Articles
Health eﬀects of dietary risks in 195 countries, 1990–2017:
a systematic analysis for the Global Burden of Disease Study
2017
GBD 2017 Diet Collaborators*
Summary
Background Suboptimal diet is an important preventable risk factor for non-communicable diseases (NCDs); however,                        Published Online
its impact on the burden of NCDs has not been systematically evaluated. This study aimed to evaluate the consumption                     April 3, 2019
                                                                                                                                         http://dx.doi.org/10.1016/
of major foods and nutrients across 195 countries and to quantify the impact of their suboptimal intake on NCD                           S0140-6736(19)30041-8
mortality and morbidity.
                                                                                                                                         See Online/Comment
                                                                                                                                         http://dx.doi.org/10.1016/
Methods By use of a comparative risk assessment approach, we estimated the proportion of disease-specific burden                         S0140-6736(19)30500-8
attributable to each dietary risk factor (also referred to as population attributable fraction) among adults aged 25 years               *Collaborators listed at the end
or older. The main inputs to this analysis included the intake of each dietary factor, the eﬀect size of the dietary factor              of the paper
on disease endpoint, and the level of intake associated with the lowest risk of mortality. Then, by use of disease-                      Correspondence to:
specific population attributable fractions, mortality, and disability-adjusted life-years (DALYs), we calculated the                     Prof Christopher J L Murray,
                                                                                                                                         Institute for Health Metrics
number of deaths and DALYs attributable to diet for each disease outcome.                                                                Evaluation, University of
                                                                                                                                         Washington, Seattle, WA 98121,
Findings In 2017, 11 million (95% uncertainty interval [UI] 10–12) deaths and 255 million (234–274) DALYs were                           USA
                                                                                                                                         cjlm@uw.edu
attributable to dietary risk factors. High intake of sodium (3 million [1–5] deaths and 70 million [34–118] DALYs),
low intake of whole grains (3 million [2–4] deaths and 82 million [59–109] DALYs), and low intake of fruits
(2 million [1–4] deaths and 65 million [41–92] DALYs) were the leading dietary risk factors for deaths and DALYs
globally and in many countries. Dietary data were from mixed sources and were not available for all countries,
increasing the statistical uncertainty of our estimates.
Interpretation This study provides a comprehensive picture of the potential impact of suboptimal diet on NCD
mortality and morbidity, highlighting the need for improving diet across nations. Our findings will inform
implementation of evidence-based dietary interventions and provide a platform for evaluation of their impact on
human health annually.
Funding Bill & Melinda Gates Foundation.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Introduction                                                                factors.10–19 These eﬀorts, although useful, had several
The relationship between dietary habits and chronic non-                    important limitations, including insuﬃcient geograph-
communicable diseases (NCDs) has been extensively                           ically representative data on dietary consumption,
investigated.1–5 Long-term randomised trials with NCD                       inaccurate characterisation of population distribution of
endpoints have not been feasible for most dietary factors,                  dietary intake, insuﬃcient accounting for biases of
but synthesis of other lines of epidemiological evidence,                   diﬀerent sources of dietary assessment, standardisation of
including long-term prospective observational studies                       the intake to 2000 kcal per day, and insuﬃcient accounting
and short-term trials of intermediate outcomes, have                        for within-person variation of intake of dietary factors.
provided supporting evidence for potential causal                             To address these limitations, as part of the Global Burden
relationships between specific dietary factors (eg, fruits,                 of Diseases, Injuries, and Risk Factors Study (GBD) 2017,
vegetables, processed meat, and trans fat intake) and                       we systematically collected geographically representative
NCDs (ischaemic heart disease, diabetes, and colorectal                     dietary data from multiple sources, characterised the
cancer).2–7 These findings have been widely used to inform                  population distribution of intake for 15 foods and nutrients
national and international dietary guidelines aimed at                      among adults aged 25 years or older across 195 countries,
preventing NCDs.8,9 However, because of the complexities                    estimated the eﬀect of each individual dietary factor on
of characterising dietary consumption across diﬀerent                       NCD mortality, and quantified the overall impact of poor
nations, assessment of the health eﬀects of suboptimal                      dietary habits on NCD mortality. We also evaluated the
diet at the population level has not been possible.                         relationship between diet and socioeconomic development,
  In the past decade, eﬀorts have been made to quantify                     and assessed the trends in disease burden of diet over
the burden of disease attributable to specific dietary                      time. This analysis supersedes all previous results from
www.thelancet.com Published online April 3, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30041-8                                                                         1