Professional Documents
Culture Documents
review article
global health
E
From the School of Public Health, Imperial xcept in eastern Europe and parts of Africa, mortality among
College London, London. Address reprint adults has declined in most countries for decades.1 Lower rates of death from
requests to Dr. Ezzati or Dr. Riboli at the
School of Public Health, Imperial College infectious diseases were the early driver of this improvement, but there have
London, Norfolk Pl., London W2 1PG, Unit- been subsequent declines in mortality from cardiovascular disease and some cancers.2,3
ed Kingdom, or at majid.ezzati@imperial There have also been important trends in various cancers2 for example, the rise
.ac.uk or e.riboli@imperial.ac.uk.
and subsequent decline in lung-cancer incidence and mortality among men in many
N Engl J Med 2013;369:954-64. high-income countries, a decline in stomach-cancer incidence and mortality as
DOI: 10.1056/NEJMra1203528
Copyright 2013 Massachusetts Medical Society.
economies develop, and the worldwide increase in breast-cancer incidence.
The hazardous effects of behavioral and dietary risk factors on noncommuni-
cable diseases, and the metabolic and physiological conditions that mediate their
effects, have been established in prospective cohort studies and randomized trials.
This knowledge, together with data from risk-factor surveillance, has helped to
establish the mortality and disease burden attributable to risk factors, globally and
by region and country.4-7 There is less information on risk-factor trends, which
makes it difficult to assess how they have affected population health in the past
or how they may do so in the future.
In this article, we summarize the available data on trends in selected behav-
ioral and dietary risk factors for noncommunicable diseases and examine the ef-
fects they have had, or may have in the future, on the health of populations around
the world. Risk factors such as smoking, alcohol consumption, excess weight,
and dietary factors are responsible for a large share of the global disease burden,
directly or through conditions such as high blood pressure and elevated blood
glucose and cholesterol levels (Fig. 1).4,5
Smok ing
High-income Central Asia Latin America Middle East and East and South Asia Sub-Saharan
regions and central and and Caribbean North Africa Southeast Asia Africa
eastern Europe and Oceania
A Deaths
High Blood Pressure
High BMI
Alcohol Use
B Burden of Disease
High Blood Pressure
Alcohol Use
High BMI
Figure 1. Deaths and Burden of Disease Attributable to Selected Behavioral and Dietary Risk Factors in 2010
and the Metabolic and Physiological Mediators of Their Hazardous Effects.
High-income regions are Australasia, the AsiaPacific region, North America, and western Europe. The figure shows deaths
(Panel A) and disease burden (Panel B) attributable to the total effects of each individual risk factor. There is overlap among the
effects of risk factors because of multicausality and because the effects of some risk factors (e.g., physical inactivity) are partly
mediated through other risk factors (e.g., high body-mass index [BMI]). Therefore, the deaths and disease burden attributable to
individual risk factors cannot simply be added together. DALYs denotes disability-adjusted life-years. Data are from Lim et al.5
Europe, where the prevalence of smoking and tion to the disease burden larger than its contri-
the prevalence of other cardiovascular risk fac- bution to mortality, relative to other risk factors
tors are concurrently high; this death toll is for noncommunicable diseases (Fig. 1).
increasing in the large populations of Asia and Alcohol consumption is the leading single
slowly declining in Western countries. In addi- cause of the disease burden in eastern Europe
tion to smoking, oral tobacco use and betel-nut and is one of the top three risk factors, along
chewing are highly prevalent in South Asia and with high blood pressure and overweight or obe-
are responsible for a large number of cases of sity, in much of Latin America, where it ranks
oral cancer and deaths from this disease.17 ahead of smoking.4,5,7 The effects of alcohol on
population health are greatest in Russia and
A l c ohol C onsump t ion some other former Soviet republics. Though re-
corded per capita alcohol consumption in Russia
Alcohol consumption is associated with numer- is the same as or only slightly higher than con-
ous diseases and injuries. Moderate alcohol con- sumption in western European countries, the
sumption has been inversely associated with the health effects are substantially larger. In tradi-
risk of cardiovascular diseases and diabetes, al- tional wine-producing countries, most alcohol
though the benefits may be greater for persons is consumed as wine during meals, in relatively
with existing cardiovascular risk factors than for modest daily amounts, by a large proportion of
those without such risk factors.18 Epidemiologic the population. In contrast, in Russia and neigh
studies that have measured both the amount and boring countries, men (especially those of low so
patterns of alcohol consumption have shown cioeconomic status) consume very large amounts
that heavy episodic (or binge) drinking not only of spirits, either as a regular daily habit or by
substantially raises the risk of injuries but can binge drinking. A substantial proportion of con
also increase the risk of or exacerbate cardiovas- sumed alcohol is from unrecorded and nonbev-
cular disease and liver disease.19-21 erage sources such as medicinal and industrial
Although cultural factors are important de- ethanol. Alcohol consumption may be respon-
terminants of alcohol consumption, including sible for one third to one half of deaths among
harmful drinking, social change and policy in- young and middle-aged men in Russia.24,26 In
terventions have modified alcohol-drinking be- contrast to the current, enormous death toll,
haviors in some countries.22,23 For example, per mortality declined temporarily in the 1980s,
capita alcohol consumption has decreased by when policies introduced under Mikhail Gor-
about one half in traditional wine-producing and bachev reduced alcohol consumption by about
wine-drinking countries such as Italy and France one half (Fig. 3).25
during the past few decades22,23; during the
same period, it has doubled in the United King- E xce ss W eigh t a nd Obe si t y
dom and Denmark, and levels of consumption
in the two groups of countries have converged Numerous observational studies in Western and
(Fig. 3). Alcohol consumption has increased Asian populations have associated different mea-
steadily in Japan, China, and many other coun- sures of adiposity and excess body weight with
tries in Asia, where it was previously low. increased total mortality and increased risks of
Alcohol consumption is responsible for about disease or death from diabetes, ischemic heart
2.7 million annual deaths and 3.9% of the disease and ischemic stroke, cancers, chronic
global burden of disease (Fig. 1).5 The major kidney disease, and osteoarthritis.27-32 The risks
contributors to the alcohol-attributable disease of diabetes and ischemic heart disease increase
burden are cancers, chronic liver disease, un monotonically with an increase in the body-mass
intentional injuries, alcohol-related violence, neu- index (BMI, the weight in kilograms divided by
ropsychiatric conditions, and, in some regions the square of the height in meters), starting at a
(especially eastern Europe) that have a high prev BMI in the low 20s. In contrast, the association
alence of binge and harmful drinking, a large with hemorrhagic stroke, which is more com-
death toll from cardiovascular diseases.4,5,24,25 mon in Asian populations than in other popula-
The role of alcohol consumption in injuries and tions, has been observed only at a BMI of 25 or
violence among young adults and in nonfatal higher.27,31 Currently, excess weight is responsi-
neuropsychiatric conditions makes its contribu- ble for about 3.4 million annual deaths and 3.8%
30
20
15 France
Denmark
Russia
10 United Kingdom
United States
Japan Italy
5 China
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Figure 3. Trends in Recorded Per Capita Alcohol Consumption by Adults in Selected Countries.
In addition to recorded consumption, there is unrecorded consumption in some countries. For example, in 2005,
adult per capita unrecorded consumption was estimated to be less than 0.5 liters per year in Japan and France;
1 to 2 liters per year in China, the United Kingdom, and the United States; and close to 5 liters per year in Russia.
Data are from the WHO Global Information System on Alcohol and Health (http://apps.who.int/gho/data/node
.main.GISAH).
of the global burden of disease, with diseases less than 22 in parts of sub-Saharan Africa and
that have low mortality and long periods of dis- Asia to 30 to 35 in some Pacific islands and
ability, such as diabetes and musculoskeletal dis- countries in the Middle East and North Africa.34
eases, accounting for a proportion of this burden The prevalence of obesity ranges from less than
(Fig. 1).5 2% in Bangladesh to more than 60% in some
In recent decades, men and women in all but Pacific islands.33
a few countries have gained weight, with the
age-standardized mean BMI increasing by more Die t a nd Nu t r i t ion
than 2 units per decade in some Pacific islands
(Fig. S1 in the Supplementary Appendix, available Centuries after the effects of specific dietary in-
with the full text of this article at NEJM.org). In takes on conditions such as scurvy were discov-
high-income regions, the BMI is higher in English- ered, nutritional epidemiology has established
speaking countries than in continental Europe the associations of specific foods and nutrients
and the AsiaPacific region, especially for wom- or overall dietary patterns with cancers, cardio-
en. The global prevalence of obesity (defined as vascular diseases, and diabetes35,36 and with in-
a BMI30) doubled between 1980 and 2008, to termediate outcomes such as weight gain, in-
9.8% among men and 13.8% among women creased blood pressure, and insulin resistance
equivalent to more than half a billion obese and hyperglycemia.37-39 The large body of obser-
people worldwide (205 million men and 297 mil- vational studies is increasingly complemented by
lion women) (Fig. 4).33,34 An additional 950 million well-designed randomized trials that have, for ex-
adults have a BMI of 25 to less than 30. The United ample, shown the benefits of lower salt intake, the
States has had the largest absolute increase in replacement of saturated fats with polyunsaturated
the number of obese people since 1980, fol- fats, and healthy dietary patterns.37,38,40,41 Low di-
lowed by China, Brazil, and Mexico.33 Current- etary intakes of fruits, vegetables, whole grains, or
ly, the age-standardized mean BMI ranges from nuts and seeds or a high dietary intake of salt are
Region
Oceania
500
East Asia
Southeast Asia
South Asia
400
No. of Obese Persons (millions)
Eastern Europe
Central Europe
Central Asia
individually responsible for 1.5% to more than 4% Parallel to this westernization trend, fruits,
of the global disease burden (Fig. 1).5 vegetables, nuts, and cereals have become more
There have so far been few population-based available in Nordic and English-speaking West-
analyses of trends in specific dietary risk fac- ern countries and in Asia, partly because tech-
tors. Administrative data, such as the United nological and economic developments have
Nations Food and Agriculture Organization (FAO) increased year-around availability through ex-
food balance sheets, provide a broad picture of panded production, imports, and storage ca-
dietary patterns and trends based on the avail- pacity (Fig. 5B). Similarly, there has been a
ability of different food types for human con- modest increase in the availability of fish and
sumption. FAO data show that consumption of other marine products in some Western and
animal fats and high-calorie foods is increasing Asian countries (Fig. 5C).
in Mediterranean countries, such as Greece, but The FAO data, which are based on agricul-
declining slightly in Nordic countries and New tural production and trade statistics, do not
Zealand,42 with consumption in these countries capture food waste or subsistence production,
converging at similar levels (Fig. 5A). These nor do they account for food processing. For
changes may also partly explain trends in serum example, these data do not include specific in-
cholesterol levels, which have declined more formation about consumption of refined flour
rapidly in Nordic countries and New Zealand versus whole grains, sugar-sweetened beverages,
than in southern Europe, with cholesterol levels and partially hydrogenated vegetables oils (and
now lower in Sweden and Finland than in Ita- hence trans-fat consumption), all of which are
ly.45 Dietary change has been even more drastic important dietary risk factors. The FAO data-
in parts of Asia, with China rapidly adopting a bases also do not record consumption of salt,
Western, animal-based diet (Fig. 5A) and having which is common in the diets of countries at all
one of the largest worldwide increases in serum stages of economic development.46 A high in-
cholesterol levels.45 take of salt is a risk factor for stomach cancer
A
100 Germany
Norway
90 Finland
New Zealand
Greece
80
40
30 Kenya
India
20
10
0
1970 1975 1980 1985 1990 1995 2000 2005 2010
B Greece
100 South Korea
China
Germany
90
Norway
80
New Zealand
Diet 2 Score (percentile)
70
Finland
60 India
50
40
30
20 Kenya
10
0
1970 1975 1980 1985 1990 1995 2000 2005 2010
C
100 South Korea
China
90
Norway
80 Finland
New Zealand
Diet 3 Score (percentile)
70
Germany
60
50
Greece
40
30
20
India
10
0 Kenya
1970 1975 1980 1985 1990 1995 2000 2005 2010
nomic factors, they can also be modified through long-term and large-scale community effective-
mechanisms that range from broad food and ness of such interventions has not been estab-
agricultural policies to targeted pricing and lished.58 Similarly, studies have modeled or
regulatory interventions related to specific qualitatively assessed the potential benefits of
harmful or beneficial dietary components. Such physical-activity interventions,59 but the empiri-
mechanisms are reviewed elsewhere.2,53 cal evidence of their effectiveness at the popu-
The availability of population-based and per- lation level remains limited. As a result, policy
sonal interventions for tobacco smoking, exces- options and recommendations for weight con-
sive alcohol consumption, and elevated blood trol60 and increased physical activity remain
pressure or lipid levels has made overweight, broad and untested but are needed to avoid a
obesity, and high blood glucose levels the wild slowdown or even reversal of the progress in
cards of noncommunicable-disease risks glob- mortality reduction.2
ally. Some have argued that the obesity epi- Although the behaviors of individuals are
demic may reverse life-expectancy gains in important factors in the patterns of risk factors
high-income nations.54 At the same time, blood for noncommunicable diseases, successful ef-
pressure and cholesterol levels, which partially forts to reduce smoking, alcohol consumption,
mediate the hazardous effects of excess weight and, more recently, trans-fat and salt consump-
on cardiovascular diseases, have declined in tion show that there is great scope for collective
most high-income countries and in parts of action through policy formulation and imple-
Latin America.43,45 This has probably helped mentation.2 Successful policies, such as tobacco
dampen or delay the effects of weight gain on and alcohol taxes and restrictions, should be
cardiovascular diseases, which have declined replicated in all populations. There is also a
impressively in industrialized countries.55 How- need for bold and creative policies that address
ever, there are currently few effective measures harmful alcohol consumption, improve diet, and
against the harms of overweight and obesity increase physical activity.
with respect to hyperglycemia, diabetes, and
Disclosure forms provided by the authors are available with
cancers, making the concurrent epidemic of the full text of this article at NEJM.org.
diabetes a global health challenge.56 Random- We thank Alexandra Fleischmann, Colin Mathers, Vladimir
ized trials of dietary changes (in some cases Poznyak, Jrgen Rehm, Robin Room, Gitanjali Singh, and
Gretchen Stevens for data sources and advice on references; and
combined with exercise) have shown moderate Mariachiara Di Cesare, Jessica Ho, Yuan Lu, and Anne-Claire
weight-loss benefits for up to 2 years,57 but the Vergnaud for assistance with figures.
References
1. Wang H, Dwyer-Lindgren L, Lofgren disease and injury attributable to 67 risk smoke, indoor air pollution and tubercu-
KT, et al. Age-specific and sex-specific factors and risk factor clusters in 21 re- losis: a systematic review and meta-analy-
mortality in 187 countries, 1970-2010: a gions, 1990-2010: a systematic analysis sis. PLoS Med 2007;4(1):e20.
systematic analysis for the Global Burden for the Global Burden of Disease Study 10. Gu D, Kelly TN, Wu X, et al. Mortality
of Disease Study 2010. Lancet 2012;380: 2010. Lancet 2012;380:2224-60. [Erratum, attributable to smoking in China. N Engl
2071-94. Lancet 2013;381:1276.] J Med 2009;360:150-9. [Erratum, N Engl J
2. Ezzati M, Riboli E. Can noncommuni- 6. Danaei G, Ding EL, Mozaffarian D, Med 2010;363:2272.]
cable diseases be prevented? Lessons et al. The preventable causes of death in 11. Nakamura K, Huxley R, Ansary-
from studies of populations and individu- the United States: comparative risk as- Moghaddam A, Woodward M. The haz-
als. Science 2012;337:1482-7. sessment of dietary, lifestyle, and meta- ards and benefits associated with smok-
3. Lozano R, Naghavi M, Foreman K, et bolic risk factors. PLoS Med 2009;6(4): ing and smoking cessation in Asia: a
al. Global and regional mortality from e1000058. meta-analysis of prospective studies. Tob
235 causes of death for 20 age groups in 7. Stevens G, Dias RH, Thomas KJ, et al. Control 2009;18:345-53.
1990 and 2010: a systematic analysis for Characterizing the epidemiological tran- 12. Jha P, Jacob B, Gajalakshmi V, et al. A
the Global Burden of Disease Study 2010. sition in Mexico: national and subnation- nationally representative casecontrol study
Lancet 2012;380:2095-128. al burden of diseases, injuries, and risk of smoking and death in India. N Engl J
4. Ezzati M, Lopez AD, Rodgers A, factors. PLoS Med 2008;5(6):e125. Med 2008;358:1137-47.
Vander Hoorn S, Murray CJ. Selected ma- 8. Willi C, Bodenmann P, Ghali WA, 13. Department of Health and Human
jor risk factors and global and regional Faris PD, Cornuz J. Active smoking and Services. The health consequences of in-
burden of disease. Lancet 2002;360:1347- the risk of type 2 diabetes: a systematic voluntary exposure to tobacco smoke: a
60. review and meta-analysis. JAMA 2007; report of the Surgeon General. Atlanta:
5. Lim SS, Vos T, Flaxman AD, et al. A 298:2654-64. National Center for Chronic Disease Pre-
comparative risk assessment of burden of 9. Lin HH, Ezzati M, Murray M. Tobacco vention and Health Promotion, Office on
Smoking and Health, 2006. (DHHS publi- nio E, et al. Separate and combined asso- disease with a Mediterranean diet. N Engl
cation no. [CDC] 89-8411.) ciations of body-mass index and abdomi- J Med 2013;368:1279-90.
14. Global status report on noncommuni- nal adiposity with cardiovascular disease: 42. Puska P, Stahl T. Health in All Policies
cable diseases 2010. Geneva: World Health collaborative analysis of 58 prospective the Finnish initiative: background,
Organization, 2011. studies. Lancet 2011;377:1085-95. principles, and current issues. Annu Rev
15. Thun M, Peto R, Boreham J, Lopez 29. Renehan AG, Tyson M, Egger M, Hell- Public Health 2010;31:315-28.
AD. Stages of the cigarette epidemic on er RF, Zwahlen M. Body-mass index and 43. Danaei G, Finucane MM, Lin JK, et al.
entering its second century. Tob Control incidence of cancer: a systematic review National, regional, and global trends in
2012;21:96-101. and meta-analysis of prospective observa- systolic blood pressure since 1980: sys-
16. Department of Health and Human tional studies. Lancet 2008;371:569-78. tematic analysis of health examination
Services. A report of the Surgeon General: 30. Ni Mhurchu C, Parag V, Nakamura M, surveys and epidemiological studies with
how tobacco smoke causes disease: the Patel A, Rodgers A, Lam TH. Body mass 786 country-years and 5.4 million partici-
biology and behavioral basis for smoking- index and risk of diabetes mellitus in the pants. Lancet 2011;377:568-77.
attributable disease. Atlanta: National Asia-Pacific region. Asia Pac J Clin Nutr 44. Danaei G, Singh GM, Paciorek CJ, et
Center for Chronic Disease Prevention 2006;15:127-33. al. The global cardiovascular risk transi-
and Health Promotion, Office on Smok- 31. Ni Mhurchu C, Rodgers A, Pan WH, tion: associations of four metabolic risk
ing and Health, 2010. (DHHS publication Gu DF, Woodward M. Body mass index factors with national income, urbaniza-
no. [CDC] 89-8411.) and cardiovascular disease in the Asia- tion, and Western diet in 1980 and 2008.
17. Secretan B, Straif K, Baan R, et al. A Pacific Region: an overview of 33 cohorts Circulation 2013;127:1493-502.
review of human carcinogens Part E: involving 310 000 participants. Int J Epi- 45. Farzadfar F, Finucane MM, Danaei G,
tobacco, areca nut, alcohol, coal smoke, demiol 2004;33:751-8. et al. National, regional, and global
and salted fish. Lancet Oncol 2009;10: 32. Pischon T, Boeing H, Hoffmann K, et trends in serum total cholesterol since
1033-4. al. General and abdominal adiposity and 1980: systematic analysis of health exami-
18. Roerecke M, Rehm J. The cardiopro- risk of death in Europe. N Engl J Med nation surveys and epidemiological stud-
tective association of average alcohol con- 2008;359:2105-20. [Erratum, N Engl J Med ies with 321 country-years and 3.0 million
sumption and ischaemic heart disease: a 2010;362:2433.] participants. Lancet 2011;377:578-86.
systematic review and meta-analysis. Ad- 33. Stevens GA, Singh GM, Lu Y, et al. 46. Asaria P, Chisholm D, Mathers C, Ez-
diction 2012;107:1246-60. National, regional, and global trends in zati M, Beaglehole R. Chronic disease pre-
19. Mathurin P, Deltenre P. Effect of adult overweight and obesity prevalences. vention: health effects and financial costs
binge drinking on the liver: an alarming Popul Health Metr 2012;10:22. of strategies to reduce salt intake and
public health issue? Gut 2009;58:613-7. 34. Finucane MM, Stevens GA, Cowan control tobacco use. Lancet 2007;370:
20. Rehm J, Baliunas D, Borges GL, et al. MJ, et al. National, regional, and global 2044-53. [Erratum, Lancet 2007;370:2004.]
The relation between different dimen- trends in body-mass index since 1980: 47. Hirayama T. Epidemiology of stom-
sions of alcohol consumption and burden systematic analysis of health examination ach cancer in Japan: with special refer-
of disease: an overview. Addiction surveys and epidemiological studies with ence to the strategy for the primary pre-
2010;105:817-43. 960 country-years and 9.1 million partici- vention. Jpn J Clin Oncol 1984;14:159-68.
21. Roerecke M, Rehm J. Irregular heavy pants. Lancet 2011;377:557-67. 48. Tuomilehto J, Geboers J, Joossens JV,
drinking occasions and risk of ischemic 35. Food, nutrition, physical activity, and Salonen JT, Tanskanen A. Trends in stom-
heart disease: a systematic review and the prevention of cancer: a global per- ach cancer and stroke in Finland: com-
meta-analysis. Am J Epidemiol 2010;171: spective. Washington, DC: American In- parison to northwest Europe and USA.
633-44. stitute for Cancer Research, 2007. Stroke 1984;15:823-8.
22. Allamani A, Prina F. Why the de- 36. Mozaffarian D, Appel LJ, Van Horn L. 49. Morris JN, Heady JA, Raffle PA, Rob-
crease in consumption of alcoholic bever- Components of a cardioprotective diet: erts CG, Parks JW. Coronary heart-disease
ages in Italy between the 1970s and the new insights. Circulation 2011;123:2870- and physical activity of work. Lancet 1953;
2000s? Shedding light on an Italian mys- 91. 265:1053-7.
tery. Contemp Drug Probl 2007;34:187-97. 37. He FJ, Li J, Macgregor GA. Effect of 50. Sattelmair J, Pertman J, Ding EL, Kohl
23. Cipriani F, Prina F. The research out- longer term modest salt reduction on HW III, Haskell W, Lee IM. Dose response
come: summary and conclusions on the blood pressure: Cochrane systematic re- between physical activity and risk of coro-
reduction in wine consumption in Italy. view and meta-analysis of randomised nary heart disease: a meta-analysis. Cir-
Contemp Drug Probl 2007;34:361-78. t rials. BMJ 2013;346:f1325. culation 2011;124:789-95.
24. Zaridze D, Brennan P, Boreham J, et 38. Sacks FM, Bray GA, Carey VJ, et al. 51. Levine JA, Weisell R, Chevassus S,
al. Alcohol and cause-specific mortality Comparison of weight-loss diets with dif- Martinez CD, Burlingame B, Coward WA.
in Russia: a retrospective case-control ferent compositions of fat, protein, and The work burden of women. Science
study of 48,557 adult deaths. Lancet 2009; carbohydrates. N Engl J Med 2009;360:859- 2001;294:812.
373:2201-14. 73. 52. Di Cesare M, Khang YH, Asaria P, et
25. Leon DA, Chenet L, Shkolnikov VM, et 39. Mozaffarian D, Hao T, Rimm EB, Wil- al. Inequalities in non-communicable dis-
al. Huge variation in Russian mortality lett WC, Hu FB. Changes in diet and life- eases and effective responses. Lancet 2013;
rates 1984-94: artefact, alcohol, or what? style and long-term weight gain in women 381:585-97.
Lancet 1997;350:383-8. and men. N Engl J Med 2011;364:2392- 53. Mozaffarian D, Afshin A, Benowitz
26. Leon DA, Shkolnikov VM, McKee M. 404. NL, et al. Population approaches to im-
Alcohol and Russian mortality: a continu- 40. Mozaffarian D, Micha R, Wallace S. prove diet, physical activity, and smoking
ing crisis. Addiction 2009;104:1630-6. Effects on coronary heart disease of in- habits: a scientific statement from the
27. Whitlock G, Lewington S, Sherliker P, creasing polyunsaturated fat in place of American Heart Association. Circulation
et al. Body-mass index and cause-specific saturated fat: a systematic review and 2012;126:1514-63.
mortality in 900 000 adults: collaborative meta-analysis of randomized controlled 54. Olshansky SJ, Passaro DJ, Hershow
analyses of 57 prospective studies. Lancet trials. PLoS Med 2010;(3)7:e1000252. RC, et al. A potential decline in life expec-
2009;373:1083-96. 41. Estruch R, Ros E, Salas-Salvad J, et tancy in the United States in the 21st cen-
28. Wormser D, Kaptoge S, Di Angelanto- al. Primary prevention of cardiovascular tury. N Engl J Med 2005;352:1138-45.
55. Di Cesare M, Bennett JE, Best N, and 2.7 million participants. Lancet 2011; adults: clinical significance and applica-
S tevens GA, Danaei G, Ezzati M. The con- 378:31-40. bility to clinical practice. Int J Obes (Lond)
tributions of risk factor trends to cardio- 57. Nordmann AJ, Nordmann A, Briel M, 2005;29:1153-67.
metabolic mortality decline in 26 indus et al. Effects of low-carbohydrate vs low- 59. Cobiac LJ, Vos T, Barendregt JJ. Cost-
trialized countries. Int J Epidemiol 2013; fat diets on weight loss and cardiovascu- effectiveness of interventions to promote
42:838-48. lar risk factors: a meta-analysis of ran- physical activity: a modelling study. PLoS
56. Danaei G, Finucane MM, Lu Y, et al. domized controlled trials. Arch Intern Med 2009;6(7):e1000110.
National, regional, and global trends in Med 2006;166:285-93. [Erratum, Arch In- 60. Gortmaker SL, Swinburn BA, Levy D,
fasting plasma glucose and diabetes prev- tern Med 2006;166:932.] et al. Changing the future of obesity: sci-
alence since 1980: systematic analysis of 58. Douketis JD, Macie C, Thabane L, ence, policy, and action. Lancet 2011;
health examination surveys and epidemi- Williamson DF. Systematic review of 378:838-47.
ological studies with 370 country-years long-term weight loss studies in obese Copyright 2013 Massachusetts Medical Society.