Articles
            age-standardised rates of diet-related mortality for               and 2017; from 406 (381–430) deaths per 100 000 population
            cancer (29 [24–34] deaths per 100 000 population and               to 275 (258–292) deaths per 100 000 population, and
            630 [529–731] DALYs per 100 000 population). The lowest            from 8536 (8063–9013) DALYs per 100 000 population to
            age-standardised rate of diet-related deaths and DALYs             6080 (5685–6472) DALYs per 100 000 population. This
            for cardiovascular disease (113 [104–122] deaths per               decrease seemed to be driven mostly by decreases in the
            100 000 population and 2156 [2005–2306] DALYs                      background mortality rate because, during the same
            per 100 000 population) and diabetes (five [4–6] deaths            period, the proportion of deaths and DALYs related to
            per 100 000 population and 444 [324–587] DALYs per                 dietary risk remained relatively stable.
            100 000 population) was observed in high SDI countries
            and lowest mortality rate for cancer was observed in low           Discussion
            SDI countries (15 [12–17] deaths per 100 000 population            Our systematic evaluation of dietary consumption
            and 324 [268–376] DALYs per 100 000 population). The               patterns across 195 countries provides a comprehensive
            highest proportions of diet-related deaths and DALYs for           picture of the health eﬀects of poor dietary habits at the
            all causes were observed in high-middle SDI countries              population level. We found that improvement of diet
            (29% [95% UI 27–31] of deaths and 19% [17–21] of DALYs),           could potentially prevent one in every five deaths
            the lowest proportion of diet-related deaths was observed          globally. Our findings show that, unlike many other risk
            in low SDI countries (16% [15–17] of deaths), and the              factors, dietary risks aﬀected people regardless of age,
            lowest proportion of DALYs was observed in high SDI                sex, and sociodemographic development of their place of
            countries (10% [9–11] of DALYs; appendix). Dietary risks           residence. Although the impact of individual dietary
            were responsible for 55% [51–59] of cardiovascular                 factors varied across countries, non-optimal intake of
            disease deaths and 60% [56–63] of DALYs in middle SDI              three dietary factors (whole grains, fruits, and sodium)
            countries, and 46% [42–49] of cardiovascular disease               accounted for more than 50% of deaths and 66% of
            deaths and 49% [46–52] of cardiovascular disease DALYs             DALYs attributable to diet.
            in high SDI countries. Middle SDI countries had the                  Our findings show that suboptimal diet is responsible
            highest proportion of cancer deaths (12% [10–14]) and              for more deaths than any other risks globally, including
            DALYs (11% [9–13]) and high SDI countries had                      tobacco smoking,11,12 highlighting the urgent need for
            the lowest proportion of attributable cancer deaths                improving human diet across nations. Although sodium,
            (8% [7–9]) and DALYs (7% [6–9]). The highest burden of             sugar, and fat have been the main focus of diet policy
            diabetes attributable to diet was observed in high SDI             debate in the past two decades,27,28 our assessment shows
            countries (35% [28–43] of deaths and 46% [38–55) of                that the leading dietary risk factors for mortality are diets
            DALYs) and lowest attributable burden was observed in              high in sodium, low in whole grains, low in fruit, low in
            the low SDI countries (31% [22–39] of deaths and                   nuts and seeds, low in vegetables, and low in omega-3
            39% [29–50] of DALYs).                                             fatty acids; each accounting for more than 2% of global
               High-middle and middle SDI countries were at the                deaths. This finding suggests that dietary policies
            greatest risk of deaths and DALYs from high consumption            focusing on promoting the intake of components of diet
            of sodium, whereas high and low-middle SDI countries               for which current intake is less than the optimal level
            had the greatest risk caused by a diet low in whole grains         might have a greater eﬀect than policies only targeting
            (figure 3). In low SDI countries, low intake of fruit was the      sugar and fat, highlighting the need for a comprehensive
            leading dietary risk for deaths and low intake of whole            food system interventions to promote the production,
            grains was the leading dietary risk for DALYs. Countries at        distribution, and consumption of these foods across
            all levels of SDI other than low SDI had the same four             nations.
            leading dietary risks: high sodium, low whole grains, low            Over the past decade, the eﬀectiveness of a range of
            fruit, and low nuts and seeds. The four leading dietary            population-level dietary interventions has been system-
            risks for low SDI countries were a diet in low whole grains,       atically evaluated and several promising interventions
            low in fruit, low in nuts and seeds, and low in vegetables.        have been identified.29–31 These include mass media
                                                                               campaigns, food and menu labeling, food pricing
            Impact of nutrition transition on exposure to dietary              strategies (subsidies and taxation), school procurement
            risks                                                              policies, and worksite wellness programmes. Cost-
            Since 1990, the number of deaths (8 million [95% UI 7–8]           eﬀectiveness analyses of these interventions have shown
            deaths) and DALYs (184 [172–197] DALYs) attributable               that targeting specific dietary factors (eg, sodium) might
            to dietary risks significantly increased to 11 million             not only be cost-eﬀective but cost-saving.32–35 However,
            (10–12) deaths and 255 million (234–274) DALYs in 2017             improvement of diet through population-level inter-
            (appendix). The main contributors to this increase                 ventions faces several major challenges. First, the
            were population growth and population ageing. After                observed eﬀects for most of these dietary interventions
            removing the eﬀect of population growth and population             are far below the level required to achieve optimal diet
            ageing, the age-standardised attributable death and                globally.29,30 Second, there is almost no evidence on the
            DALY rates showed a significant decrease between 1990              eﬀectiveness of these interventions on several important
10                                                  www.thelancet.com Published online April 3, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30041-8