. Imp o emen s in bu den a ibu able o low bi hweigh and sho ges a ion ha e been la gely d i en by o he ac o s in luencing neona al dea h a es, gi en ha exposu e o low bi hweigh and sho ges a ion ha e no imp o ed much o e he pas 27 yea s. Li le p og ess in exposu e sugges s subop imal co e age o in e en ions and p og ammes ha can p e en low bi hweigh and sho ges a ion. These include women- cen ed se ices o op imising nu i ion (including minimising obesi y), in ec ion con ol, smoking cessa ion, and p e en i e ca e o p egnan women o hose con empla ing p egnancy.45–47 E o s should also ocus on maximising he quali y o an ena al ca e se ices o iden i y and app op ia ely manage a - isk and high- isk p egnancies,48 including a oidance o p o ide -ini ia ed p e e m deli e y. I e idence-based in e en ions a e employed, i should be possible e en in esou ce-limi ed se ings o shi he isk cu e o hose babies who will be bo n ea ly, small, o bo h, despi e bes e o s. Be o e bi h, his includes po en ially an ena al s e oid adminis a ion o p omo e lung de elopmen ;49 a bi h, his equi es p esence o adequa ely ained and equipped neona al esusci a ion se ices;50,51 pos -deli e y, i should include physicians wi h neona al specialisa ion and a ailabili y o suppo i e equipmen such as con inuous posi i e ai way p essu e.52 Facili y-based in ec ion con ol measu es a e c ucial o p e en nosocomial ansmission, as such e en s a e highly le hal in low bi hweigh o sho ges a ion neona es.53 The inclusion o his isk o a majo cause o DALYs—namely, neona al mo ali y—also expands he sha e o o e all bu den ha can be a ibu ed o isks in gene al. Mo e wo k emains, howe e , o unde s and he ela ionship be ween low bi hweigh and sho ges a ion and childhood g ow h ailu e a e 1 mon h. Ou analysis o da e may ac ually unde es ima e he impo ance o his isk i he sha e o childhood g ow h ailu e ha can be aced o low bi hweigh and ges a ional age is ully es ablished. Alcohol Globally, alcohol is es ima ed o be he se en h-leading isk ac o in 2016 in bo h DALYs (4·2% [3·7–4·6]) and dea hs (5·2% [4·4–6·0]). P e ious s udies ha e no ed he possibili y ha he p e en i e e ec s o alcohol migh ha e been o e s a ed due o selec ion bias and choice o he e e ence popula ion.2,54–56 Ou indings lend u he c edence o hese hypo heses; wi h he excep ion o IHD, ou esul s show ei he a mino o non-signi ican p e en i e e ec o causes p e iously es ima ed o ha e la ge p e en i e e ec s. Fu he , ou analysis no ed a much la ge isk o neoplasms due o alcohol use han p e iously epo ed. Combined wi h ou new da a o alcohol use exposu e, alcohol use is anked as one o he leading isk ac o s, su passing choles e ol as a sha e o o al DALYs, compa ied wi h p e ious i e a ions o GBD.4–6 Ensemble dis ibu ions In GBD 2016 we ha e in oduced a mo e accu a e me hod o de eloping he dis ibu ions o exposu e o many isk ac o s. Ou wo k on dis ibu ions and he shi o ensemble dis ibu ions shows ha he assessmen o a ibu able bu den is sensi i e o dis ibu ional assump ions. Gi en ha a numbe o isks, such as BMI, SBP, choles e ol, and FPG, ise exponen ially as a unc ion o exposu e, he es ima ion o he ail o he dis ibu ion has an impo an e ec on he esul s. The ensemble modelling app oach can p o ide mo e accu a e es ima ion o he ull dis ibu ion, including he ails o he dis ibu ion. In gene al, we belie e ha he assessmen o he dis- ib u ion o he isks dese es mo e ca e ul a en ion in u u e esea ch. Compa ison o GBD 2016 o o he es ima es The GBD s udy is he mos comp ehensi e e o o conduc a popula ion-le el CRA ac oss coun ies and isks. Di e ences be ween GBD 2016 es ima es and o he global es ima es a e gene ally ela ed o app oaches o da a p ocessing, access o da a sou ces, and analysis decisions. Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1411 Fo se e al isks, including smoking,57 ambien ozone pollu ion, household ai pollu ion om solid uels, lead exposu e,58 in ima e pa ne iolence,59 unsa e wa e sou ce,60 and b eas eeding, GBD es ima es we e lowe han published WHO es ima es.57–60 These disc epancies can be a ibu ed o di e en de ini ions, me hodological decisions, g anula i y, and inpu da a. Fo some indings, annual es ima es migh disag ee, bu egional pa e ns we e consis en be ween WHO and GBD. UNICEF61 p oduces es ima es o child s un ing ha a e lowe han GBD es ima es wi h some disag eemen whe e p og ess has been made globally. The e is mo e consis ency in es ima es be ween UNICEF and GBD o child was ing and child unde weigh .61 GBD es ima es o he p e alence o low bi hweigh and sho ges a ion a e sligh ly lowe when compa ed wi h WHO es ima es, bu show simila geog aphical pa e ns.62 Scien i ic li e a u e e eals simila esul s o GBD o impai ed kidney unc ion63 and low bi hweigh and sho ges a ion;64,65 esea ch analysing ambien ai pollu ion66 di e ed om GBD es ima es due o olde me hods and less g anula i y. Resea ch published on i on-de iciency anaemia67 di e s om GBD in me hods and de ini ions, esul ing in gene ally highe GBD es ima es. GBD es ima es we e much lowe han published esea ch on occupa ional es ima es,3,68,69 la gely due o di e en cause-ou come pai s and GBD’s applica ion o he CRA app oach (see appendix 1 p 10). Fu u e di ec ions In e p e a ion o ou esul s and p io i isa ion a he na ional le el migh also need o ake in o accoun he a iable s eng h o e idence suppo ing he causal connec ion o each isk-ou come pai . In GBD 2016, we ha e con inued o use he Wo ld Cance Resea ch Fund c i e ia o con incing o p obable e idence o selec isk- ou come pai s o inclusion. Some aspec s o hese de ini ions a e subjec i e. No all esea che s would ag ee on he in e p e a ion o he a ailable e idence as ul illing hese c i e ia. Fo example, he e a e six s udies on non- exclusi e b eas eeding and LRI; he e a e wo s udies on discon inued b eas eeding and dia hoeal diseases. We ha e sough o quan i y he numbe o s udies o di e en kinds ha a e a ailable o suppo hese judgemen s in able 1, bu no all s udies suppo causali y o he same ex en . Randomised ials, i well conduc ed, p o ide he s onges e idence o causali y, because hey a e likely no a ec ed by con ounding. Bu e en andomised ials can ha e biases when he e a e missing obse a ions, as is o en he case. Randomised ials a e also no easible in many cases, o i easible, no ep esen a i e o many isks, including en i onmen al isks. Coho s udies can p o ide compelling e idence, bu many coho s do no adequa ely con ol o socioeconomic con ounde s and can su e om many o he issues ela ed o he quali y o exposu e measu emen o ou come asce ainmen . To go beyond, he quan i ica ion o he numbe o s udies o each ype we ha e p o ided he e will necessi a e a deepe analysis o he po en ial limi a ions o all 2579 s udies used ac oss he isk-ou come pai s. In u u e wo k, we plan o e alua e he quali y o each o hese s udies wi h a s anda dised app oach and wo k owa d an o e all e idence summa y. The e is also a mo e undamen al philosophical ques ion abou he p esen a ion o isk in o ma ion. Should decision make s only pay a en ion o isk ac o quan i ica ion o hose isks suppo ed by he s onges causal e idence such as andomised ials? O do no ions such as he p ecau iona y p inciple sugges ha we should pay a en ion o isk quan i ica ion e en o isk-ou come pai s whe e he e idence is less de ini i e.70–72 Because he social esponse o isks, pa icula ly isks ha migh be eme ging, can ake conside able ime, igno ing isks o which he e idence is less de ini i e migh ac ually lead o wo se ou comes o socie y. Con e sely, in a wo ld o sca ce poli ical and inancial esou ces, de o ing a en ion o isks ha migh u n ou no o be causal migh lead o less ac ion on mo e well documen ed isks. As pa o u u e i e a ions o GBD, we plan o quan i y he bu den a ibu able o some dis al social isks. We ha e emba ked on his wo k, bu i p o es o ha e challenges ha a e quali a i ely di e en han many o he isks included he e. Fo nea ly all isk-ou come pai s, we assume in he absence o o he e idence ha he RRs by age and sex a e gene alisable ac oss popula ions ( he excep ion is o BMI in Asian and non-Asian popula ions o b eas cance ). In p inciple, i he e is e idence o s a is ically signi ican RRs o di e en popula ion g oups, we would inco po a e hese in o he CRA. Fo dis al social isks, he pa hways o ou comes can be modi ied in many ways by o he isks o by heal h-sys em in e en ions. We expec ha he RR due o low educa ion o 40-yea -old men would be di e en in No way han in Kenya. Gi en he g ea e po en ial o a ia ion in RRs o dis al isks, inclusion in GBD will equi e mo e local quan i ica ion o RRs and hen a u he modelling s ep o es ima e RRs o hese de e minan s o all loca ions. Ou i s planned a ge o his quan i ica ion is educa ional a ainmen . Gi en he global policy ocus on he po en ial heal h e ec s o clima e change d i en by ising le els o g eenhouse gases, and consequen ly empe a u e, we will add empe a u e and p ecipi a ion as isk ac o s ha a e quan i ied on an annual basis in u u e i e a ions o GBD. E en hough mos o he po en ial ha m ha migh come om ising empe a u es o ex eme wea he e en s will occu in he u u e, in some loca ions, we migh al eady ind signi ican a ibu able bu den.73 This analysis will need o examine he ela ionship be ween disease and mo ali y isk and empe a u e o each ele an ou come. Fo some ou comes, hese ela ionships a e likely o be U shaped, wi h an op imal empe a u e o minimum isk. These U-shaped ela ionships could mean ha o some ou comes in some loca ions, ising empe a u e migh educe ha m, e en i in mos loca ions i will inc ease bu den. Likewise, a majo issue in unde s anding he empe a u e and heal h ou come ela ionships is ha we Global Heal h Me ics 1412 www. helance .com Vol 390 Sep embe 16, 2017 would expec hese o be a enua ed in high-SDI se ings, whe e many indi iduals can p o ec hemsel es om some o he consequences. In o he wo ds, gene alising om s udies in high-SDI loca ions o o he loca ions migh unde es ima e he isk ela ionships. In he GBD CRA app oach, he TMREL is he le el o isk exposu e ha leads o minimum isk o indi iduals. In p inciple, he TMREL could a y by loca ion, age, and sex. To da e, he TMREL in he GBD wo k has been selec ed o be uni e sal. Fo mo e de ail on TMREL, see appendix 1 (p 22). The analysis o alcohol, whe e o IHD he e is a p o ec i e e ec a mild o mode a e consump ion bu a ha m ul e ec o neoplasms and inju ies, is a good example o whe e i would be desi able o a y TMREL by age. In younge ages, inju ies will be mo e impo an han ca dio ascula diseases, pushing he TMREL owa d ze o consump ion o alcohol, whe eas a olde ages, he TMREL migh be highe . Le ing he TMREL a y by age and sex and e en loca ion will add an ex a analy ical s ep o GBD; like all o he es ima ion s eps, his can ha e es ima ion e o . To da e, we ha e hough he es ima ion e o associa ed wi h a TMREL ha a ies may no make he e o wo hwhile. As e idence accumula es on some isks like alcohol, we will ca e ully e alua e his posi ion. Limi a ions A s udy o his scope has many limi a ions. He e we discuss he limi a ions ha apply o he o e all isk ac o analy ical amewo k and limi a ions in he es ima ion app oach o new isks and isks ha ha e unde aken signi ican e isions om GBD 2015. Mo e de ails and limi a ions o he analy ical app oach o each isk ac o a e p esen ed in appendix 1 (p 43). Fi s , we con inue o include isk-ou come pai s ha mee he Wo ld Cance Resea ch Fund c i e ia o con incing o p obable e idence o causali y. While hese c i e ia ha e p o en a use ul ba o inclusion, he e is an impo an subjec i e elemen o hei in e p e a ion. Some isk-ou come pai s included in his s udy migh no mee hese c i e ia o al e na i e c i e ia ha a e de eloped as new andomised ials, coho s udies, o case-con ol s udies a e published. Second, we used published coho s udies o e alua e he deg ee o which di e en isks a e media ed h ough o he isks. Es ima es o pa hways o media ion a e used o compu e he bu den a ibu able o agg ega es o isk ac o s such as all beha iou al isks o all isks combined. While we ha e conduc ed pooled coho analyses o s eng hen he assessmen o media ion, his wo k was no ye eady o inclusion in his assessmen . Pooled coho s udies ha e he ad an age o p o iding a mo e s anda dised amewo k o assessing media ion ac oss mul iple isks. A ela ed issue is he alida ion o he agg ega ion o isks in GBD. Pooled coho s udies will allow (in some ci cums ances) he oppo uni y o es ima e i he agg ega ion o GBD RRs is as p edic i e o ou comes as sugges ed by he isk-by- isk analysis wi h media ion. Thi d, we ha e used he Das Gup a o mula applied o each 5-yea in e al and o GBD Le el 3 causes. Agg ega ions a highe le els o causes and o longe pe iods o ime a e based on hese mo e g anula analyses o gua an ee consis ency. Gi en he non-linea na u e o he Das Gup a decomposi ion o mula, howe e , al e na i e esul s a e possible using di e en ime pe iods and causes in he o mula. Fou h, we ha e in oduced he use o ensemble dis ibu ions o imp o e he empi ical i ing o dis ibu ions o isk exposu e in se ings whe e only mean and s anda d de ia ion a e known o whe e we use models o p edic he mean and s anda d de ia ion o exposu e. Ensemble models p o ide mo e accu a e i s as assessed ou o sample o se ings wi h mic oda a. The unde lying assump ion is ha he same ensemble weigh s a e applicable ac oss all se ings. I is possible ha he shape o dis ibu ions o isk exposu e migh a y ac oss loca ions, o example because o he e ec s o access o ea men . Limi a ions ha apply o new isks in GBD 2016 o isks wi h signi ican es ima ion upda es a e p esen ed he e. Fo low bi hweigh and sho ges a ion, we ha e included he e ec o low bi hweigh and sho ges a ion only on neona al ou comes; we ha e no ound he e idence o mee ou inclusion c i e ia o he link be ween low bi hweigh and sho ges a ion and NCDs in adul age g oups. Ou analysis o RRs has used a e y la ge US-linked bi h coho da ase and much mo e limi ed da a om middle-SDI and low-SDI popula ions. Gi en he la ge numbe o obse a ions om he USA, ou esul s a e hea ily in luenced by he pa e n o RRs ac oss bi hweigh and ges a ional age in ha popula ion. The mic oda a used o de elop he ensemble dis ibu ions o bi hweigh and ges a ional age a e la gely om middle-SDI and high-SDI loca ions. The es i ma ion o alcohol use elies hea ily on sales da a, which a e limi ed and whose quali y we canno easily assess. Also, he es ima ion o un eco ded con sump ion o alcohol is based on limi ed da a and has signi ican unce ain y; ne e heless, we eel i is impo an o include i and plan o con inue o look o addi ional sou ces o in o ma ion o imp o e he es ima ion o un eco ded consump ion in u u e i e a ions o GBD. Las ly, me hods o calcula ing TMREL ely on obse ed DALYs o a gi en ime a he han on he expec ed sha e o DALYs es ima ed om alcohol use alone. Fu u e i e a ions o GBD will likely need o es his assump ion u he and de e mine i sepa a e TMREL by age and sex should be calcula ed. Conclusion Unde s anding he le els and ends o majo isks o human heal h is essen ial o p io i ise public heal h ac ion and e alua e he success o di e en p og ammes and policies. This s udy p o ides a comp ehensi e and compa able assessmen o 84 me abolic, en i onmen al, occupa ional, and beha iou al isks ac oss loca ions and ime. Ou indings show ha isk modi ica ion has been an impo an con ibu o o educ ions in communicable, ma e nal, neona al, and nu i ional causes, bu has played a ela i ely small pa in ends in NCDs. Con lic ing ends in isks o NCDs a he global le el, such as he decline in Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1413 smoking p e alence coupled wi h he ise in obesi y, FPG, and SBP, accoun o his inding. By con as wi h ends in diseases and inju ies a he global le el and e en a he na ional le el, he e is much g ea e he e ogenei y o global ends ac oss isks and conside able geog aphical a ia ion in leading isks as well. Public heal h ac ion in each coun y and egion needs o ocus on he majo isks in ha communi y. Ou indings ein o ce he c ucial need o obus moni o ing o he exposu e o isks o heal h and assessmen o he e idence suppo ing causal e ec s o each isk-ou come pai ; GBD p o ides he main global mechanism o his moni o ing unc ion. GBD 2016 Risk Fac o s Collabo a o s Emmanuela Gakidou, Ashkan A shin, Amanuel Alemu Abajobi , Kalkidan Hassen Aba e, C is iana Abba a i, Kaja M Abbas, Foad Abd-Allah, Abdishaku M Abdulle, Semaw Fe ede Abe a, Vic o Aboyans, Lai h J Abu-Raddad, Ni een M E Abu-Rmeileh, Geb e Yi ayih Abyu, Isaac Akinkunmi Adedeji, Ola unji Ade okunboh, Mohsen A a ideh, Anu ag Ag awal, Su apa Ag awal, Aliasgha Ahmad Kiadali i, Hamid Ahmadieh, Muk a Beshi Ahmed, Amani Nidhal Aichou , Ib ihel Aichou , Miloud Taki Eddine Aichou , Ru us Olusola Akinyemi, Nadia Aksee , Fa es Alahdab, Ziyad Al-Aly, Khu shid Alam, Noo e Alam, Tahiya Alam, Deena Alas oo , Ke yalew Addis Alene, Komal Ali, Reza Alizadeh-Na aei, Ala’a Alke wi, F ançois Alla, Pe e Allebeck, Rajaa Al-Raddadi, Ubai Alsha i , Khalid A Al i kawi, Nelson Al is-Guzman, Azme aw T Ama e, E an Amini, Walid Amma , Yaw Ampem Amoako, Hossein Ansa i, Josep M An ó, Ca l Abela do T An onio, Palwasha Anwa i, Nicholas A ian, Johan Ä nlö , Al A aman, K ishna Kuma A yal, Hamid Asayesh, Solomon Weldegeb eal Asgedom, Tes ay Meha i A ey, Le icia A ila-Bu gos, Eu ipide F inel G A hu A okpaho, Ashish Awas hi, Pe e Azzopa di, Uma Bacha, Alaa Badawi, Kalpana Balak ishnan, Shoshana H Ballew, Aleksand a Ba ac, Ryan M Ba be , Suzanne L Ba ke -Collo, Till Bä nighausen, Simon Ba que a, La s Ba ega d, Lope H Ba e o, Ca olina Ba is, Ka he ine E Ba le, Be nha d T Baune, Jus in Bea dsley, Nee aj Bedi, E o e Beghi, Michelle L Bell, De ick A Benne , James R Benne , Isabela M Benseno , Adugnaw Be hane, De bew Fikadu Be he, Edua do Be nabé, Balem Dem su Be su, Mi cea Beu an, Addisu Shunu Beyene, Anil Bhansali, Zul iqa A Bhu a, Bo is Bikbo , Cha les Bi ungi, S an Bi yuko , Ch is ophe D Blosse , Dube Ja a Boneya, Ib ahim R Bou-O m, Michael B aue , Nicholas J K B ei bo de, He mann B enne , T aolach S B ugha, Lemma Negesa Bul o Bul o, Blai R Baumga ne , Zahid A Bu , Luce o Cahuana-Hu ado, Rosa io Cá denas, Juan Jesus Ca e o, Ca los A Cas añeda-O juela, Fe án Ca alá-López, Kelly Ce cy, Hsing-Yi Chang, Fiona J Cha lson, Odge el Chimed-Ochi , Vespe Hichilombwe Chisumpa, Abdulaal A Chi hee , Hanne Ch is ensen, De asahayam Jesudas Ch is ophe , Massimo Ci illo, Aa on J Cohen, Haley Com o , Cy us Coope , Jose Co esh, Leslie Co naby, Paolo Angelo Co esi, Michael H C iqui, John A C ump, Lali Dandona, Rakhi Dandona, José das Ne es, Gail Da ey, D agos V Da i oiu, Kai a Da le o , Ba bo a de Cou en, Louisa Degenha d , Selina Deipa ine, Robe P Della alle, Kebede De ibe, Ani uddha Deshpande, Sama h D Dha ma a ne, E ic L Ding, Shi in Djalalinia, Huyen Phuc Do, Kla a Doko a, Da id Teye Doku, E Ray Do sey, Tim R D iscoll, Manisha Dubey, B uce Ba holow Duncan, Sa ah Duncan, Na alie Ebe , Hedyeh Eb ahimi, Ziad Ziad El-Kha ib, Ahmadali Enaya i, Aman Yesu End ies, Se gey Pe o ich E mako , Holly E E skine, Babak Esh a i, Sha a eh Eskanda ieh, Ali eza Es eghama i, Ka a Es ep, Eme i o Jose Aquino Fa aon, Ca la So ia e Sa Fa inha, And é Fa o, Fa shad Fa zad a , Kai s en Fay, Vale y L Feigin, Seyed-Mohammad Fe esh ehnejad, João C Fe nandes, Alize J Fe a i, Tes aye Regassa Feyissa, I ina Filip, Flo ian Fische , Ch is ina Fi zmau ice, Ab aham D Flaxman, Na aliya Foig , Kyle J Fo eman, Joseph J F os ad, Nancy Fullman, Thomas Fü s , Joao M Fu ado, Mo saleh Ganji, Albe o L Ga cia-Bas ei o, Tsegaye Tewelde Geb ehiwo , Johanna M Geleijnse, Ayele Gele o, Bikila Lencha Gemechu, Hailay Ab ha Gesesew, Pe e W Ge hing, Ali eza Ghaja , Ka he ine B Gibney, Pa amji Singh Gill, Richa d F Gillum, Ababi Ze gaw Gi e , Melkamu Dede o Gishu, Gio gia Giussani, William W Godwin, Philimon N Gona, Amado Good idge, Samee Vali Gopalani, Ye geniy Go yakin, Alessand a Ca alho Goula , Nicholas G ae z, Ha ish Chande Gugnani, Jingwen Guo, Rajee Gup a, Tanush Gup a, Vipin Gup a, Reyna A Gu ié ez, Vladimi Hachinski, Nima Ha ezi-Nejad, Gessessew Bugssa Hailu, Randah Ribhi Hamadeh, Same Hamidi, Mouhanad Hammami, Alexis J Handal, G aeme J Hankey, Hilda L Ha b, Hab amu Abe a Ha e i, Mohammad Sadegh Hassan and, Rasmus Ha moelle , Cai lin Hawley, Simon I Hay, Mohammad T Hedaya i, Delia Hend ie, Ileana Bea iz He edia-Pi, Hans W Hoek, Nobuyuki Ho i a, H Dean Hosgood, So in Hos iuc, Damian G Hoy, Mohamed Hsai i, Guoqing Hu, Hsiang Huang, John J Huang, Kim Moesgaa d Ibu g, Chad Ikeda, Manami Inoue, Caleb Mackay Salpe e I ine, Ma ia Delo es Jackson, Ka h yn H Jacobsen, Nade Jahanmeh , Mihajlo (Michael) B Jako lje ic, Alejand a Jau egui, Mehdi Ja anbakh , Panniyammakal Jeemon, La s R K Johansson, Ca he ine O Johnson, Jos B Jonas, Mikk Jü isson, Zubai Kabi , Rajend a Kadel, Amaha Kahsay, Ri ul Kamal, And é Ka ch, Co ine Kakizi Ka ema, Ami Kasaeian, Nicholas J Kassebaum, Anshul Kas o , S ini asa Vi al Ka iki eddi, No i o Kawakami, Pe e Njenga Keiyo o, Se onias Ge achew Kelbo e, Lau a Kemme , And e Pascal Kengne, Chand asekha an Nai Kesa achand an, Youse Saleh Khade , Ib ahim A Khalil, Ejaz Ahmad Khan, Young-Ho Khang, A deshi Khos a i, Jagdish Khubchandani, Ch is ian Kieling, Daniel Kim, Jun Y Kim, Yun Jin Kim, Ru h W Kimoko i, Yohannes Kin u, Adnan Kisa, Ka a zyna A Kissimo a-Ska bek, Mika Ki imaki, Luke D Knibbs, Ann K is in Knudsen, Jacek A Kopec, Soewa a Kosen, Pa aiz A Koul, Ai Koyanagi, Michael K a chenko, K is ophe J K ohn, Hans K omhou , Ba helemy Kua e De o, Bu cu Kucuk Bice , G Anil Kuma , Michael Ku z, Hmwe H Kyu, Dha mesh Kuma Lal, Ra ilal Lalloo, Tea Lallukka, Qing Lan, Van C Lansingh, Ande s La sson, Alexande Lee, Paul H Lee, James Leigh, Janni Leung, Mi iam Le i, Yichong Li, Yongmei Li, Xiao eng Liang, Misgan Legesse Liben, Shai Linn, Pa ick Liu, Rakesh Lodha, Gianca lo Log oscino, Ka he ine J Looke , Alan D Lopez, S e an Lo kowski, Paulo A Lo u o, Ra ael Lozano, Raimundas Lune icius, E lyn Rachelle King Maca ayan, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Ma ek Majdan, Reza Majdzadeh, Azeem Majeed, Reza Malekzadeh, Rajesh Malho a, Debo ah Ca alho Mal a, Abdullah A Mamun, Helena Mangue a, Lo enzo G Man o ani, Chabila C Mapoma, Randall V Ma in, Jose Ma inez-Raga, F ancisco Roge lândio Ma ins-Melo, Manu Raj Ma hu , Kunihi o Ma sushi a, Richa d Ma zopoulos, Mohsen Mazidi, Colm McAlinden, John J McG a h, Su esh Meha a, Man Mohan Mehndi a a, Toni Meie , Yohannes Adama Melaku, Pe e Memiah, Ziad A Memish, Wal e Mendoza, Melkamu Me id Mengesha, Geo ge A Mensah, Ge B M Mensink, Seid Tiku Me e a, A e Me e oja, Tuomo J Me e oja, Ha ay Be hane Mezgebe, Rena a Micha, Anoushka Millea , Ted R Mille , Shawn Minnig, Mojde Mi a e in, E kin M Mi akhimo , Awoke Misganaw, Shi a Raj Mish a, Ka zan Abdulmuhsin Mohammad, Kedi End is Mohammed, Sha iu Mohammed, No linah Mohamed Ib ahim, Mu ali B V Mohan, Ali H Mokdad, Lo enzo Monas a, Julio Cesa Mon añez He nandez, Ma cella Mon ico, Mazia Mo adi-Lakeh, Paula Mo aga, Lidia Mo awska, Shane D Mo ison, Cli Moun joy-Venning, Ul ich O Muelle , E in C Mullany, Ka e Mulle , Gudla alle i Venka a Sa yana ayana Mu hy, Kama ul Im an Musa, Mohsen Nagha i, Aliya Naheed, Vinay Nangia, Gopalak ishnan Na a ajan, Ionu Negoi, Ruxand a I ina Negoi, Cuong Ta Nguyen, G an Nguyen, Minh Nguyen, Quyen Le Nguyen, T ang Huyen Nguyen, Emma Nichols, Dina Nu Angg aini Ning um, Ma ika Nomu a, Vuong Minh Nong, Ole F No heim, Bo No ing, Jean Jacques N Noubiap, Ca la Makhlou Obe meye , Felix Akpojene Ogbo, In-Hwan Oh, Olan ewaju Oladimeji, And ew Toyin Olagunju, Tinuke Oluwase unmi Olagunju, Ped o R Oli a es, Helen E Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal O en, Albe o O iz, E ika O a, Mayowa O Owolabi, Mahesh PA, Rosana E Pacella, Ad ian Pana, Basan Kuma Panda, Songhomi a Panda-Jonas, Jeya aj D Pandian, Ch is ina Papach is ou, Eun-Kee Pa k, Cha les D Pa y, Sco B Pa en, Geo ge C Pa on, Da id M Pe ei a, No be o Pe ico, Kon ad Pesudo s, Max Pe zold, Michael Robe Phillips, Julian Da id Pillay, Global Heal h Me ics 1414 www. helance .com Vol 390 Sep embe 16, 2017 Michael A Pi ado , Fa had Pishga , Die ich Plass, Ma in A Ple che , Suzanne Polinde , S e lana Popo 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ich Vlasso , S ein Emil Vollse , Theo Vos, Fiseha Wadilo, Tolassa Wakayo, Mi chell T Wallin, Yuan-Pang Wang, Sco Weichen hal, Elisabe e Weide pass, Robe G Wein aub, Daniel J Weiss, And ea We decke , Ronny Wes e man, Ha ey A Whi e o d, Cha les Shey Wiysonge, Bele e Ge ahun Woldeyes, Cha les D A Wol e, Rachel Woodb ook, Abdulhalik Wo kicho, Sa ah Wul Hanson, Denis Xa ie , Gelin Xu, Simon Yadgi , Be eke Yakob, Lijing L Yan, Mehdi Yase i, Hassen Hamid Yimam, Paul Yip, Naohi o Yonemo o, Seok-Jun Yoon, Ma cel Yo ebieng, Mus a a Z Younis, Zoubida Zaidi, Maysaa El Sayed Zaki, Luis Za ala-A ciniega, Xueying Zhang, S ephanie Raman M Zimsen, Ben Zipkin, Sanjay Zodpey, S ephen S Lim, Ch is ophe J L Mu ay. A ilia ions Ins i u e o Heal h Me ics and E alua ion (P o E Gakidou PhD, A A shin MD, T Alam MPH, K Ali BSc, N A ian BA, R M Ba be BS, J R Benne BA, S Bi yuko BS, P o M B aue ScD, B Bumga ne MBA, K Ce cy BS, F J Cha lson PhD, A J Cohen DSc, H Com o BS, L Co naby BS, P o L Dandona MD, P o R Dandona PhD, P o L Degenha d PhD, S Deipa ine, A Deshpande MPH, S Duncan, H E E skine PhD, K Es ep MPA, K Fay BS, A J Fe a i PhD, C Fi zmau ice MD, A D Flaxman PhD, K J Fo eman PhD, J J F os ad MPH, N Fullman MPH, W W Godwin BS, N G ae z MPH, J Guo BS, C Hawley MSPH, P o S I Hay DSc, C Ikeda BS, C M S I ine BA, C O Johnson PhD, N J Kassebaum MD, L Kemme PhD, I A Khalil MD, J Y Kim BS, K J K ohn BA, M Ku z BS, H H Kyu PhD, A Lee BA, J Leung PhD, P o S S Lim PhD, P Liu MPH, H Mangue a BS, A Millea BA, S Minnig MS, M Mi a e in MPH, A Misganaw PhD, P o A H Mokdad PhD, C Moun joy-Venning BA, E C Mullany BA, K Mulle MPH, P o M Nagha i PhD, G Nguyen MPH, M Nguyen BS, E Nichols BA, H E Olsen MA, M A Ple che BS, C Pu cell BS, R C Reine PhD, M B Rei sma BS, Y Roman MLIS, G A Ro h MD, N Sada MA, J Salama MSc, D San omau o PhD, C Shields BS, E L Slepak MLIS, P o D L Smi h PhD, M Smi h MPA, R J D So ensen MPH, V S ini asan BA, C S eine MPH, B S ub BS, M Suba BA, P J Su BA, O Thamsuwan PhD, A M Theis BA, A To e BS, R Updike AB, V Venka eswa an BDS, P o S E Vollse D PH, P o T Vos PhD, P o H A Whi e o d PhD, R Woodb ook MLIS, S Wul Hanson MPH, S Yadgi BS, S R M Zimsen MA, B Zipkin BS, P o C J L Mu ay DPhil), Di ision o Hema ology, Depa men o Medicine (C Fi zmau ice MD), Cen e o Heal h T ends and Fo ecas s, Ins i u e o Heal h Me ics and E alua ion (P o M B Jako lje ic PhD), Uni e si y o Washing on, Sea le, WA, USA (C D Blosse MD, S D Mo ison MD); School o Public Heal h (A A Abajobi MPH, F J Cha lson PhD, H E E skine PhD, A J Fe a i PhD, L D Knibbs PhD, J Leung PhD, D San omau o PhD, L J Vee man PhD, P o H A Whi e o d PhD), School o Den is y (P o R Lalloo PhD), Uni e si y o Queensland, B isbane, QLD, Aus alia (S R Mish a MPH); Depa men o Epidemiology, College o Heal h Sciences (M B Ahmed MPH), Jimma Uni e si y, Jimma, E hiopia (K H Aba e MS, P o T T Geb ehiwo MPH, H A Gesesew MPH, S T Me e a PhD, T Wakayo MS, A Wo kicho MPH); La Sapienza Uni e si y, Rome, I aly (C Abba a i PhD); Vi ginia Tech, Blacksbu g, VA, USA (P o K M Abbas PhD); Depa men o Neu ology, Cai o Uni e si y, Cai o, Egyp (P o F Abd-Allah MD); New Yo k Uni e si y Abu Dhabi, Abu Dhabi, Uni ed A ab Emi a es (A M Abdulle PhD); School o Public Heal h (S F Abe a MSc, Y A Melaku MPH), College o Heal h Sciences (S F Abe a MSc, K E Mohammed MPH), School o Pha macy (D F Be he MS), Mekelle Uni e si y, Mekelle, E hiopia (P o G Y Abyu MS, S W Asgedom MS, T M A ey MS, B D Be su MS, G B Hailu MSc, A Kahsay MPH, H B Mezgebe MS, K B Tuem MS); Food Secu i y and Ins i u e o Biological Chemis y and Nu i ion, Uni e si y o Hohenheim, S u ga , Ge many (S F Abe a MSc); Dupuy en Uni e si y Hospi al, Limoges, F ance (P o V Aboyans PhD); In ec ious Disease Epidemiology G oup, Weill Co nell Medical College in Qa a , Doha, Qa a (L J Abu-Raddad PhD); Ins i u e o Communi y and Public Heal h, Bi zei Uni e si y, Ramallah, Pales ine (N M Abu-Rmeileh PhD); Olabisi Onabanjo Uni e si y, Ago-Iwoye, Nige ia (I A Adedeji MS); Depa men o Psychia y (P o C D Pa y PhD), S ellenbosch Uni e si y, Cape Town, Sou h A ica (O Ade okunboh MD, P o S Seeda PhD, P o C S Wiysonge PhD); CSIR - Ins i u e o Genomics and In eg a i e Biology, Delhi, India (A Ag awal PhD); Depa men o In e nal Medicine, Baylo College o Medicine, Hous on, TX, USA (A Ag awal PhD); Cen e o Con ol o Ch onic Condi ions (P Jeemon PhD), Indian Ins i u e o Public Heal h (P o G V S Mu hy MD), Public Heal h Founda ion o India, Gu ug am, India (S Ag awal PhD, P o L Dandona MD, P o R Dandona PhD, G A Kuma PhD, D K Lal MD, M R Ma hu PhD, P o S Zodpey PhD); Depa men o Clinical Sciences Lund, O hopedics, Clinical Epidemiology Uni (A Ahmad Kiadali i PhD), Skane Uni e si y Hospi al, Depa men o Clinical Sciences Lund, Neu ology (P o B No ing PhD), Lund Uni e si y, Lund, Sweden; Oph halmic Resea ch Cen e (H Ahmadieh MD, S Sa i MS, M Yase i PhD), School o Public Heal h (N Jahanmeh PhD), Shahid Behesh i Uni e si y o Medical Sciences, Teh an, I an; Depa men o Oph halmology, Labba inejad Medical Cen e , Teh an, I an (H Ahmadieh MD); Uni e si y Fe ha Abbas o Se i , Se i , Alge ia (A N Aichou BS); Na ional Ins i u e o Nu sing Educa ion, Se i , Alge ia (I Aichou MS); High Na ional School o Ve e ina y Medicine, Algie s, Alge ia (M T Aichou MD); Uni e si y o Ibadan, Ibadan, Nige ia (R O Akinyemi PhD); Newcas le Uni e si y, Newcas le upon Tyne, UK (R O Akinyemi PhD); Cen e o Global Child Heal h, The Hospi al o Sick Child en, To on o, ON, Canada (N Aksee MSc, Z A Bhu a PhD); Dalla Lana School o Public Heal h (N Aksee MSc, P o J Rehm PhD), Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1415 Depa men o Nu i ional Sciences, Facul y o Medicine (A Badawi PhD), Cen e o Addic ion and Men al Heal h (S Popo a PhD), Uni e si y o To on o, To on o, ON, Canada; Mayo Clinic Founda ion o Medical Educa ion and Resea ch, Roches e , MN, USA (F Alahdab MD); Sy ian Ame ican Medical Socie y, Washing on, DC, USA (F Alahdab MD); Washing on Uni e si y in S Louis, S Louis, MO, USA (Z Al-Aly MD); Mu doch Child ens Resea ch Ins i u e (K Alam PhD, P Azzopa di PhD, R G Wein aub MBBS), Depa men o Paedia ics (P Azzopa di PhD, P o G C Pa on MD), Melbou ne School o Popula ion and Global Heal h (P o A D Lopez PhD), Depa men o Medicine (A Me e oja PhD), Ins i u e o Heal h and Ageing (P o C E I Szoeke PhD), The Uni e si y o Melbou ne, Melbou ne, VIC, Aus alia (K Alam PhD, M A Rahman PhD, R G Wein aub MBBS); Sydney School o Public Heal h (P o T R D iscoll PhD), The Uni e si y o Sydney, Sydney, NSW, Aus alia (K Alam PhD, J Leigh PhD); Depa men o Heal h, Queensland, B isbane, QLD, Aus alia (N Alam MAppEpid); Minis y o Heal h, Al Khuwai , Oman (D Alas oo MSc); Depa men o Epidemiology and Bios a is ics, Ins i u e o Public Heal h (K A Alene MPH), Uni e si y o Gonda , Gonda , E hiopia (B Tesssema PhD); Depa men o Global Heal h, Resea ch School o Popula ion Heal h, Aus alian Na ional Uni e si y, Canbe a, ACT, Aus alia (K A Alene MPH); Gas oin es inal Cance Resea ch Cen e (R Alizadeh-Na aei PhD), Depa men o Medical Mycology and Pa asi ology, School o Medicine (P o M T Hedaya i PhD), Mazanda an Uni e si y o Medical Sciences, Sa i, I an; Luxembou g Ins i u e o Heal h, S assen, Luxembou g (A Alke wi PhD); School o Public Heal h, Uni e si y o Lo aine, Nancy, F ance (P o F Alla PhD); Depa men o Public Heal h Sciences (P Allebeck PhD, Z Z El-Kha ib PhD), Depa men o Neu obiology, Ca e Sciences and Socie y, Di ision o Family Medicine and P ima y Ca e (P o J Ä nlö PhD), Depa men o Medical Epidemiology and Bios a is ics (P o J J Ca e o PhD, E Weide pass PhD), Depa men o Neu obiology, Ca e Sciences and Socie y (NVS) (S Fe esh ehnejad PhD), Ka olinska Ins i u e , S ockholm, Sweden (R Ha moelle PhD); Join P og am o Family and Communi y Medicine, Jeddah, Saudi A abia (R Al-Raddadi PhD); Cha i é Uni e si ä smedizin, Be lin, Ge many (U Alsha i MPH, N Ebe MD, P o E Schae ne MSc); King Saud Uni e si y, Riyadh, Saudi A abia (K A Al i kawi MD, B H A Sobaih MD); Uni e sidad de Ca agena, Ca agena de Indias, Colombia (P o N Al is-Guzman PhD); School o Medicine (A T Ama e MPH, P o B T Baune PhD, Y A Melaku MPH), Discipline o Psychia y, School o Medicine (A T Olagunju MD), Uni e si y o Adelaide, Adelaide, Sou h Aus alia, Aus alia; College o Medicine and Heal h Sciences, Bahi Da Uni e si y, Bahi Da , E hiopia (A T Ama e MPH); U o-Oncology Resea ch Cen e (E Amini MD, F Pishga MD), Non- Communicable Diseases Resea ch Cen e (H Eb ahimi MD, F Fa zad a MD, A Khos a i PhD, F Pishga MD), Endoc inology and Me abolism Resea ch Cen e (E Amini MD, P o A Es eghama i MD, N Ha ezi-Nejad MD, A Kasaeian PhD), Cen e o Ai Pollu ion Resea ch, Ins i u e o En i onmen al Resea ch (M S Hassan and PhD), Hema ology- Oncology and S em Cell T ansplan a ion Resea ch Cen e (A Kasaeian PhD), Knowledge U iliza ion Resea ch Cen e and Communi y Based Pa icipa o y Resea ch Cen e (P o R Majdzadeh PhD), Li e and Panc ea icobilia y Diseases Resea ch Cen e (H Eb ahimi MD), Diges i e Diseases Resea ch Ins i u e (P o R Malekzadeh MD, G Roshandel PhD, S G Sepanlou PhD), I anian Na ional Cen e o Addic ion S udies (INCAS) (A Rahimi-Mo agha MD), Sina T auma and Su ge y Resea ch Cen e (P o V Rahimi-Mo agha MD, M Sa da ian MD), Ins i u e o En i onmen al Resea ch (M Shamsipou PhD), Cance Resea ch Cen e (P o R Shi koohi PhD), Teh an Uni e si y o Medical Sciences, Te han, I an (M A a ideh MD, M Ganji MD, A Ghaja MD, M Yase i PhD); Minis y o Public Heal h, Bei u , Lebanon (W Amma PhD, I R Bou-O m MD, H L Ha b MPH); Depa men o Medicine, Kom o Anokye Teaching Hospi al, Kumasi, Ghana (Y A Amoako MD); Heal h P omo ion Resea ch Cen e , Depa men o Epidemiology and Bios a is ics, Zahedan Uni e si y o Medical Sciences, Zahedan, I an (H Ansa i PhD); ISGlobal Ba celona Ins i u e o Global Heal h, Ba celona, Spain (P o J M An ó MD); Depa men o Heal h Policy and Adminis a ion, College o Public Heal h (C A T An onio MD, E J A Fa aon MD), Uni e si y o he Philippines Manila, Manila, Philippines; Sel -employed, Kabul, A ghanis an (P Anwa i MS); School o Heal h and Social S udies, Dala na Uni e si y, Falun, Sweden (P o J Ä nlö PhD); Uni e si y o Mani oba, Winnipeg, MB, Canada (A A aman PhD); Nepal Heal h Resea ch Council, Ka hmandu, Nepal (K K A yal MPH); Uni e si y o Oslo, Oslo, No way (K K A yal MPH); Depa men o Medical Eme gency, School o Pa amedic, Qom Uni e si y o Medical Sciences, Qom, I an (H Asayesh MS); Na ional Council o Science and Technology (C Ba is PhD), Na ional Ins i u e o Public Heal h, Cue na aca, Mexico (L A ila-Bu gos PhD, S Ba que a PhD, L Cahuana-Hu ado PhD, I B He edia-Pi PhD, A Jau egui MSc, R Lozano PhD, J C Mon añez He nandez MSc, LMReynales-Shigema suPhD, P o J A Ri e a PhD, T G Sánchez-Pimien a MSc, P o E E Se an-Mo i MSc, T Shamah Le y PhD, L Za ala-A ciniega MS); Ins i u de Reche che Clinique du Bénin (IRCB), Co onou, Benin (E F G A A okpaho MPH); Labo a oi e d’E udes e de Reche che-Ac ion en San é (LERAS A ique), Pa akou, Benin (E F G A A okpaho MPH); Indian Ins i u e o Public Heal h, Gandhinaga , India (A Awas hi PhD); Bu ne Ins i u e, Melbou ne, VIC, Aus alia (P Azzopa di PhD); Wa dlipa ingga Abo iginal Resea ch Uni , Sou h Aus alian Heal h and Medical Resea ch Ins i u e, Adelaide, Sou h Aus alia, Aus alia (P Azzopa di PhD); School o Heal h Sciences, Uni e si y o Managemen and Technology, Laho e, Pakis an (U Bacha PhD); Public Heal h Agency o Canada, To on o, ON, Canada (A Badawi PhD); Depa men o En i onmen al Heal h Enginee ing, S i Ramachand a Uni e si y, Chennai, India (K Balak ishnan PhD); Johns Hopkins Bloombe g School o Public Heal h (S H Ballew PhD, J Co esh PhD, K Ma sushi a PhD), Johns Hopkins Uni e si y, Bal imo e, MD, USA (B X T an PhD); Facul y o Medicine (A Ba ac PhD), Ins i u e o Social Medicine, Facul y o Medicine (M M San ic Milice ic PhD), Cen e School o Public Heal h and Heal h Managemen , Facul y o Medicine (M M San ic Milice ic PhD), Uni e si y o Belg ade, Belg ade, Se bia; School o Psychology, Uni e si y o Auckland, Auckland, New Zealand (S L Ba ke -Collo PhD); Depa men o Global Heal h and Popula ion, Ha a d T H Chan School o Public Heal h (P o T Bä nighausen MD, J A Salomon PhD), Ha a d T H Chan School o Public Heal h (E L Ding ScD), A iadne Labs (E R K Maca ayan PhD), Ha a d Uni e si y, Bos on, MA, USA; A ica Heal h Resea ch Ins i u e, M uba uba, Sou h A ica (P o T Bä nighausen MD); Ins i u e o Public Heal h, Heidelbe g Uni e si y, Heidelbe g, Ge many (P o T Bä nighausen MD, S Mohammed PhD); Depa men o Occupa ional and En i onmen al Medicine, Sahlg enska Academy, Uni e si y o Go henbu g, Go henbu g, Sweden (P o L Ba ega d MD); Depa men o Indus ial Enginee ing, School o Enginee ing, Pon i icia Uni e sidad Ja e iana, Bogo a, Colombia (L H Ba e o ScD); Mala ia A las P ojec , Ox o d Big Da a Ins i u e (K E Ba le DPhil), Li Ka Shing Cen e o Heal h In o ma ion and Disco e y (P o S I Hay DSc), Nu ield Depa men o Popula ion Heal h (D A Benne PhD), Depa men o Zoology (P W Ge hing PhD), Uni e si y o Ox o d, Ox o d, UK (D J Weiss PhD); Ox o d Uni e si y, Ho Chi Minh Ci y, Vie nam (J Bea dsley MBChB); College o Public Heal h and T opical Medicine, Jazan, Saudi A abia (N Bedi MD); IRCCS - Is i u o di Rice che Fa macologiche Ma io Neg i, Be gamo, I aly (E Beghi MD, B Bikbo MD, G Giussani BiolD, N Pe ico MD, P o G Remuzzi MD); Yale Uni e si y, New Ha en, CT, USA (P o M L Bell PhD, J J Huang MD); Cen e o Clinical and Epidemiological Resea ch Cen e , Hospi al Uni e si a io (A C Goula PhD), In e nal Medicine Depa men (P o I S San os PhD), Uni e si y o São Paulo, São Paulo, B azil (I M Benseno PhD, P o P A Lo u o D PH); College o Heal h Sciences, Deb e Be han Uni e si y, Deb e Be han, E hiopia (A Be hane PhD); Uni e si y Medical Cen e G oningen (D F Be he MS), Depa men o Psychia y, Uni e si y Medical Cen e G oningen (P o H W Hoek MD), Uni e si y o G oningen, G oningen, Ne he lands (J F M an Bo en PhD); Di ision o Heal h and Social Ca e Resea ch (P o C D Wol e MD), King’s College London, London, UK (E Be nabé PhD); Ca ol Da ila Uni e si y o Medicine and Pha macy, Bucha es , Romania (P o M Beu an PhD, D V Da i oiu PhD, S Hos iuc PhD, I Negoi PhD, R I Negoi PhD); Eme gency Hospi al o Bucha es , Bucha es , Romania (P o M Beu an PhD, I Negoi PhD); College o Heal h and Medical Sciences (A S Beyene MPH, M M Mengesha MPH), Ha amaya Uni e si y, Ha a , E hiopia (L N B Bul o MS, A Gele o MPH, M D Gishu MS, K T Roba PhD, M S Shi e aw MS); Pos g adua e Ins i u e o Medical Educa ion and Resea ch, Chandiga h, India (A Bhansali DM); Cen e o Excellence in Women and Child Heal h, Aga Khan Uni e si y, Ka achi, Pakis an (Z A Bhu a PhD); Depa men o Epidemiology and Public Heal h (P o M Ki imaki PhD), Ins i u e o Epidemiology & Heal h (T Tillmann MSc), Uni e si y College London, London, UK (C Bi ungi MS, Global Heal h Me ics 1416 www. helance .com Vol 390 Sep embe 16, 2017 M R Ma hu PhD); Depa men o Public Heal h (D J Boneya MPH), Deb e Ma kos Uni e si y, Deb e Ma kos, E hiopia (T K Tegegne MPH); Uni e si y o B i ish Columbia, Vancou e , BC, Canada (P o M B aue ScD, J A Kopec PhD, F Pou malek PhD); College o Medicine (J Shen PhD), The Ohio S a e Uni e si y, Columbus, OH, USA (P o N J K B ei bo de PhD, M Yo ebieng PhD); Ge man Cance Resea ch Cen e , Heidelbe g, Ge many (P o H B enne MD); Uni e si y o Leices e , Leices e , UK (P o T S B ugha MD); Al Shi a T us Eye Hospi al, Rawalpindi, Pakis an (Z A Bu PhD); Me opoli an Au onomous Uni e si y, Mexico Ci y, Mexico (R Cá denas ScD); Colombian Na ional Heal h Obse a o y, Ins i u o Nacional de Salud, Bogo a, Colombia (C A Cas añeda-O juela MSc); Epidemiology and Public Heal h E alua ion G oup, Public Heal h Depa men , Uni e sidad Nacional de Colombia, Bogo a, Colombia (C A Cas añeda-O juela MSc); Depa men o Medicine, Uni e si y o Valencia, INCLIVA Heal h Resea ch Ins i u e and CIBERSAM, Valencia, Spain (F Ca alá-López PhD, P o R Taba és-Seisdedos PhD); Clinical Epidemiology P og am, O awa Hospi al Resea ch Ins i u e, O awa, ON, Canada (F Ca alá-López PhD); Na ional Heal h Resea ch Ins i u es, Zgunan Town, Taiwan (H Chang D PH); Na ional Yang-Ming Uni e si y, Taipei, Taiwan (H Chang D PH); Queensland Cen e o Men al Heal h Resea ch, B isbane, QLD, Aus alia (F J Cha lson PhD, H E E skine PhD, A J Fe a i PhD, D San omau o PhD, P o H A Whi e o d PhD); Depa men o En i onmen al Epidemiology, Uni e si y o Occupa ional and En i onmen al Heal h, Ki akyushu, Japan (O Chimed-Ochi MPH); Uni e si y o Zambia, Lusaka, Zambia (V H Chisumpa MPhil, C C Mapoma PhD); Uni e si y o Wi wa e s and, Johannesbu g, Sou h A ica (V H Chisumpa MPhil); Minis y o Heal h, Baghdad, I aq (A A Chi hee MD); Bispebje g Uni e si y Hospi al, Copenhagen, Denma k (P o H Ch is ensen DMSCi); Ch is ian Medical College, Vello e, India (P o D J Ch is ophe MD, P o S Va ughese DM); Uni e si y o Sale no, Ba onissi, I aly (P o M Ci illo MD); Heal h E ec s Ins i u e, Bos on, MA, USA (A J Cohen DSc); MRC Li ecou se Epidemiology Uni ed, Uni e si y o Sou hamp on, Sou hamp on, UK (P o C Coope MD); NIHR Biomedical Resea ch Cen e, Uni e si y o Sou hamp on and Uni e si y Hospi al Sou hamp on NHS Founda ion T us , Sou hamp on, UK (P o C Coope MD); Resea ch Cen e on Public Heal h (CESP), Uni e si y o Milan-Bicocca, Monza, I aly (P A Co esi PhD); Uni e si y o Cali o nia, San Diego, La Jolla, CA, USA (M H C iqui MD); Cen e o In e na ional Heal h, Dunedin School o Medicine (P o J A C ump MD), Uni e si y o O ago, Dunedin, New Zealand (P o R G Poul on PhD); i3S - Ins i u o de In es igação e Ino ação em Saúde and INEB - Ins i u o de Engenha ia Biomédica (J das Ne es PhD), UCIBIO@REQUIMTE, Toxicology G oup, Facul y o Pha macy (J P Sil a PhD), Uni e si y o Po o, Po o, Po ugal; Wellcome T us B igh on & Sussex Cen e o Global Heal h Resea ch, B igh on, UK (P o G Da ey MD); Republican Ins i u e o Ca diology and In e nal Diseases, Alma y, Kazakhs an (K Da le o PhD); School o Public Heal h, Kazakh Na ional Medical Uni e si y, Alma y, Kazakhs an (K Da le o PhD); Depa men o Medicine, School o Clinical Sciences a Monash Heal h (P o A G Th i PhD), Monash Uni e si y, Melbou ne, VIC, Aus alia (P o B de Cou en PhD); Na ional D ug and Alcohol Resea ch Cen e (P o L Degenha d PhD), B ien Holden Vision Ins i u e (P o S Resniko MD), School o Op ome y and Vision Science (P o S Resniko MD), Uni e si y o New Sou h Wales, Sydney, NSW, Aus alia; Uni e si y o Colo ado School o Medicine and he Colo ado School o Public Heal h, Au o a, CO, USA (R P Della alle MD); B igh on and Sussex Medical School, B igh on, UK (K De ibe MPH); School o Public Heal h (K De ibe MPH), Addis Ababa Uni e si y, Addis Ababa, E hiopia (A Z Gi e PhD, H A Ha e i MS, S G Kelbo e MPH, B G Woldeyes MPH); Depa men o Communi y Medicine, Facul y o Medicine, Uni e si y o Pe adeniya, Pe adeniya, S i Lanka (S D Dha ma a ne MD); Unde sec e a y o Resea ch & Technology, Minis y o Heal h & Medical Educa ion, Teh an, I an (S Djalalinia PhD); Ins i u e o Global Heal h Inno a ions, Duy Tan Uni e si y, Da Nang, Vie nam (H P Do MSc, C T Nguyen MSc, Q L Nguyen MD, T H Nguyen MSc, V M Nong MSc); Depa men o Social Medicine, Facul y o Public Heal h, Medical Uni e si y - Va na, Va na, Bulga ia (K Doko a PhD); Uni e si y o Cape Coas , Cape Coas , Ghana (D T Doku PhD); Uni e si y o Tampe e, Tampe e, Finland (D T Doku PhD); Uni e si y o Roches e Medical Cen e , Roches e , NY, USA (E R Do sey MD); In e na ional Ins i u e o Popula ion Sciences, Mumbai, India (M Dubey MPhil, A Kas o MPhil, B K Panda MPhil, M H U Rahman MPhil, P o U Ram PhD); Fede al Uni e si y o Rio G ande do Sul, Po o Aleg e, B azil (B B Duncan PhD, C Kieling MD, P o M I Schmid MD); Uni e si y o No h Ca olina, Chapel Hill, NC, USA (B B Duncan PhD); Depa men o Global Heal h and Social Medicine, Ha a d Medical School, Kigali, Rwanda (Z Z El-Kha ib PhD); School o Public Heal h and Heal h Sciences Resea ch Cen e , Sa i, I an (P o A Enaya i PhD); A ba Minch Uni e si y, A ba Minch, E hiopia (A Y End ies MPH); The Ins i u e o Social and Economic S udies o Popula ion, Russian Academy o Sciences, Moscow, Russia (P o S P E mako DSc); Fede al Resea ch Ins i u e o Heal h O ganiza ion and In o ma ics, Minis y o Heal h o he Russian Fede a ion, Moscow, Russia (P o S P E mako DSc); Minis y o Heal h and Medical Educa ion, Teh an, I an (B Esh a i PhD); A ak Uni e si y o Medical Sciences, A ak, I an (B Esh a i PhD); Mul iple Scle osis Resea ch Cen e , Teh an, I an (S Eskanda ieh PhD); Depa men o Heal h, Manila, Philippines (E J A Fa aon MD); DGS Di ec o a e Gene al o Heal h, Lisboa, Po ugal (C S E S Fa inha MSc); Uni e sidade Abe a, Lisboa, Po ugal (C S E S Fa inha MSc); Fede al Uni e si y o Se gipe, A acaju, B azil (P o A Fa o PhD); Na ional Ins i u e o S oke and Applied Neu osciences, Auckland Uni e si y o Technology, Auckland, New Zealand (V L Feigin PhD); CBQF - Cen e o Bio echnology and Fine Chemis y - Associa e Labo a o y, Facul y o Bio echnology, Ca holic Uni e si y o Po ugal, Po o, Po ugal (J C Fe nandes PhD); Wollega Uni e si y, Nekem e, E hiopia (T R Feyissa MPH); Kaise Pe manen e, Fon ana, CA, USA (I Filip MD); School o Public Heal h, Biele eld Uni e si y, Biele eld, Ge many (F Fische PhD); F ed Hu chinson Cance Resea ch Cen e , Sea le, WA, USA (C Fi zmau ice MD); Ins i u e o Ge on ology, Academy o Medical Science, Kyi , Uk aine (N Foig PhD); Depa men o In ec ious Disease Epidemiology (T Fü s PhD), Depa men o P ima y Ca e & Public Heal h (P o A Majeed MD), Impe ial College London, London, UK (K J Fo eman PhD, P o S Rawa MD, L Rush on PhD, S Saxena MD, H Shoman MPH); Depa men o Epidemiology and Public Heal h (T Fü s PhD), Swiss T opical and Public Heal h Ins i u e, Basel, Swi ze land (C K Ka ema MSc); Swiss T opical and Public Heal h Ins i u e (P o M Tanne PhD), Uni e si y o Basel, Basel, Swi ze land (T Fü s PhD); Faculdade de Medicina de Ribei ão P e o, Uni e sidade de São Paulo, Ribei ão P e o, B azil (J M Fu ado MD); Manhiça Heal h Resea ch Cen e , Manhiça, Mozambique (A L Ga cia-Bas ei o MSc); Ba celona Ins i u e o Global Heal h, Ba celona, Spain (A L Ga cia-Bas ei o MSc); Di ision o Human Nu i ion, Wageningen Uni e si y, Wageningen, Ne he lands (J M Geleijnse PhD); Uni e si y o Newcas le, Newcas le, NSW, Aus alia (A Gele o MPH); Madda Walabu Uni e si y, Bale Goba, E hiopia (B L Gemechu MPH); Flinde s Uni e si y, Adelaide, SA, Aus alia (H A Gesesew MPH, P o K Pesudo s PhD); The Pe e Dohe y Ins i u e o In ec ion and Immuni y, The Uni e si y o Melbou ne & The Royal Melbou ne Hospi al, Melbou ne, VIC, Aus alia (K B Gibney MBBS); Wa wick Medical School, Uni e si y o Bi mingham, Bi mingham, UK (P o P S Gill DM); Howa d Uni e si y, Washing on, DC, USA (R F Gillum MD); Ke sa Heal h and Demog aphic Su eillance Sys em, Ha a , E hiopia (M D Gishu MS); Uni e si y o Massachuse s Bos on, Bos on, MA, USA (P o P N Gona PhD); Ins i u o de In es igaciones Cien i icas y Se icios de Al a Tecnologia - INDICASAT- AIP, Cuidad del Sabe , Panama (A Good idge PhD); Depa men o Heal h and Social A ai s, Go e nmen o he Fede a ed S a es o Mic onesia, Paliki , Fede a ed S a es o Mic onesia (S V Gopalani MPH); O ganisa ion o Economic Co-ope a ion and De elopmen , Pa is, F ance (Y Go yakin PhD); Cen e o Check o Hospi al Si io Libanes, São Paulo, B azil (A C Goula PhD); Depa men s o Mic obiology and Epidemiology & Bios a is ics, Sain James School o Medicine, The Qua e , Anguilla (P o H C Gugnani PhD); E e nal Hea Ca e Cen e and Resea ch Ins i u e, Jaipu , India (R Gup a PhD); Mon e io e Medical Cen e , B onx, NY, USA (T Gup a MD, C D Rehm PhD); Albe Eins ein College o Medicine, B onx, NY, USA (T Gup a MD, P o H D Hosgood PhD); Depa men o An h opology, Uni e si y o Delhi, Delhi, India (V Gup a PhD); Na ional Ins i u e o Psychia y Ramon de la Fuen e, Mexico Ci y, Mexico (R A Gu ié ez PhD); Depa men o Clinical Neu ological Sciences (L A Sposa o MD), Wes e n Uni e si y, London, ON, Canada (P o V Hachinski DSc, T O Olagunju MD); Kil e Awlaelo Heal h and Demog aphic Su eillance Sys em, Mekelle, E hiopia (G B Hailu MSc); A abian Gul Uni e si y, Manama, Bah ain (P o R R Hamadeh DPhil); Hamdan Bin Mohammed Sma Uni e si y, Dubai, Uni ed A ab Emi a es Global Heal h Me ics www. helance .com Vol 390 Sep embe 16, 2017 1417 (S Hamidi D PH); Wayne Coun y Depa men o Heal h and Human Se ices, De oi , MI, USA (M Hammami MD); Uni e si y o New Mexico, Albuque que, NM, USA (A J Handal PhD); School o Medicine and Pha macology, Uni e si y o Wes e n Aus alia, Pe h, WA, Aus alia (P o G J Hankey MD); Ha y Pe kins Ins i u e o Medical Resea ch, Nedlands, WA, Aus alia (P o G J Hankey MD); Wes e n Aus alian Neu oscience Resea ch Ins i u e, Nedlands, WA, Aus alia (P o G J Hankey MD); School o Public Heal h (D Hend ie PhD), Cen e o Popula ion Heal h (T R Mille PhD), Cu in Uni e si y, Pe h, WA, Aus alia; Depa men o Epidemiology, Mailman School o Public Heal h, Columbia Uni e si y, New Yo k, NY, USA (P o H W Hoek MD); Depa men o Pulmonology, Yokohama Ci y Uni e si y G adua e School o Medicine, Yokohama, Japan (N Ho i a MD); Public Heal h Di ision, The Paci ic Communi y, Noumea, New Caledonia (D G Hoy PhD); Depa men o Epidemiology, Salah Azaiz Ins i u e, Tunis, Tunisia (P o M Hsai i MD); Depa men o Epidemiology and Heal h S a is ics, School o Public Heal h, Cen al Sou h Uni e si y, Changsha, China (G Hu PhD); Camb idge Heal h Alliance, Camb idge, MA, USA (H Huang MD); Na ional Cen e o Regis e -Based Resea ch, Aa hus School o Business and Social Sciences (P o J J McG a h PhD), Aa hus Uni e si y, Aa hus, Denma k (K M Ibu g PhD); Di ision o Coho Conso ium Resea ch, Epidemiology and P e en ion G oup, Cen e o Public Heal h Sciences, Na ional Cance Cen e , Tokyo, Japan (M Inoue MD); Uni e si y o he Wes Indies, Kings on, Jamaica (P o M D Jackson PhD); Depa men o Global and Communi y Heal h, Geo ge Mason Uni e si y, Fai ax, VA, USA (K H Jacobsen PhD); Facul y o Medical Sciences, Uni e si y o K aguje ac, K aguje ac, Se bia (P o M B Jako lje ic PhD); Uni e si y o Abe deen, Abe deen, UK (M Ja anbakh PhD); Cen e o Ch onic Disease Con ol, New Delhi, India (P Jeemon PhD); Independen Consul an , Oslo, No way (L R K Johansson PhD); Depa men o Oph halmology, Medical Facul y Mannheim, Rup ech -Ka ls-Uni e si y Heidelbe g, Mannheim, Ge many (P o J B Jonas MD); Ins i u e o Family Medicine and Public Heal h, Uni e si y o Ta u, Ta u, Es onia (M Jü isson MD); Uni e si y College Co k, Co k, I eland (Z Kabi PhD); London School o Economics and Poli ical Science, London, UK (R Kadel MPH); CSIR - Indian Ins i u e o Toxicology Resea ch, Lucknow, India (R Kamal MSc, C N Kesa achand an PhD); Epidemiological and S a is ical Me hods Resea ch G oup, Helmhol z Cen e o In ec ion Resea ch, B aunschweig, Ge many (A Ka ch MD); Hanno e -B aunschweig Si e, Ge man Cen e o In ec ion Resea ch, B aunschweig, Ge many (A Ka ch MD); Quali y and Equi y Heal h Ca e, Kigali, Rwanda (C K Ka ema MSc); Depa men o Anes hesiology & Pain Medicine, Sea le Child en’s Hospi al, Sea le, WA, USA (N J Kassebaum MD); MRC/CSO Social & Public Heal h Sciences Uni , Uni e si y o Glasgow, Glasgow, UK (S V Ka iki eddi PhD); School o Public Heal h (P o N Kawakami MD), Uni e si y o Tokyo, Tokyo, Japan (K Shibuya MD); Ins i u e o T opical and In ec ious Diseases, Nai obi, Kenya (P N Keiyo o PhD); School o Con inuing and Dis ance Educa ion, Nai obi, Kenya (P N Keiyo o PhD); Alcohol, Tobacco & O he D ug Resea ch Uni (P o C D Pa y PhD), UKZN Gas oin es inal Cance Resea ch Cen e (P o B Sa o ius PhD), Sou h A ican Medical Resea ch Council, Cape Town, Sou h A ica (A P Kengne PhD, R Ma zopoulos PhD); School o Public Heal h and Family Medicine (R Ma zopoulos PhD), Depa men o Psychia y (P o D J S ein PhD), Uni e si y o Cape Town, Cape Town, Sou h A ica (A P Kengne PhD, J J N Noubiap MD); Depa men o Communi y Medicine, Public Heal h and Family Medicine, Jo dan Uni e si y o Science and Technology, I bid, Jo dan (P o Y S Khade ScD); Heal h Se ices Academy, Islamabad, Pakis an (E A Khan MD); Depa men o Heal h Policy and Managemen , Seoul Na ional Uni e si y College o Medicine, Seoul, Sou h Ko ea (P o Y Khang MD); Ins i u e o Heal h Policy and Managemen , Seoul Na ional Uni e si y Medical Cen e , Seoul, Sou h Ko ea (P o Y Khang MD); I anian Minis y o Heal h and Medical Educa ion, Teh an, I an (A Khos a i PhD); Depa men o Nu i ion and Heal h Science, Ball S a e Uni e si y, Muncie, IN, USA (J Khubchandani PhD); Hospi al de Clinicas de Po o Aleg e, Po o Aleg e, B azil (C Kieling MD); Depa men o Heal h Sciences, No heas e n Uni e si y, Bos on, MA, USA (P o D Kim D PH); School o Medicine, Xiamen Uni e si y Malaysia Campus, Sepang, Malaysia (Y J Kim PhD); Simmons College, Bos on, MA, USA (R W Kimoko i MD); Cen e o Resea ch and Ac ion in Public Heal h, Uni e si y o Canbe a, Canbe a, ACT, Aus alia (Y Kin u PhD); Oslo Uni e si y, Oslo, No way (P o A Kisa PhD); Ins i u e o Public Heal h, Facul y o Heal h Sciences (R Topo -Mad y PhD), Jagiellonian Uni e si y Medical College, K akow, Poland (K A Kissimo a-Ska bek PhD); Clinicum, Facul y o Medicine (P o M Ki imaki PhD), Finnish Ins i u e o Occupa ional Heal h, Wo k O ganiza ions, Wo k Disabili y P og am, Depa men o Public Heal h, Facul y o Medicine (T Lallukka PhD, R Shi i PhD), Uni e si y o Helsinki, Helsinki, Finland (T J Me e oja PhD); Cen e o Disease Bu den, No wegian Ins i u e o Public Heal h, Be gen, No way (A K Knudsen PhD, P o S E Vollse D PH); Depa men o Psychosocial Science (A K Knudsen PhD), Depa men o Global Public Heal h and P ima y Ca e (P o S E Vollse D PH), Uni e si y o Be gen, Be gen, No way (P o O F No heim PhD, M C Tollanes PhD); Cen e o Communi y Empowe men , Heal h Policy and Humani ies, Na ional Ins i u e o Heal h Resea ch & De elopmen , Jaka a, Indonesia (S Kosen MD); She -i-Kashmi Ins i u e o Medical Sciences, S inaga , India (P o P A Koul MD); Resea ch and De elopmen Uni , Pa c Sani a i San Joan de Deu (CIBERSAM), Ba celona, Spain (A Koyanagi MD); Resea ch Cen e o Neu ology, Moscow, Russia (M K a chenko PhD, P o M A Pi ado DSc); Ins i u e o Risk Assessmen Sciences, U ech Uni e si y, U ech , Ne he lands (P o H K omhou PhD); Depa men o Social and P e en i e Medicine, School o Public Heal h and Depa men o Demog aphy and Public Heal h Resea ch Ins i u e, Uni e si y o Mon eal, Mon eal, QC, Canada (P o B Kua e De o PhD); Ins i u e o Public Heal h, Hace epe Uni e si y, Anka a, Tu key (B Kucuk Bice PhD); Na ional Cance Ins i u e, Rock ille, MD, USA (Q Lan PhD); Help Me See, Inc, New Yo k, NY, USA (V C Lansingh PhD); Ins i uo Mexicano de O almologia, Que e a o, Mexico (V C Lansingh PhD); Depa men o Medical Sciences, Uppsala Uni e si y, Uppsala, Sweden (P o A La sson PhD); Hong Kong Poly echnic Uni e si y, Hong Kong, China (P H Lee PhD); Tuscany Regional Cen e o Occupa ional Inju ies and Diseases, Flo ence, I aly (M Le i PhD); Depa men o Da a Managemen , Peking Uni e si y Clinical Resea ch Ins i u e, Beijing, China (Y Li PhD); Na ional Cen e o Ch onic and Noncommunicable Disease Con ol and P e en ion (Y Li PhD), Chinese Cen e o Disease Con ol and P e en ion, Beijing, China (P o X Liang MD); San F ancisco VA Medical Cen e , San F ancisco, CA, USA (Y Li PhD); Sama a Uni e si y, Sama a, E hiopia (M L Liben MPH); Uni e si y o Hai a, Hai a, Is ael (P o S Linn MD); All India Ins i u e o Medical Sciences, New Delhi, India (R Lodha MD, P o R Malho a MS, P o N Tandon PhD); Uni e si y o Ba i, Ba i, I aly (P o G Log oscino PhD); Uni e si y o B is ol, B is ol, UK (K J Looke PhD); Ins i u e o Nu i ion, F ied ich Schille Uni e si y Jena, Jena, Ge many (P o S Lo kowski PhD); Ain ee Uni e si y Hospi al Na ional Heal h Se ice Founda ion T us , Li e pool, UK (P o RLune icius PhD); School o Medicine, Uni e si y o Li e pool, Li e pool, UK (P o R Lune icius PhD); Compe ence Clus e o Nu i ion and Ca dio ascula Heal h (nu iCARD) Halle-Jena-Leipzig, Jena, Ge many (P o S Lo kowski PhD); A eneo de Manila Uni e si y, Manila, Philippines (E R K Maca ayan PhD); Mansou a Facul y o Medicine, Mansou a, Egyp (H Magdy Abd El Razek MBBCH); Aswan Facul y o Medicine, Aswan Uni e si y Hospi al, Aswan, Egyp (M Magdy Abd El Razek MBBCH); Facul y o Heal h Sciences and Social Wo k, Depa men o Public Heal h, T na a Uni e si y, T na a, Slo akia (M Majdan PhD); Na ional Ins i u e o Heal h Resea ch, Teh an, I an (P o R Majdzadeh PhD); Uni e sidade Fede al de Minas Ge ais, Belo Ho izon e, B azil (P o D C Mal a PhD); The Uni e si y o Queensland, B isbane, QLD, Aus alia (P o A A Mamun PhD); Uni e si y o Milano Bicocca, Monza, I aly (P o L G Man o ani DSc); Depa men o Physics and A mosphe ic Science (A an Donkelaa PhD), Dalhousie Uni e si y, Hali ax, NS, Canada (P o R V Ma in PhD); Hospi al Uni e si a io Doc o Pese , Valencia, Spain (J Ma inez-Raga PhD, M To ajada PhD); CEU Ca dinal He e a Uni e si y, Moncada, Spain (J Ma inez-Raga PhD); Fede al Ins i u e o Educa ion, Science and Technology o Cea á, Caucaia, B azil (F R Ma ins-Melo PhD); Key S a e Labo a o y o Molecula De elopmen al Biology, Ins i u e o Gene ics and De elopmen al Biology, Chinese Academy o Sciences, Beijing, China (M Mazidi PhD); Uni e si y Hospi als B is ol NHS Founda ion T us , B is ol, UK (C McAlinden PhD); Public Heal h Wales, Swansea, UK (C McAlinden PhD); Queensland Cen e o Men al Heal h Resea ch, The Pa k Cen e o Men al Heal h, Wacol, QLD, Aus alia (P o J J McG a h PhD); Queensland B ain Ins i u e (P o J J McG a h PhD), Uni e si y o Queensland, B isbane, QLD, Aus alia (S R Mish a MPH); Ipas Nepal, Ka hmandu, Nepal (S Meha a PhD); Janakpu i Supe special y Hospi al, New Delhi, India