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)00685-8

摘要内容如下：

背景

疾病负担和健康驱动因素的未来趋势引起了政策制定者和广大公众的极大兴趣。这些信息可用于政策和长期健康投资、规划和优先排序。作为全球疾病、伤害和风险因素负担研究（GBD）的一部分，我们对之前的预测进行了扩展和改进，并提供了参考预测（最有可能的未来），以及评估疾病负担轨迹的替代情景，前提是到2050年选定的风险因素从当前水平消除。

方法

使用主要健康驱动因素的预测，如社会人口指数（SDI；滞后分布的人均收入、平均受教育年限和25岁以下总生育率的综合衡量）和GBD捕获的全套风险因素暴露，我们提供了死亡率、寿命损失年数（YLLs）、残疾生活年数（YLDs）、以及2022年至2050年204个国家和地区、21个GBD区域、7个超级区域和全世界按年龄和性别分列的残疾调整生命年。所有的分析都是在病因特异性水平上进行的，因此只有GBD比较风险评估认为有因果关系的风险因素才会影响每种疾病的未来死亡轨迹。使用混合效应模型对特定原因死亡率进行建模，其中SDI和时间作为主要协变量，因果风险因素的综合影响作为模型中的补偿。在全因死亡率水平上，我们通过使用具有漂移衰减的自回归积分移动平均模型对残差进行建模来捕捉无法解释的变化。这些全因预测使用级联死亡率模型在GBD原因层次的连续更深层次上限制了特定原因预测，从而确保了对特定原因死亡率的稳健估计。对于非致命性指标（如下腰痛），根据混合效应模型预测发病率和患病率，以SDI作为主要协变量，并根据由此产生的患病率预测和GBD的平均残疾权重计算YLD。通过将风险因素的适当参考轨迹替换为从当前水平到2050年逐步消除风险因素暴露的假设轨迹，构建了替代未来情景。这些情景是根据各种风险因素构建的：环境风险（更安全的环境情景），与传染性疾病、孕产妇疾病、新生儿疾病和营养性疾病相关的风险（CMNNs；改善儿童营养和疫苗接种情景）、与主要非传染性疾病相关的风险（非传染性疾病；改善行为和代谢风险情景）以及这三种情景的综合影响。使用共享社会经济路径气候情景SSP2-4.5作为参考，SSP1-1.9作为更安全环境情景中的乐观替代方案，我们通过使用最新的政府间气候变化专门委员会（IPCC）温度预测和已发布的环境空气污染轨迹，说明了气候变化对健康的影响。使用标准方法计算预期寿命和健康预期寿命。预测框架包括为每个地点和每个情景分别计算特定年龄和性别的未来人口。每个单独的未来估计的95%不确定性区间（UI）是从通过多级计算管道传播500个绘图所生成的分布的2.5和97.5个百分位数中得出的。

调查结果

在参考情景预测中，从2022年到2050年，全球和超区域预期寿命有所增加，但改善速度低于COVID-19大流行之前的三十年（从2020年开始）。据预测，与预期寿命较高的超级区域（如高收入超级区域）相比，预期寿命相对较低的超级区域（如撒哈拉以南非洲）的未来预期寿命增长最大，导致从现在到2050年，各地的预期寿命趋于一致。在超级区域层面，预测的健康预期寿命模式与预期寿命模式相似。对参考情景的预测发现，未来几十年健康状况将得到改善，每个GBD超级区域的全因年龄标准化DALY比率都将下降。然而，以计数衡量的DALY总负担在每个超级区域都将增加，这在很大程度上是人口老龄化和增长的结果。我们还预测，DALY计数和年龄标准化DALY比率将继续从CMNNS转移到NCDs。最显著的变化发生在撒哈拉以南非洲（2022年60.1%[95%UI 56.8-63.1]的DALY来自CMNN，而2050年为35.8%[31.0-45.0]）和南亚（31.7%[29.2-34.1]至15.5%[13.7-17.5]）。这一转变反映在残疾调整寿命年数的全球主要原因中，2050年的前四大原因是缺血性心脏病、中风、糖尿病和慢性阻塞性肺病，而2022年的前四大原因是缺血性心脏病、新生儿疾病、中风和下呼吸道感染。从2022年到2050年，YLD导致的全球残疾调整寿命年数（DALY）比例同样从33.8%（27.4-40.3）增加到41.1%（33.9-48.1），这表明总体疾病负担从过早死亡向发病率发生了重要转变。据预测，这种类型的最大转变发生在撒哈拉以南非洲，从2022年20.1%（15.6-25.3）的残疾调整寿命年数（DALY）到2050年的35.6%（26.5-43.0）。和改进的行为和代谢风险情景）表明，与参考情景相比，2050年全球残疾调整寿命年数（DALY）负担显著下降15.4%（13.5-17.5），各超级区域的下降幅度从高收入超级区域的10.4%（9.7-11.3）到北非和中东的23.9%（20.7-27.3）不等。更安全的环境情景在撒哈拉以南非洲的降幅最大（5.2%[3.5-6.8]），北非和中东的行为和代谢风险情景有所改善（23.2%[20.2-26.5]），撒哈拉以南非洲的营养和疫苗接种情景有所改善（2.0%[-0.6至3.6]）。

解释

在全球范围内，预期寿命和年龄标准化疾病负担预计将在2022年至2050年期间有所改善，大部分负担将继续从慢性非传染性疾病转移到非传染性疾病。尽管如此，减少CMNN疾病负担的持续进展将取决于维持对CMNN疾病预防和治疗的投资和政策重点。主要是由于人口增长和老龄化，各种原因造成的死亡人数和残疾调整寿命年数总体上将增加。通过构建到2050年消除某些风险暴露的替代未来情景，我们已经表明，通过协调一致的努力，防止暴露于既定的风险因素，并扩大关键健康干预措施的可及性，有机会在未来大幅改善健康结果。

英文原文如下：

Abstracts

BACKGROUND  Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS  Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS  In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION  Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

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