本文由小咖机器人翻译整理

期刊来源：Lancet

原文链接：https://doi.org/10.1016/S0140-6736(24)00933-4

摘要内容如下：

背景

了解与暴露于风险因素相关的健康后果对于为公共卫生政策和实践提供信息是必要的。为了系统地量化风险因素暴露对特定健康结果的影响，2021年全球疾病、伤害和风险因素研究（GBD）旨在提供1990年至2021年204个国家和地区以及811个次国家地点的88个风险因素的暴露水平、相对健康风险和可归因疾病负担的综合估计。

方法

GBD 2021风险因素分析使用来自54561个不同来源的数据，对总共631个风险-结果对的88个风险因素及其相关健康结果进行流行病学估计。在数据驱动确定风险-结果关联的基础上纳入配对。在全球、区域和国家各级生成了按年龄、性别、地点和年份分列的估计数。我们的方法遵循比较风险评估框架，该框架基于分层组织的、潜在组合的、可修改的风险的因果网络。对于每个风险-结果对，分别估计作为风险因素暴露的函数发生的给定结果的相对风险（RR），并估计每个风险因素的代表风险加权暴露流行率的综合暴露值（SEV）和理论最小风险暴露水平（TMREL）。这些估计值用于计算人群归因分数（PAF；即，如果暴露于风险因素减少到TMREL，将发生的健康风险的比例变化）。PAFS和与给定结果相关的疾病负担的乘积（以残疾调整生命年（DALY）衡量）产生了可归因负担的指标（即，可归因于特定风险因素或风险因素组合的总疾病负担的比例）。对中介进行调整，以说明涉及通过中间风险间接影响结果的风险因素的关系。根据社会人口指数（SDI）五分位数对可归因负担估计进行分层，并以计数、年龄标准化率和排名的形式表示。为了补充RR和归因负担的估计，应用新开发的举证责任风险函数（BPRF）方法，基于潜在证据的一致性，产生风险-结果关联的补充、保守解释，解释来自不同研究的输入数据之间无法解释的异质性。报告的估计值代表估计值分布中500次抽彩的平均值，95%不确定性区间（UIs）计算为抽彩的2.5和97.5百分位值。

调查结果

在本研究分析的具体风险因素中，可吸入颗粒物空气污染是2021年全球疾病负担的主要贡献者，占总DALYs的8.0%（95%UI6.7-9.4），其次是高收缩压（SBP；7.8%[6.4-9.2]）、吸烟（5.7%[4.7-6.8]）、出生体重低和孕龄短（5.6%[4.8-6.3]）、空腹血糖（FPG；5·4% [4·8-6·0]).对于较年轻的人群（即0-4岁和5-14岁的人群），低出生体重和妊娠时间短以及不安全的水、卫生设施和洗手（WASH）等风险是主要的风险因素，而对于年龄较大的人群，高收缩压、高体重指数（BMI）、高FPG和高LDL胆固醇等代谢风险的影响更大。从2000年到2021年，全球健康挑战发生了明显变化，主要归因于行为风险（下降20.7%[13.9-27.7]）和环境与职业风险（下降22.0%[15.5-28.8]）的所有年龄段的残疾调整寿命年数下降。加上代谢风险导致的DALYs增加49.4%（42.3-56.9），所有这些都反映了全球范围内人口老龄化和生活方式的改变。在此期间，可归因于高BMI和高FPG的年龄标准化全球DALY比率显著上升（高BMI为15.7%[9.9-21.7]，高FPG为7.9%[3.3-12.9]）。高BMI和高FPG人群暴露于这些风险的年增长率分别为1.8%（1.6-1.9）和1.3%（1.1-1.5）。相比之下，全球风险归因负担和许多其他风险因素的暴露下降，特别是儿童生长障碍和不安全水源等风险，儿童生长障碍的年龄标准化可归因残疾调整寿命年数下降了71.5%（64.4-78.8），不安全水源的年龄标准化可归因残疾调整寿命年数下降了66.3%（60.2-72.0）。根据随时间变化的轨迹，我们将风险因素分为三组：归因负担减少的因素，主要是由于风险暴露减少（如反式脂肪含量高的饮食和家庭空气污染），但也由于儿童和青年人口比例较小（如儿童和孕产妇营养不良）；主要由于人口老龄化（如吸烟），尽管风险暴露下降，但负担适度增加；以及由于风险暴露增加和人口老龄化（如环境可吸入颗粒物空气污染、高BMI、高FPG和高SBP）而导致负担显著增加的人群。

解释

在减少一系列风险因素，特别是与孕产妇和儿童保健、饮水、环卫和讲卫生运动以及家庭空气污染有关的风险因素所造成的全球疾病负担方面，已经取得重大进展。继续努力将这些风险因素的影响降至最低，特别是在SDI较低的地区，这对于维持进展是必要的。通过减少风险暴露减轻吸烟相关负担的成功突出表明，需要推进减少其他主要风险因素暴露的政策，如环境可吸入颗粒物、空气污染和高收缩压。高FPG、高BMI和其他与肥胖和代谢综合征相关的危险因素的增加表明迫切需要确定和实施干预措施。

英文原文如下：

Abstracts

BACKGROUND  Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS  The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS  Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION  Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

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