"Table 4.1 CRA Risk Factors, Exposure Variables, Theoretical-Minimum-Risk Exposure Distributions, and Disease Outcomes ",,,,,
Risk factor ,Exposure variable ,Theoretical-minimum-risk exposure distribution,Disease outcomesa,,
Childhood and maternal undernutrition ,,,,,
Childhood underweight ,Children <–1 SD weight-for-age compared to the international reference group in 1 SD increments,Same proportion of children below –1 SD weight-for-age as the international reference group,"Mortality and acute morbidity from diarrhea, malaria, measles, pneumonia, and selected other Group I (communicable, maternal, perinatal, and nutritional) diseases; long-term risks of undernutrition",,
Iron-deficiency anemia,"Hemoglobin concentration distribution, estimated from prevalence of anemia ",Hemoglobin distributions that are estimated to occur if all iron deficiency were eliminatedb,"Anemia and its sequelae (including cognitive impairment), maternal and perinatal mortality",,
Vitamin A deficiency,"Prevalence of vitamin A deficiency, estimated as low serum retinol concentrations (< 0.70 µmol/L) among children aged 0–4 years and among pregnant women (aged 15–44 years) ",No vitamin A deficiency ,"Mortality due to diarrhea, measles, malaria, and miscellaneous infectious causes of disease (children under five), morbidity due to malaria (children under five), maternal mortality (pregnant women), vitamin A deficiency and its sequelae (all age groups); maternal morbidity, low birthweight, and other perinatal conditions",,
Zinc deficiency,Less than the U.S. recommended dietary allowances for zinc ,"The entire population consuming sufficient dietary zinc to meet physiological needs, taking into account routine and illness-related losses and bioavailability","Diarrhea, pneumonia, malaria; adult and pregnancy outcomes",,
Other nutrition-related risk factors and physical activity ,,,,,
High blood pressure,Usual level of systolic blood pressure ,115 SD 6 mmHg ,"IHD, stroke, hypertensive disease, and selected other cardiovascular diseases; renal failure",,
High cholesterol,,3.8 SD 0.6 mmol/L ,"IHD, stroke; other cardiovascular diseases",,
Overweight and obesity (high BMI) ,BMI (height/weight squared),21 SD 1 kg/m2,"IHD, stroke, hypertensive disease, diabetes, osteoarthritis, endometrial and colon cancers, postmenopausal breast cancer; gallbladder cancer, kidney cancer, breathlessness, back pain, dermatitis, menstrual disorders and infertility, gallstones, psychological effects",,
Low fruit and vegetable intake,Daily fruit and vegetable intake,600 SD 50 g intake per day for adults ,"IHD, stroke, colorectal cancer, gastric cancer, lung cancer, esophageal cancer",,
Physical inactivity,"Three categories of inactive, insufficiently active (< 2.5 hours per week of moderate-intensity activity, or less than 4,000 KJ/week), and sufficiently active. Activity in discretionary-time, work, and transport considered","All having at least 2.5 hours per week of moderate-intensity activity or equivalent (4,000 KJ/week)","IHD, breast cancer, colorectal cancer, diabetes; falls and osteoporosis, osteoarthritis, lower back pain, prostate cancer",,
Addictive substances ,,,,,
Smoking,Current levels of smoking impact ratio (indirect indicator of accumulated smoking risk based on excess lung cancer mortality),No smoking ,"Lung cancer, upper aerodigestive cancer, stomach cancer, liver cancer, pancreas cancer, cervix uteri cancer, bladder cancer, leukemia, COPD, other respiratory diseases, IHD, stroke, selected other cardiovascular diseases except hypertensive heart disease, and selected other medical causes in adults over 30 years of age; fire injuries, maternal outcomes, and perinatal conditionsc ",,
Alcohol use,Current alcohol consumption volumes and patterns,No alcohol used,"IHD, stroke, hypertensive disease, diabetes, liver cancer, mouth and oropharynx cancer, breast cancer, esophageal cancer, selected other cancers, cirrhosis of the liver, epilepsy, alcohol use disorders, depression, intentional and unintentional injuries; selected other cardiovascular diseases and cancers, social consequences",,
Illicit drug use,"Use of amphetamine, cocaine, heroin, or other opioids, and intravenous drug use",No illicit drug use ,"HIV/AIDS, overdose, drug use disorder, suicide, and trauma; other neuropsychological diseases, social consequences, hepatitis B and hepatitis C",,
Sexual and reproductive health ,,,,,
Unsafe sex,Sex with an infected partner without any measures to prevent infection,No unsafe sex ,"HIV/AIDS, sexually transmitted infections, and cervical cancer",,
Non-use and use of ineffective methods of contraception,Prevalence of traditional methods or non-use of contraception ,Use of modern contraceptives for all women who want to space or limit future pregnancies,Maternal mortality and morbidity; increased perinatal and child mortality with lower birth intervals ,,
Environmental risks ,,,,,
"Unsafe water, sanitation, and hygiene","Six scenarios, ranging from regulated water and sanitation with hygiene to no improved water supply and no improved sanitation ","Absence of transmission of diarrheal disease through water, sanitation, and hygiene ",Diarrheal diseases ,,
Urban air pollution,Estimated annual average particulate matter concentration for particles with aerodynamic diameters less than 2.5 or 10 microns (PM2.5 or PM10) ,7.5 µg/m3 for PM2.5                                       15 µg/m3 for PM10,"Mortality from combined respiratory and selected cardiovascular causes in adults over 30, lung cancer, acute respiratory infection mortality in children under five; cardiovascular and respiratory morbidity",,
Indoor smoke from household use of solid fuels,Household use of solid fuels and ventilation,No household solid fuel use ,"Acute lower respiratory infections in children under five, COPD, lung cancer (coal);e low birthweight, cataracts, tuberculosis, asthma, lung cancer from biomass ",,
Other selected risks ,,,,,
Contaminated injections in health care settings,Exposure to at least one contaminated injection,No contaminated injections ,"Acute infection with hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV, cirrhosis and liver cancer",,
Child sexual abuse ,"Prevalence of noncontact abuse, contact abuse, and intercourse",No abuse ,"Depression, panic disorder, alcohol abuse/dependence, drug abuse/dependence, post-traumatic stress disorder and suicide in adulthood; non-mental health outcomes, such as sexually transmitted diseases, unwanted pregnancies, and injuries",,
"Sources: Table 1 in Ezzati and others 2002, and individual risk factor chapters in Ezzati and others 2004 for data sources. ",,,,,
"Note: BMI = body mass index, COPD = chronic obstructive pulmonary disease, IHD = ischemic heart disease, KJ = kilo joules, SD = standard deviation. New disease outcomes are used here when more recent epidemiological analyses enabled improvements over those of the CRA project (for example, multiple cancer sites assessed separately, versus grouped together, for smoking). Several risk factors (lead exposure, global climate change, and selected occupational risks) were included in the CRA project but not in the current analysis because of conceptual and empirical difficulties in converting estimates of exposure and/or hazards from the GBD analysis subregions to the World Bank regions.",,,,,
a. Outcomes in italic are those that are likely to be causal but not quantified due to lack of sufficient evidence on the magnitude of hazardous effect. ,,,,,
"b. The resulting hemoglobin levels vary across regions and age-sex groups because the other risks for anemia (for example, malaria) vary. ",,,,,
"c. In estimating years of life lost because of disability (YLD) due to smoking in the CRA project (Ezzati and Lopez 2004), population attributable fractions (PAFs) for disease incidence were assumed to be the same as PAFs for mortality for cancers and COPD, and one-half of PAFs for mortality for all other diseases. In the current analysis, PAFs for disease incidence were assumed to be the same as those for mortality for cancers, COPD, and cardiovascular diseases—for which smoking is expected to increase mortality through increasing incidence—and zero for all other diseases. The estimated total disease burden from smoking is robust to assumptions about the effects of smoking on incidence of diseases other than major chronic diseases (cancers, COPD, and cardiovascular diseases).",,,,,
"d. The theoretical-minimum-risk exposure level for alcohol is zero, the global theoretical minimum. Specific population subgroups or diseases may have a non-zero theoretical-minimum-risk exposure (see figure 4.2) (Rehm and others 2004).",,,
"e. In the CRA project, PAFs for indoor smoke from household use of solid fuels were applied to COPD and lung cancer mortality and disease burden after subtracting the smoking-attributable burden (Smith, Mehta, and Maeusezahl-Feuz 2004). This overlooks multi-causality of COPD and lung cancer, which is also illustrated empirically in the analysis of the hazards of smoking in China (Liu and others 1998). Therefore, we applied PAFs to total mortality from COPD and lung cancer.",,,
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