Background Trends in food availability and metabolic risk factors in Brazil suggest a shift toward unhealthy dietary patterns and increased cardiometabolic disease risk, yet little is known about the impact of dietary and metabolic risk factors on cardiometabolic mortality in Brazil. Methods Based on data from Global Burden of Disease (GBD) Study, we used comparative risk assessment to estimate the burden of 11 dietary and 4 metabolic risk factors on mortality due to cardiovascular diseases and diabetes in Brazil in 2010. Information on national diets and metabolic risks were obtained from the Brazilian Household Budget Survey, the Food and Agriculture Organization database, and large observational studies including Brazilian adults. Relative risks for each risk factor were obtained from meta-analyses of randomized trials or prospective cohort studies; and disease-specific mortality from the GBD 2010 database. We quantified uncertainty using probabilistic simulation analyses, incorporating uncertainty in dietary and metabolic data and relative risks by age and sex. Robustness of findings was evaluated by sensitivity to varying feasible optimal levels of each risk factor. Results In 2010, high systolic blood pressure (SBP) and suboptimal diet were the largest contributors to cardiometabolic deaths in Brazil, responsible for 214,263 deaths (95% uncertainty interval [UI]: 195,073 to 233,936) and 202,949 deaths (95% UI: 194,322 to 211,747), respectively. Among individual dietary factors, low intakes of fruits and whole grains and high intakes of sodium were the largest contributors to cardiometabolic deaths. For premature cardiometabolic deaths (before age 70 years, representing 40% of cardiometabolic deaths), the leading risk factors were suboptimal diet (104,169 deaths; 95% UI: 99,964 to 108,002), high SBP (98,923 deaths; 95%UI: 92,912 to 104,609) and high body-mass index (BMI) (42,643 deaths; 95%UI: 40,161 to 45,111). Conclusion suboptimal diet, high SBP, and high BMI are major causes of cardiometabolic death in Brazil, informing priorities for policy initiatives.
Bibliographical noteFunding Information:
The Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) authorship group includes: Core Group: Dariush Mozaffarian, MD, DrPh, Tufts University Friedman School of Nutrition Science and Health Policy, Boston, MA, USA; Majid Ezzati, PhD, Imperial College London, London, UK; Saman Fahimi, MD, MPH, University of Cambridge, Cambridge, UK; Shahab Khatibzadeh, MD, MPH, Harvard School of Public Health, Boston, MA, USA; Renata Micha, PhD, Tufts University Friedman School of Nutrition Science and Health Policy, Boston, MA, USA; John Powles, MB, BS, MA, FFPH, University of Cambridge, Cambridge, UK; Peilin Shi, PhD, Tufts University Friedman School of Nutrition Science and Health Policy, Boston, MA, USA. Other Members: Ibrahim Elmadfa, PhD, Institute of Nutritional Sciences, University of Vienna, Vienna, Austria; Mayuree Rao, BA, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Pattra Wirojratana, Harvard School of Public Health, Boston, MA, USA; Gitanjali Singh, PhD, Tufts University Friedman School of Nutrition Science and Health Policy, Boston, MA USA. Dietary Exposure Imputation: Stephen S. Lim, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA; Kathryn G. Andrews, MPH, African Leaders Malaria Alliance, Dar es Salaam, Tanzania; Rebecca E Engell, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Dietary Exposures—Corresponding Members (alphabetical order): Pamela A. Abbott, PhD, University of Aberdeen, United Kingdom; Morteza Abdollahi, MD, MPH, National Nutrition and Food Technology Research Institute Iran; Enrique Abeyá Gilardon, MD, MPH, Ministerio de Salud, Argentina; Habibul Ahsan, MD, University of Chicago, USA; Mohannad Abed Alfattah Al Nsour, MD, Eastern Mediterranean Public Health Network (EMPHNET), Jordan; Suad N. Al-Hooti, MSc, Kuwait Institute for Scientific Research, Kuwait; Carukshi Arambepola, MD, Faculty of Medicine, University of Colombo, Sri Lanka; Hubert Barennes, PhD, Institut Francophone pour la Médecine Tropicale, Lao PDR; Simon Barquera, PhD, Instituto Nacional de Salud Publica (INSP), Mexico; Ana Baylin, MD, DrPH, University of Michigan, US; Wulf Becker, PhD, National Food Agency, Sweden; Peter Bjerregaard, MD, DrMedSci, National Institute of Public Health, University of Southern Denmark, Denmark; Lesley T. Bourne, PhD, Environment and Health Research Unit, Medical Research Council, South Africa; Neville Calleja, MD, MFPH, Department of Health Information & Research, Malta; Mario V. Capanzana, PhD, Food and Nutrition Research Institute, Philippines; Katia Castetbon, PhD, Institut de Veille Sanitaire, France; Hsing-Yi Chang, DrPH, National Health Research Institutes, Taiwan; Yu Chen, PhD, New York University School of Medicine, United States; Melanie J. Cowan, MPH, WHO, Switzerland; Stefaan De Henauw, MD, PhD, Ghent University, Department of Public Health, Belgium; Eric L. Ding, ScD, Harvard Medical School and Harvard School of Public Health, USA; Charmaine A. Duante, MSc, Food and Nutrition Research Institute,Department of Science and Technology, Philippines; Pablo Duran, PhD, Dirección Nacional de Maternidad e Infancia, Ministerio de Salud de la Nación, Argentina; Ibrahim Elmadfa, Professor, Institute of Nutritional Sciences, University of Vienna, Austria; Heléne Enghardt Barbieri, National Food Agency, Uppsala, Sweden; Farshad Farzadfar, MD, ScD, Tehran University of Medical Sciences, Iran; Dulitha N. Fernando, PhD, Faculty of Medicine, University of Colombo, Sri Lanka; Aida Filipovic Hadziomeragic, MD, MSc, Institute of Public Health of Federation of Bosnia and Herzegovina, Bosnia and Herzegovina; Regina M. Fisberg, PhD, Faculty of Public Health,University of São Paulo, Brazil; Simon Forsyth, BA (UQ), School of Population Health, University of Queensland, Australia; Didier Garriguet, MSc, Statistics Canada, Canada; Jean-Michel Gaspoz, MD, MPH, Geneva University Hospitals and Faculty of Medicine of Geneva,Switzerland; Dorothy Gauci, Post Graduate Diploma (Epidemiology), Department of Health Information and Research, Malta; Brahmam N.V. Ginnela, MB, BS, DPH, National Institute of Nutrition, Indian Council of Medical Research, India; Idris Guessous, MD, Geneva University Hospitals, Switzerland; Martin C. Gulliford, FFPH, King's College London, UK; Wilbur Hadden; Christian Haerpfer, PhD, University of Aberdeen, United Kingdom; Daniel J. Hoffman, PhD, Rutgers, the State University of New Jersey, USA; Anahita Houshiar-Rad MSc, National Nutrition and Food Technology Research Institute Shahid Beheshti University of Medical Sciences, Iran; Inge Huybrechts, PhD, Ghent University, Department of Public Health, Belgium; Nahla C. Hwalla, PhD, American University of Beirut, Lebanon; Hajah Masni Ibrahim, SM, Ministry of Health, Brunei; Manami Inoue, MD, PhD, Epidemiology and Prevention Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Japan; Maria D. Jackson, PhD, University of the West Indies, Jamaica; Lars Johansson, PhD, Norwegian Directorate of Health, Norway; Lital Keinan- Boker, MD, PhD, Ministry of Health, Israel; Cho-il Kim, PhD, Korea Health Industry Development Institute, Republic of Korea; Eda Koksal, PhD, Gazi University, Turkey; Hae- Jeung Lee; Yanping Li, PhD, Harvard School of Public Health, USA; Nur Indrawaty Lipoeto, PhD, Andalas University, Indonesia; Guansheng Ma, PhD, National Institute for Nutrition and Food Safety, Chinese Center for Disease Control and Prevention, China; Guadalupe L. Mangialavori, MS RD, Ministerio de Salud de la Nación (National Health Ministry), Argentina; Yasuhiro Matsumura, PhD, Bunkyo University, Japan; Stephen T. McGarvey, PhD, Brown University, USA; Mei Fen Chan; Gert B.M. Mensink, PhD, Robert Koch Institute, Germany; Rafael A. Monge-Rojas, PhD, Costa Rican Institute for Research and Education and Nutrition and Health (INCIENSA), Costa Rica; Abdulrahman O. Musaiger, PhD, Arab Center for Nutrition, Bahrain; Nagalla Balakrishna, PhD, National Institute of Nutrition, Hyderabad, India; Androniki Naska, PhD, Dept. of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Greece; Marga C. Ocke, PhD, National Institute for Public Health and the Environment, Netherlands; Maciej Oltarzewski, MSc, National Food and Nutrition Institute, Poland; Philippos Orfanos, MSc, Dept. of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Greece; Marja- Leena Ovaskainen, PhD, National Institute for Health andWelfare, Finland; Wen-Harn Pan, PhD, Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, Taiwan; Demosthenes B. Panagiotakos, PhD, Harokopio University, Greece; Gulden A. Pekcan, PhD, Hacettepe University Department of Nutrition and Dietetics, Turkey; Stefka Petrova, MD, PhD, National Center of Public Health and Analyses, Bulgaria; Noppawan Piaseu, PhD, Mahidol University, Thailand; Christos Pitsavos, MD, Athens University Medical School, Greece; Luz Gladys Posada, RD, MS, Universidad de Antioquia, Colombia; Leanne M. Riley, MSc, WHO, Switzerland; Luz Maria Sánchez-Romero, MD MSc, National Institute of Public Health, Mexico; Rusidah BT. Selamat, MSc, Nutrition Division, Ministry of Health, Malaysia; Sangita Sharma; Abla Mehio Sibai, PhD, American University of Beirut Faculty of Health Sciences, Lebanon; Rosely Sichieri, MD,PhD, State University of Rio de Janeiro, Brazil; Chansimaly Simmala, MD, Institut of Tropical Medecin, Laos; Laufey Steingrimsdottir, PhD, Professor, Iceland; Gillian Swan; Elżbieta Halina. Sygnowska, MSc PhD, National Institute of Cardiology, Poland; Lucjan Szponar, MD;PhD, National Food and Nutrition Institute, Poland; Heli Tapanainen, MSc, National Institute for Health and Welfare, Finland; Robert Templeton; Anastasia Thanopoulou, MD, PhD, Diabetes Center, 2nd Department of Internal Medicine, National University of Athens, Hippokration General Hospital, Greece; Holmfridur Thorgeirsdóttir, MSc, Directorate of Health, Iceland; Inga Thorsdottir; Antonia Trichopoulou, MD, Hellenic Health Foundation, Greece; Shoichiro Tsugane, MD, PhD, National Cancer Center, Japan; Aida Turrini, MD, National Research Institute on Food and Nutrition, Italy; Sirje Vaask, PhD, Tallinn University of Technology, Estonia; Coline van Oosterhout, National Institute for Public Health and the Environment, Netherlands; J Lennert Veerman, PhD, The University of Queensland, Australia; Nowak Verena; Anna Waskiewicz, MSc, PhD., Institute of Cardiology, Department of Cardiovascular Diseases Epidemiology, Prevention and Health Promotion, Poland; Sahar Zaghloul, PhD., National Nutrition Institute, Egypt; Gábor Zajkás, MD, National Institute of Food and Nutrition Sciences, Hungary.
Dr. Otto was supported by the National Heart, Lung and Blood Institute of the National Institutes of Health under award number R01HL085710 and by unrestricted educational grants from Bunge LLC and from Swiss Re. Dr. Mozaffarian was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (R21 HL109924). Dr. Mozaffarian reports ad hoc honoraria or consulting from Bunge, Haas Avocado Board, Nutrition Impact, Amarin, Astra Zeneca, Boston Heart Diagnostics, GOED, and Life Sciences Research Organization; and scientific advisory boards, Unilever North America and Elysium Health. This work was undertaken as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. The results in this paper are prepared independently of the final estimates of the Global Burden of Diseases, Injuries, and Risk Factors study. We thank the Russia Longitudinal Monitoring Survey Phase 2, funded by the USAID and NIH (R01-HD38700), Higher School of Economics and Pension Fund of Russia, and the University of North Carolina Population Center (5 R24 HD050924) (Source: "Russia Longitudinal Monitoring survey, RLMS-HSE”), conducted by HSE and ZAO “Demoscope” together with Carolina Population Center, University of North Carolina at Chapel Hill and the Institute of Sociology RAS (RLMS-HSE sites: http://www.cpc.unc.edu/projects/rlms , http://www.hse.ru/org/hse/rlms ) for sharing data with us. We thank Barbara Bowman, MS, PhD, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA; Patricia Constante Jamie, PhD, School of Public Health, University of São Paulo, Sao Paolo, Brazil; Karen Lock, PhD, London School of Hygiene and Tropical Medicine, London, UK; and Joceline Pomerleau, PhD, London School of Hygiene and Tropical Medicine, London, UK for advising and guidance on initial search strategy. We thank Louise Dekker, MSc, Jenna Golan, MPH, Shadi Kalantarian, MD, MPH, Liesbeth Smit, PhD, and Georgina Waweru Harvard School of Public Health, Boston, MA, USA for assistance with data collection.
©2016 de Oliveira Otto et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in anymedium, provided the original author and source are credited.
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