Articles
            factors along the causal pathways. Although many                          Fares Alahdab, Umar Bacha, Victoria F Bachman, Hamid Badali,
            cohort studies have collected dietary data, only a few of                 Alaa Badawi, Isabela M Bensenor, Eduardo Bernabe, Stan H Biryukov,
                                                                                      Sibhatu Kassa K Biadgilign, Leah E Cahill, Juan J Carrero, Kelly M Cercy,
            them have published results of their assessment, which                    Lalit Dandona, Rakhi Dandona, Anh Kim Dang, Meaza Girma Degefa,
            increases the possibility of publication bias. These                      Maysaa El Sayed Zaki, Alireza Esteghamati, Sadaf Esteghamati,
            limitations highlight the need for a collaborative eﬀort                  Jessica Fanzo, Carla Sofia E Sá Farinha, Maryam S Farvid,
            to collect and harmonise all available dietary data from                  Farshad Farzadfar, Valery L Feigin, Joao C Fernandes, Luisa Sorio Flor,
                                                                                      Nataliya A Foigt, Mohammad H Forouzanfar, Morsaleh Ganji,
            cohort studies and to do a pooled analysis for each diet–                 Johanna M Geleijnse, Richard F Gillum, Alessandra C Goulart,
            disease pair and quantify the eﬀect size after adjusting                  Giuseppe Grosso, Idris Guessous, Samer Hamidi, Graeme J Hankey,
            for the same set of confounders.                                          Sivadasanpillai Harikrishnan, Hamid Yimam Hassen, Simon I Hay,
              Other potential limitations should also be considered in                Chi Linh Hoang, Masako Horino, Farhad Islami, Maria D Jackson,
                                                                                      Spencer L James, Lars Johansson, Jost B Jonas, Amir Kasaeian,
            interpreting and using the findings of our study. We did                  Yousef Saleh Khader, Ibrahim A Khalil, Young-Ho Khang,
            not evaluate the eﬀect of other forms of malnutrition                     Ruth W Kimokoti, Yoshihiro Kokubo, G Anil Kumar, Tea Lallukka,
            (ie, undernutrition and obesity). The epidemiological                     Alan D Lopez, Stefan Lorkowski, Paulo A Lotufo, Rafael Lozano,
            evidence supporting a causal relationship between                         Reza Malekzadeh, Winfried März, Toni Meier, Yohannes A Melaku,
                                                                                      Walter Mendoza, Gert B M Mensink, Renata Micha, Ted R Miller,
            dietary risks and disease endpoints were mostly from                      Mojde Mirarefin, Viswanathan Mohan, Ali H Mokdad,
            observational studies, and the strength of evidence was                   Dariush Mozaﬀarian, Gabriele Nagel, Mohsen Naghavi,
            generally weaker than the strength of evidence supporting                 Cuong Tat Nguyen, Molly R Nixon, Kanyin L Ong, David M Pereira,
            a causal relationship between other established risks                     Hossein Poustchi, Mostafa Qorbani, Rajesh Kumar Rai,
                                                                                      Christian Razo-García, Colin D Rehm, Juan A Rivera,
            factors (eg, tobacco use and high systolic blood pres-                    Sonia Rodríguez-Ramírez, Gholamreza Roshandel, Gregory A Roth,
            sure) and chronic diseases. Additionally, the strength of                 Juan Sanabria, Tania G Sánchez-Pimienta, Benn Sartorius,
            evidence varied across foods and nutrients. Dietary data                  Josef Schmidhuber, Aletta Elisabeth Schutte, Sadaf G Sepanlou,
                                                                                      Min-Jeong Shin, Reed J D Sorensen, Marco Springmann,
            were from mixed sources and were not available for all
                                                                                      Lucjan Szponar, Andrew L Thorne-Lyman, Amanda G Thrift,
            countries. These factors increase the statistical uncertainty             Mathilde Touvier, Bach Xuan Tran, Stefanos Tyrovolas,
            of our estimates for exposure to dietary risks. For sodium,               Kingsley Nnanna Ukwaja, Irfan Ullah, Olalekan A Uthman,
            we did not include data from spot urine sample, which                     Masoud Vaezghasemi, Tommi Juhani Vasankari, Stein Emil Vollset,
                                                                                      Theo Vos, Giang Thu Vu, Linh Gia Vu, Elisabete Weiderpass,
            resulted in a lower data representativeness index for
                                                                                      Andrea Werdecker, Tissa Wijeratne, Walter C Willett, Jason H Wu,
            sodium than that of other dietary risks. In estimation of                 Gelin Xu, Naohiro Yonemoto, Chuanhua Yu, and
            the NCD burden of diet, we assumed that the distribution                  Christopher J L Murray.
            of dietary factors is independent within each unit of                     Aﬃliations
            analysis (ie, country, age, and sex group), which might                   Department of Health Metrics Sciences (A Afshin MD,
            have resulted in underestimation or overestimation of the                 Prof S I Hay FMedSci, I A Khalil MD, Prof A H Mokdad PhD,
                                                                                      Prof M Naghavi MD, Prof S E Vollset DrPH, Prof T Vos PhD,
            combined eﬀect of dietary factors. To quantify the eﬀect of               Prof C J L Murray DPhil), Institute for Health Metrics and Evaluation
            correlation of dietary factors, we used individual-level data             (A Afshin MD, P J Sur MPH, K A Fay BS, L Cornaby BS, G Ferrara BA,
            from the US National Health and Nutrition Examination                     J S Salama MSc, E C Mullany BA, S H Biryukov BS, K M Cercy BS,
            Survey and estimated the overall burden of dietary risks                  Prof L Dandona MD, Prof R Dandona PhD, Prof V L Feigin PhD,
                                                                                      M H Forouzanfar MD, Prof S I Hay FMedSci, S L James MD,
            (ie, joint population attributable fractions) with and                    I A Khalil MD, Prof A D Lopez PhD, Prof R Lozano MD,
            without taking into account their correlation. The absolute               Prof A H Mokdad PhD, Prof M Naghavi MD, M R Nixon PhD,
            diﬀerence in the joint population attributable fractions,                 K L Ong PhD, G A Roth MD, R J D Sorensen MPH,
            on average, was less than 2%. Additionally, deaths due to                 Prof S E Vollset DrPH, Prof T Vos PhD, Prof C J L Murray DPhil),
                                                                                      Department of Epidemiology (A Aggarwal PhD), School of Medicine
            some dietary risk factors might not be mutually exclusive,                (V F Bachman BA), Division of Cardiology (G A Roth), Department of
            which could result in overestimation of the burden of                     Global Health (R J D Sorensen), University of Washington, Seattle, WA,
            disease attributable to diet.                                             USA; School of Medicine, University of California Riverside, Riverside,
              In summary, we found that poor dietary habits are                       CA, USA (P J Sur); Department of Population and Family Health, Jimma
                                                                                      University, Jimma, Ethiopia (K H Abate PhD); Department of Law,
            associated with a range of chronic diseases and can                       Philosophy and Economic Studies, La Sapienza University, Rome, Italy
            potentially be a major contributor to NCD mortality in                    (C Abbafati PhD); Human Nutrition Department (Z Abebe MSc),
            all countries worldwide. This finding highlights the                      Institute of Public Health (Y A Melaku MPH), University of Gondar,
            urgent need for coordinated global eﬀorts to improve the                  Gondar, Ethiopia; Endocrinology and Metabolism Research Center
                                                                                      (M Afarideh MD, Prof A Esteghamati MD, M Ganji MD), Endocrine
            quality of human diet. Given the complexity of dietary                    Research Center (S Esteghamati MD), Non-communicable Diseases
            behaviours and the wide range of influences on diet,                      Research Center (F Farzadfar MD), Hematologic Malignancies Research
            improving diet requires active collaboration of a variety                 Center (A Kasaeian PhD), Digestive Diseases Research Institute
            of actors throughout the food system, along with policies                 (Prof R Malekzadeh MD, H Poustchi PhD, G Roshandel PhD,
                                                                                      S G Sepanlou MD), Hematology-Oncology and Stem Cell
            targeting multiple sectors of the food system.                            Transplantation Research Center (A Kasaeian), Tehran University of
            GBD 2017 Diet Collaborators                                               Medical Sciences, Tehran, Iran; Vital Strategies, Gurugram, India
            Ashkan Afshin, Patrick John Sur, Kairsten A Fay, Leslie Cornaby,          (S Agrawal PhD); Department of Epidemiology, University of Kentucky,
            Giannina Ferrara, Joseph S Salama, Erin C Mullany,                        Lexington, KY, USA (T Akinyemiju PhD); Evidence Based Practice
            Kalkidan Hassen Abate, Cristiana Abbafati, Zegeye Abebe,                  Center, Mayo Clinic Foundation for Medical Education and Research,
            Mohsen Afarideh, Anju Aggarwal, Sutapa Agrawal, Tomi Akinyemiju,          Rochester, MN, USA (F Alahdab MD); School of Health Sciences,
12                                                         www.thelancet.com Published online April 3, 2019 http://dx.doi.org/10.1016/S0140-6736(19)30041-8