title: Impact of Dietary and Metabolic Risk Factors on Cardiovascular and Diabetes Mortality in South Asia: Analysis From the 2010 Global Burden of Disease Study.
abstract: OBJECTIVE
  To quantify cardiovascular disease and diabetes deaths attributable to dietary and metabolic risks by country, age, sex, and time in South Asian countries.
  
  
  METHODS
  We used the 2010 Global Burden of Disease national surveys to characterize risk factor levels by age and sex. We derived etiological effects of risk factors-disease endpoints, by age, from meta-analyses. We defined optimal levels. We combined these inputs with cause-specific mortality rates to compute population-attributable fractions as a percentage of total cardiometabolic deaths.
  
  
  RESULTS
  Suboptimal diet was the leading cause of cardiometabolic mortality in 4 of 5 countries, with population-attributable fractions from 40.7% (95% uncertainty interval = 37.4, 44.1) in Bangladesh to 56.9% (95% uncertainty interval = 52.4, 61.5) in Pakistan. High systolic blood pressure was the second leading cause, except in Bangladesh, where it superseded suboptimal diet. This was followed in all nations by high fasting plasma glucose, low fruit intake, and low whole grain intake. Other prominent burdens were more variable, such as low intake of vegetables, low omega-3 fats, and high sodium intake in India, Nepal, and Pakistan.
  
  
  CONCLUSIONS
  Important similarities and differences are evident in cardiometabolic mortality burdens of modifiable dietary and metabolic risks across these countries, informing health policy and program priorities.
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Mohammad Y
authors.initials: MY
authors.lastname: Yakoob
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Renata
authors.initials: R
authors.lastname: Micha
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Shahab
authors.initials: S
authors.lastname: Khatibzadeh
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Gitanjali M
authors.initials: GM
authors.lastname: Singh
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Peilin
authors.initials: P
authors.lastname: Shi
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Habibul
authors.initials: H
authors.lastname: Ahsan
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Nagalla
authors.initials: N
authors.lastname: Balakrishna
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Ginnela N V
authors.initials: GN
authors.lastname: Brahmam
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Yu
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Ashkan
authors.initials: A
authors.lastname: Afshin
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Saman
authors.initials: S
authors.lastname: Fahimi
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Goodarz
authors.initials: G
authors.lastname: Danaei
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: John W
authors.initials: JW
authors.lastname: Powles
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Majid
authors.initials: M
authors.lastname: Ezzati
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
authors.forename: Dariush
authors.initials: D
authors.lastname: Mozaffarian
authors.affiliation: Mohammad Y. Yakoob is with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Saman Fahimi is with the Department of Epidemiology, Harvard School of Public Health, Boston, MA. Renata Micha, Gitanjali M. Singh, Peilin Shi, and Dariush Mozaffarian are with Tufts Friedman School of Nutrition Science and Policy, Boston. Shahab Khatibzadeh and Goodarz Danaei are with the Department of Global Health and Population, Harvard School of Public Health. Habibul Ahsan is with the Department of Health Studies, University of Chicago, IL. Nagalla Balakrishna and Ginnela N. V. Brahmam are with the National Institute of Nutrition, Hyderabad, Andhra Pradesh, India. Yu Chen is with the Department of Population Health (Epidemiology) and Environmental Medicine, New York University School of Medicine, New York, NY. Ashkan Afshin is with the Institute for Health Metrics and Evaluation, Seattle, WA. John W. Powles is with the Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, UK. Majid Ezzati is with the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK.
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001208:Asia / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000401:mortality*; D003920:Diabetes Mellitus / Q000401:mortality*; D005260:Female; D000071219:Global Burden of Disease; D006801:Humans; D008297:Male; D024821:Metabolic Syndrome; D008875:Middle Aged; D018570:Risk Assessment / Q000706:statistics & numerical data; D012307:Risk Factors