China’s declining population and debt burden will limit its growth rate to 2-3%: Breakout’s Sharma CNBC Television
China’s deflation risk: Spillover effects will be ‘greater in Europe,’ strategist says Yahoo Finance
China Weakness Suggests Reduced Trade Dependency, Nagel Says Bloomberg
We need to prepare for a negative shock from China, says IIF’s Tim Adams on weak China economic data CNBC Television
China State Planner: Persistent Economic Recovery Faces Risks and Challenges Including Insufficient Demand, Sluggish Momentum and Weak Confidence Forex Factory
A recent study published in the International Forum of Allergy and Rhinology discusses ear, nose, and throat (ENT)-related post-acute symptoms of the coronavirus disease 2019 (COVID-19), of which include vertigo, dyspnea, anosmia, ageusia, and sore throat. Furthermore, post-acute or long COVID symptoms were found to be more common in females and White identifying individuals between the ages of 35-49 years, as well as the disabled.
Study: The growing burden of Long Covid in the United Kingdom: Insights from the UK coronavirus infection survey. Image Credit: Darren Baker / Shutterstock.com
Background
Long COVID refers to prolonged symptoms that persist for more than 12 weeks after recovery from infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several long COVID symptoms have been reported, some of which include headache, myalgia, fatigue, as well as loss of taste and smell. Additionally, parosmia, brain fog, and memory loss have been reported to persist for several months after the initial infection.
Current estimates indicate that long COVID currently affects between 3% and 12% of the population in the United Kingdom. Although post-viral syndromes are widely documented following other types of infection, the scale of long COVID, combined with the rapid spread of SARS-CoV-2, necessitates a better understanding of the epidemiology and risk factors of this syndrome.
The COVID-19 Infection Survey (CIS) is the largest regular survey of COVID-19 and provides essential information to assist the U.K. in response to the pandemic. As a part of the survey, the government was informed on how many people tested positive for COVID-19 in England, Wales, Northern Ireland, and Scotland. This information was subsequently used to assist in decision-making for healthcare policies and public awareness.
About the study
The current study examines the prevalence of ENT-related symptoms of long COVID and aimed to identify demographic groups at greatest risk for long COVID.
In a longitudinal follow-up program involving patients identified through repeated cross-sectional national surveys, a random sample of volunteers residing in private households was selected. The participants selected were aged two years or older. Children under the age of 12 were surveyed by their parents and caregivers.
The responses were analyzed between March 6, 2022, and April 3, 2022. The presence of COVID-19 was confirmed by sampling and testing nose and throat swabs, as well as blood tests.
Patients exhibiting COVID-19 symptoms were asked about their symptoms and how their general well-being was affected by the disease on a daily basis.
Self-reported long COVID syndrome was defined as symptoms persisting for more than four weeks after the first suspected SARS-CoV-2 infection, without being explained by any other factor. With adjustments for age, sex, and region, Bayesian multilevel regression post-stratification was used for the final analysis.
Study findings
ENT-related long COVID symptoms identified in this investigation included vertigo, anosmia, dyspnea, ageusia, and sore throat. The most prevalent complaint was fatigue, while other common symptoms included vertigo, wheezing, rhinorrhea, sneezing, dyspnea, loss of smell, loss of taste, and sore throat.
Adults aged 35-49 years of White ethnic background had the highest estimated prevalence of self-reported long COVID at 4.13%. Women had a greater estimated predilection for long COVID than men at 3.20% and 2.34%, respectively.
Conclusions
The current study was based on a large and weighted sample of participants and a longitudinal follow-up period, which contributed to the strength of the study. The study findings indicate that future policies should focus on identifying and aiding the most vulnerable groups in the U.K. by increasing access to treatments for chemosensory disorders and COVID clinics.
However, the likelihood of confounding results could not be ruled out due to the lack of response or follow-up dropouts that impeded validation of long COVID. Furthermore, the prevalence of post-COVID syndrome could have been overestimated by including symptoms only after four weeks after the infection confirmation.
Additionally, the survey relied on self-reporting. Specific data confirming a connection between rhinorrhea, sneezing, and wheezing symptoms and the individual COVID variants were not available for this analysis.
Journal reference:
Gokani, S. A., Ta, N. H., Espehana, A., et al. (2022). The growing burden of Long Covid in the United Kingdom: Insights from the UK coronavirus infection survey. International Forum of Allergy & Rhinology. doi:10.1002/alr.23103
BEIJING, Dec 6 (Reuters) – People in China’s capital Beijing were allowed to enter parks, supermarkets, offices and airports without showing proof of a negative COVID-19 test on Tuesday, the latest in a mix of easing steps nationwide after last month’s historic protests.
“Beijing readies itself for life again” read a headline in the government-owned China Daily newspaper, adding that people were “gradually embracing” their newfound freedoms.
Authorities have been loosening some of the world’s toughest COVID curbs to varying degrees and softening their tone on the threat of the virus, in what many hope could herald a more pronounced shift towards normalcy three years into the pandemic.
“This might be the first step towards reopening from this pandemic,” Hu Dongxu, 27, told Reuters as he swiped his travel card to enter a train station in Beijing, which has also dropped the need for tests to ride the subway.
Both of the city’s airports also no longer require people to test to enter the terminal, state media reported on Tuesday, although there was no indication of changes to rules requiring passengers to show negative tests prior to boarding.
But further loosening beckons after a string of protests last month that marked the biggest show of public discontent in mainland China since President Xi Jinping took power in 2012.
China may announce 10 new national easing measures as early as Wednesday, two sources with knowledge of the matter told Reuters.
The prospect of further relaxation of the rules has sparked optimism among investors that the world’s second biggest economy would regather strength, and help to boost global growth.
The Chinese yuan has risen about 5% against the dollar since early November on expectations of an eventual reopening of China’s economy.
But on the ground, many people have been slow to adapt to the changing rules. Commuter traffic in major cities such as Beijing and Chongqing has remained at a fraction of normal levels.
Some people remain wary of catching the virus, especially the elderly, while there is concern about the strain the loosening could put on China’s fragile health system.
“My parents are still very cautious,” said James Liu, 22, a student in Shenzhen in the southern province of Guangdong, where authorities “abruptly” dropped testing requirements for entry into the family’s residential compound.
China has reported 5,235 COVID-related deaths as of Monday, but some experts have warned that toll could rise above 1 million if the exit is too hasty.
[1/7] People line up at a nucleic acid testing site to get tested for the coronavirus disease (COVID-19) in Beijing, China December 6, 2022. REUTERS/Florence Lo
NEXT PHASE
Analysts at Nomura estimate that areas now under lockdown represent around 19.3% of China’s total GDP, equivalent to the size of India’s economy but down from 25.1% last Monday.
This marks the first decline in Nomura’s closely watched China COVID lockdown index since the start of October.
Meanwhile, officials continue to play down the dangers posed by the virus, bringing China closer to what other countries have been saying for more than a year as they dropped restrictions and opted to live with the virus.
Tong Zhaohui, director of the Beijing Institute of Respiratory Diseases, said on Monday that the latest Omicron variant of the disease had caused fewer cases of severe illness than the 2009 global influenza outbreak, according to Chinese state television.
China’s management of the disease may be downgraded as soon as January, to the less strict Category B from the current top-level Category A of infectious disease, Reuters reported exclusively on Monday.
“The most difficult period has passed,” the official Xinhua news agency said in a commentary published late on Monday, citing the weakening pathogenicity of the virus and efforts to vaccinate 90% of the population.
Hu Xijin, a prominent commentator and former editor-in-chief of state-run tabloid Global Times, called for more measures to allow people to travel freely around the country.
“The general direction for the return to normal life is already very clear, and it is essential to restore the free movement of people across provinces to restore the economy,” he wrote in a blog post on Monday.
Analysts now predict China may reopen the economy and drop border controls sooner than expected next year, with some seeing it fully open in spring.
But more than half of Chinese say they will put off travel abroad even if borders reopen tomorrow, according to a survey of 4,000 consumers in China by consultancy Oliver Wyman.
But for all those wary of returning to normality, there are others clamouring for more freedoms.
“Let’s implement these policies quickly,” a Beijing-based lawyer surnamed Li wrote on WeChat, reacting to Tuesday’s announcement of the drop in testing requirements in the capital.
“Our lives and work have been affected for so long.”
Reporting by Ryan Woo, Martin Quin Pollard, Bernard Orr and the Beijing newsroom; Writing by John Geddie; Editing by Simon Cameron-Moore and Edmund Klamann
Our Standards: The Thomson Reuters Trust Principles.
The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.
Methods
For this analysis, we constructed burden-weighted dose–response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15–95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.
Findings
The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15–39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0–0) and 0·603 (0·400–1·00) standard drinks per day, and the NDE varied between 0·002 (0–0) and 1·75 (0·698–4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0–0·403) to 1·87 (0·500–3·30) standard drinks per day and an NDE that ranged between 0·193 (0–0·900) and 6·94 (3·40–8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3–65·4) were aged 15–39 years and 76·9% (73·0–81·3) were male.
Interpretation
There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.
Funding
Bill & Melinda Gates Foundation.
Introduction
Alcohol use accounted for 1·78 million (95% uncertainty interval [UI] 1·39–2·27) deaths in 2020 and was the leading risk factor for mortality among males aged 15–49 years (Bryazka D, unpublished). The relationship between moderate alcohol use and health is complex, as shown in multiple previous studies.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
,
2
Shield K
Manthey J
Rylett M
et al.
National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study.
,
3
Wood AM
Kaptoge S
Butterworth AS
et al.
Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.
,
4
Rehm J
Gmel Sr, GE
Gmel G
et al.
The relationship between different dimensions of alcohol use and the burden of disease-an update.
,
5
Millwood IY
Walters RG
Mei XW
et al.
Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China.
,
6
van de Luitgaarden IAT
van Oort S
Bouman EJ
et al.
Alcohol consumption in relation to cardiovascular diseases and mortality: a systematic review of Mendelian randomization studies.
Alcohol consumption at any level is associated with health loss from several diseases, including liver cirrhosis, breast cancer, and tuberculosis, as well as injuries.
7
Liu Y
Nguyen N
Colditz GA
Links between alcohol consumption and breast cancer: a look at the evidence.
,
8
Imtiaz S
Shield KD
Roerecke M
Samokhvalov AV
Lönnroth K
Rehm J
Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease.
,
9
Taylor B
Irving HM
Kanteres F
et al.
The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together.
,
10
Roerecke M
Vafaei A
Hasan OSM
et al.
Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis.
At the same time, some studies have found that consumption of small amounts of alcohol lowers the risk of cardiovascular diseases and type 2 diabetes.
11
Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers.
,
12
Pietraszek A
Gregersen S
Hermansen K
Alcohol and type 2 diabetes. A review.
,
13
Ding C
O’Neill D
Bell S
Stamatakis E
Britton A
Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women.
As a corollary, the amount of alcohol that minimises health loss is likely to depend on the distribution of underlying causes of disease burden in a given population. Since this distribution varies widely by geography, age, sex, and time, the level of alcohol consumption associated with the lowest risk to health would depend on the age structure and disease composition of that population.
14
Sherk A
Gilmore W
Churchill S
Lensvelt E
Stockwell T
Chikritzhs T
Implications of cardioprotective assumptions for national drinking guidelines and alcohol harm monitoring systems.
,
15
Sherk A
Thomas G
Churchill S
Stockwell T
Does drinking within low-risk guidelines prevent harm? Implications for high-income countries using the international model of alcohol harms and policies.
,
16
WHO Global status report on alcohol and health 2018.
Two quantities are crucially relevant when formulating effective, evidence-based guidelines and alcohol-control policies: the theoretical minimum risk exposure level (TMREL), which represents the level of consumption that minimises health loss from alcohol for a population, and the non-drinker equivalence (NDE) level, which measures the level of alcohol consumption at which the risk of health loss for a drinker is equivalent to that of a non-drinker. The majority of studies to date consider one or a small subset of health outcomes associated with alcohol consumption at a time, although several broader systematic meta-analyses have been done.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
,
4
Rehm J
Gmel Sr, GE
Gmel G
et al.
The relationship between different dimensions of alcohol use and the burden of disease-an update.
,
17
Corrao G
Bagnardi V
Zambon A
La Vecchia C
A meta-analysis of alcohol consumption and the risk of 15 diseases.
,
18
Xi B
Veeranki SP
Zhao M
Ma C
Yan Y
Mi J
Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults.
,
19
Alcohol consumption levels as compared with drinking habits in predicting all-cause mortality and cause-specific mortality in current drinkers.
Findings from these studies vary in their estimates of the TMREL. Several studies have found evidence of a J-shaped relationship between alcohol use and all-cause mortality.
3
Wood AM
Kaptoge S
Butterworth AS
et al.
Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.
,
18
Xi B
Veeranki SP
Zhao M
Ma C
Yan Y
Mi J
Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults.
,
20
Patra J
Buckley C
Kerr WC
Brennan A
Purshouse RC
Rehm J
Impact of body mass and alcohol consumption on all-cause and liver mortality in 240 000 adults in the United States.
However, others have reported that the all-cause or attributable cause burden weighted TMREL of alcohol is zero standard drinks per day.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
,
21
Habtemichael LH
Djekic D
Rosengren AR
et al.
Alcohol consumption in young men and risk of heart failure and all-cause mortality—a cohort study.
Uncertainty about the effect of alcohol on all-cause health loss results from differences in the relative disease composition between studies, conflicting studies on individual health outcomes, differences in study covariates and methods, estimation of drinking patterns, as well as issues relating to selection bias.
22
Fillmore KM
Stockwell T
Chikritzhs T
Bostrom A
Kerr W
Moderate alcohol use and reduced mortality risk: systematic error in prospective studies and new hypotheses.
,
23
Wallach JD
Serghiou S
Chu L
et al.
Evaluation of confounding in epidemiologic studies assessing alcohol consumption on the risk of ischemic heart disease.
Research in context
Evidence before this study
The risks of moderate alcohol use on health outcomes have been widely studied and debated for many years. Studies have considered the health impacts associated with alcohol consumption through a variety of approaches, ranging from exploring the effects on a single disease, to considering multiple health outcomes, to using all-cause mortality as an outcome. Several systematic reviews have also been published on this topic, and in recent years several publications have used Mendelian randomisation to explore the association between alcohol use and health outcomes. Overall, the findings have varied, which partly contributes to this topic being controversial and a subject of debate. Several studies have found evidence of a J-shaped relationship between alcohol use and all-cause mortality or burden; in other words, at low levels of consumption, alcohol lowers the risk of all-cause mortality, whereas above some threshold it increases the risk. However, other studies, including a publication by the GBD 2016 Alcohol Collaborators in The Lancet in 2018, have reported that the level of alcohol consumption that minimises health loss is zero standard drinks per day. The apparent contradiction in findings across existing studies highlights the significance of continuing to study this topic and updating the evidence base as more information becomes available. Importantly, few previous studies analysing the effects of alcohol consumption on all-cause mortality have considered how the relationship between alcohol use and health is contingent on background rates of disease. We did a systematic review of the literature in which we searched PubMed and previous published meta-analyses using search terms such as “alcohol” and “drinking behavior”, terms concerning study outcomes such as “risk”, “odds ratio”, and “hazard ratio”, and terms concerning the specific causes included in the study, such as “ischemic heart disease” or “tuberculosis”. We searched for studies published up to Dec 31, 2019; the search was limited to English language publications.
Added value of this study
In this systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, we estimated levels of alcohol consumption that minimise health loss using updated systematic reviews and meta-regressions, building on results from GBD 2016 and incorporating region-specific background rates of diseases and injuries within our assessment. To the best of our knowledge, this is the first study to consider the implications of background rates of disease on levels of alcohol consumption that minimise health loss. We updated the previously published systematic review and meta-regressions to consider all published studies through to December, 2019, reporting on the association between alcohol and the six alcohol-attributable health outcomes accounting for the highest number of global disability-adjusted life-years. We found insufficient evidence for an association between alcohol use and one of these outcomes and subsequently omitted it from further analysis. This analysis has yielded updated relationships on the relative risk of mortality for five causes, at various levels of alcohol consumption, which we combined with relative risk estimates from GBD 2016 for an additional 17 outcomes. We used this information, along with information on the burden of disease from these 22 diseases and injuries, to estimate the level of alcohol consumption that minimises health loss separately for each age group, sex, year, and region. In addition to estimating the level of consumption that is associated with minimising health loss, known as the theoretical minimum risk exposure level (TMREL), we also estimated the level of alcohol consumption at which the risk to health for a drinker is equivalent to that of a non-drinker—a quantity we refer to as the non-drinker equivalence.
Implications of all the available evidence
Our results are consistent with previous findings at the global level, and at the same time the more nuanced analysis done in this study strongly suggests that statements, guidelines, and recommendations on the optimal level of alcohol consumption need to take into consideration the background rates of diseases and injuries for each population. We provide clear evidence that the level of alcohol consumption that minimises health loss varies significantly across populations and remains zero or very close to zero for several population groups, particularly young adults. At the same time, small amounts of alcohol consumption are associated with improved health outcomes in populations that predominantly face a high burden of cardiovascular diseases, particularly older adults in many world regions. Given these findings, we recommend a modification of existing policy guidelines to focus on emphasising differential optimal consumption levels by age, rather than the current practice of recommending different consumption levels by sex. This study highlights the importance of prioritising interventions targeted at minimising alcohol consumption among young adults.
Importantly, no study to date has examined the variation in the theoretical minimum risk of alcohol consumption by geography, age, sex, and time, conditioned on background rates of disease. National dietary guidelines on low-risk drinking, such as those in the USA, UK, France, and Australia, base recommendations on studies of the risk of alcohol use on all-cause mortality and some cause-specific outcomes.
24
Dietary Guidelines Advisory Committee Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and Secretary of Health and Human Services.
,
25
UK Department of Health UK Chief Medical Officers’ Alcohol Guidelines Review. Summary of the proposed new guidelines.
,
26
Santé Publique France Alcool et santé: améliorer les connaissances et réduire les risques.
,
27
NHMRC Australian guidelines to reduce health risks from drinking alcohol.
This complicates interpretation of the risk of alcohol use on mortality, given three aspects of all-cause mortality. First, causal pathways between alcohol use and cause-specific outcomes can differ, creating multiple confounding structures that are not readily adjustable when embedded within models analysing the effects of alcohol use on all-cause mortality.
28
Stockwell T
Zhao J
Panwar S
Roemer A
Naimi T
Chikritzhs T
Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality.
Second, all-cause mortality includes non-causally related outcomes, further increasing the threat to internal validity for evidence produced from analysing the effects of alcohol use on all-cause mortality. Third, and most importantly for the present study, the composition of causes within all-cause mortality can differ substantially between populations, changing the proportional risk of mortality due to alcohol use across these populations.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
,
29
Why the relationship between level of alcohol-use and all-cause mortality cannot be addressed with meta-analyses of cohort studies.
In tandem, these features limit the applicability of determining minimum risk exposures on the basis of observational data on alcohol use and all-cause mortality.
In this study, we used the distribution of causes of disability-adjusted life-years (DALYs) in each population, along with alcohol consumption patterns from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, to estimate the TMREL and NDE for each region, age group, sex, and year from 1990 to 2020. Using these estimates, we quantified the proportion of the population consuming alcohol in amounts exceeding these thresholds by location, age, sex, and year, serving as a guide for targeting alcohol control efforts.
This manuscript was produced as part of the GBD Collaborator Network and in accordance with the GBD Protocol.
30
Institute for Health Metrics and Evaluation Protocol for the global burden of diseases, injuries, and risk factors study (GBD).
Methods
Overview
GBD is the most comprehensive effort to date to understand the changing health challenges around the world.
31
Murray CJL
Aravkin AY
Zheng P
et al.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
In the most recent revision, GBD 2020, estimates were produced for the mortality and health burden from 287 causes of death, 370 diseases and injuries, and 88 risk factors in 204 countries and territories by 5-year age groups and sex from 1990 to 2020. As part of GBD 2020, we estimated the TMREL and NDE of alcohol consumption for 21 regions by 5-year age group, sex, and year for individuals aged 15–95 years and older from 1990 to 2020 (Bryazka D, unpublished). Using the comparative risk assessment framework, we also quantified the population consuming alcohol in harmful amounts, by 5-year age group, country or territory, sex, and year. In the following sections, we provide an overview of our methods. This study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement.
32
Stevens GA
Alkema L
Black RE
et al.
Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.
Estimating dose–response relative risks
As part of GBD, a previous systematic literature review and meta-analysis was published in 2018 that included 592 cohort and case-control studies across 23 outcomes associated with alcohol use.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
These outcomes included ischaemic stroke, intracerebral haemorrhage, ischaemic heart disease, hypertensive heart disease, atrial fibrillation and flutter, lip and oral cavity cancer, nasopharynx cancer, other pharynx cancer, oesophageal cancer, larynx cancer, colon and rectum cancer, breast cancer, liver cancer, type 2 diabetes, cirrhosis and other chronic diseases of the liver, pancreatitis, idiopathic epilepsy, tuberculosis, lower respiratory infection, transport injuries, unintentional injuries, self-harm, and interpersonal violence. As part of this previous meta-analysis, dose–response relative risk curves for each of these outcomes were estimated through use of a Bayesian meta-regression tool, DisMod ODE.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
,
33
An integrative metaregression framework for descriptive epidemiology.
For GBD 2020, we updated this review for the six alcohol-attributable outcomes that accounted for the greatest number of global DALYs: ischaemic heart disease, ischaemic stroke, intracerebral haemorrhage, type 2 diabetes, tuberculosis, and lower respiratory infection. Through the update, we included 71 additional studies. After evaluating all available evidence, we found insufficient evidence for a relationship between alcohol use and lower respiratory infection. Based on these results, we removed this as a risk–outcome pair for GBD 2020 and from this analysis, resulting in 22 remaining relative risk curves. Further details of the systematic review, including search strings, inclusion criteria, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagrams, and relative risk curves are provided in appendix 1 (pp 18–47).
Using the updated data for these five outcomes, we revised the relative risk curves associated with each outcome using the meta-regression Bayesian, regularised, trimmed (MR-BRT) meta-regression tool. MR-BRT is a tool that is well suited to the complex task of estimating the dose–response risk association between alcohol and health because it is does not enforce a log-linear functional form, instead parameterising the log relative risk as a B-spline (Zheng P, Institute for Health Metrics and Evaluation, personal communication). It uses an ensemble approach for knot selection of splines based on level of exposure, and incorporates unexplained between-study heterogeneity into the uncertainty of the relative risk estimates. To adjust for aspects of study design that contribute to bias in relative risks, we included covariates for study reference group, adjustment for sick quitter bias, sex, age, population representativeness, outcome reporting method, exposure measurement timing, geographical representativeness, outcome measure (incidence versus mortality), and adjustment for confounders in risk estimation. The MR-BRT tool uses a generalised Lasso approach to select the most relevant bias covariates to adjust for in the final model. A full list of the confounders tested and included in each of these five models is summarised on in appendix 1 (p 15). Consistent with the previous systematic review,
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
we utilised a reference group of non-drinkers. We estimated parameter uncertainty using 1000 draws from the posterior distribution, sampled at 1 g intervals of pure alcohol consumption between 0 g and 100 g per day. Further details of the meta-regression approach are available in appendix 1 (pp 14–16).
Estimating TMREL and NDE
The TMREL and NDE are based on aggregate, burden-weighted relative risk curves across health outcomes associated with alcohol use. Burden was quantified with DALY rates for each region, age, sex, and year obtained from GBD 2020 (Bryazka D, unpublished). DALYs are the sum of years of life lost (capturing the effect of premature mortality) and years lived with disability (capturing the effect of morbidity). For each region, age, sex, and year, we produced all-attributable cause relative risk curves as a weighted average of cause-specific relative risk curves, with weights based on the share of the overall DALY rates from each cause. The step-by-step process and formula for computing the weighted all-attributable cause curves are provided in appendix 1 (p 16). Using these estimates, we computed the TMREL and NDE by region, age, sex, and year. Uncertainty in the relative risk curve, based on 1000 draws of each cause-specific relative risk curve and 1000 draws of DALY rates used for weighting, was propagated to the estimates of TMREL and NDE. All estimates are presented to three significant figures. An example of a weighted all-attributable cause alcohol relative risk curve, for all 22 alcohol associated causes combined, is shown in figure 1.
Figure 1Exemplifying a weighted all-attributable cause alcohol relative risk curve
Show full caption
Points mark the theoretical minimum risk exposure level and non-drinker equivalence level. The shaded areas denote consumption levels with a lower risk (green) and greater risk (purple), compared to no consumption. The solid line indicates the mean aggregate relative risk estimate, whereas the shaded area reflects the 95% uncertainty interval of the aggregate relative risk estimate. One standard drink is equivalent to 10 g of pure ethanol.
Since alcohol use contributes to the DALY rates that are used as weighting factors when constructing the TMREL and NDE, we did a sensitivity analysis that utilised risk-deleted DALY rates as alternative weights. We generated risk-deleted DALY rates by multiplying the DALY rate of each cause by the complement of the cause-specific population-attributable fraction due to alcohol (Bryazka D, unpublished). Additionally, our weighted attributable-cause relative risk curves were based on only 22 of 24 health outcomes since no relative risk curves could be computed for alcohol use disorder or alcoholic cardiomyopathy due to the paucity of studies on dose–response relative risks. To assess whether inclusion of these two outcomes could potentially affect the TMREL and NDE levels, we did a second sensitivity analysis in which we generated conservative hypothetical relative risk functions for alcohol use disorder and alcoholic cardiomyopathy and re-computed TMREL and NDE levels that reflect all 24 alcohol-associated outcomes. Additional details of the sensitivity analyses are presented in the appendix (p 17).
Estimating prevalence of alcohol use and alcohol consumption
To estimate the proportion of the population consuming alcohol in excess of the NDE, estimates of alcohol consumption in units of grams of pure ethanol consumed per day, on average, by current drinkers for 204 countries and territories, by age, sex, and year, were obtained from GBD 2020 (Bryazka D, unpublished). Briefly, this process combines supply-side data, household survey data, and administrative data, which allows us to adjust for under-reporting due to self-report bias in surveys, account for unrecorded alcohol consumption, and adjust for consumption among tourists. Current drinkers were defined as individuals who had consumed at least one standard drink in the past 12 months. To facilitate interpretation, we report estimates in terms of standard drinks per day, where one standard drink is defined as 10 g of pure ethanol, consistent with previous GBD publications (Bryazka D, unpublished).
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Further details on estimation of the prevalence of alcohol use and alcohol consumption have been published previously.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Role of the funding source
The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Results
The distribution of DALYs arising from outcomes associated with alcohol by GBD super-region, age, and sex for 2020 are shown in figure 2. The TMREL and NDE by region, age, and sex for 2020 are shown in figure 3. Overall, we found that the TMREL remained low regardless of geography, age, sex, or time, varying between 0 (95% UI 0–0) and 1·87 (0·500–3·30) standard drinks per day. As a result of the differences in the cause distributions across world regions, both the TMREL and NDE varied by region. The TMREL and NDE did not vary significantly by sex or year. There was significant variation in the TMREL and the NDE across ages, with younger age groups having much lower TMREL and NDE levels than older adults. In 2020, the TMREL varied between 0 (0–0) and 0·603 (0·400–1·00) standard drinks per day among individuals aged 15–39 years and between 0·114 (0–0·403) and 1·87 (0·500–3·30) standard drinks per day among individuals aged 40 years and older. The NDE varied between 0·002 (0–0) and 1·75 (0·698–4·30) standard drinks per day among individuals aged 15–39 years and between 0·193 (0–0·900) and 6·94 (3·40–8·30) standard drinks per day among individuals aged 40 years and older. This result was mainly driven by differences in the major causes of death and disease burden across ages, as seen in figure 2. Overall, we did not observe any significant differences in the TMREL and NDE between males and females in any age group. In all super-regions, among individuals aged 15–39 years, injuries accounted for the majority of alcohol-related DALYs in 2020. Globally, in this age range, all injuries accounted for 66·3% (95% UI 65·1–67·5) of alcohol-related DALYs for males and 47·9% (46·0–49·8) of alcohol-related DALYs for females; transport injuries comprised 25·9% (25·0–27·0) of alcohol-related DALYs among males and 12·7% (12·0–13·4) among females, self-harm comprised 11·7% (10·1–13·3) of alcohol-related DALYs among males and 12·3% (10·8–13·8) among females, and interpersonal violence comprised 12·4% (11·8–13·0) of alcohol-related DALYs among males and 6·70% (5·90–7·69) among females. The TMREL among males aged 15–39 years in 2020 was 0·136 (0–0·400) standard drinks per day. Among females aged 15–39 years in 2020, the TMREL was 0·273 (0–0·500) standard drinks per day. The NDE was 0·249 (0–1·00) standard drinks per day among males and 0·546 (0–1·30) standard drinks per day among females. The differences in the TMREL and the NDE between females and males were not statistically significant.
Figure 2Relative proportions of DALYs for causes associated with alcohol use, by GBD super-region, age group, and sex, in 2020
Show full caption
The proportions represent the weights associated with each cause-specific relative risk curve when constructing each all-cause relative risk curve. The green shades signify causes with a lower risk at low levels of consumption, compared to no consumption. The red and purple shades signify causes with an entirely harmful effect at all levels of consumption. The black line separates causes for which moderate alcohol use lowers risk from causes with an entirely harmful effect. Diabetes includes only type 2 diabetes. Cancers include lip and oral cavity cancer, nasopharynx cancer, other pharynx cancer, oesophageal cancer, larynx cancer, colon and rectum cancer, breast cancer, and liver cancer. Cirrhosis includes cirrhosis and other chronic diseases of the liver. Infectious disease includes tuberculosis. Injuries includes transport injuries, unintentional injuries, self-harm, and interpersonal violence. Other causes include pancreatitis, idiopathic epilepsy, hypertensive heart disease, and atrial fibrillation and flutter. DALY=disability-adjusted life-year.
Figure 3Mean theoretical minimum risk exposure levels (A) and non-drinker equivalence levels (B), in units of standard drinks per day, by region, age group, and sex, in 2020
In individuals aged 40–64 years, the health outcomes contributing to the alcohol-related burden shifted to chronic health conditions, including cardiovascular disease and cancer. In this population, ischaemic heart disease comprised 24·1% (95% UI 23·0–25·3) of alcohol-related DALYs among males and 19·5% (18·0–21·0) among females, and intracerebral haemorrhage comprised 10·3% (9·61–10·9) of alcohol-related DALYs among males and 11·7% (10·7–12·8) among females, whereas injuries, such as transport or unintentional injuries, remained significant sources of burden, comprising 23·0% (21·7–24·4) of alcohol-related DALYs among males and 16·7% (15·3–18·3) of alcohol-related DALYs among females. Health outcomes for which moderate alcohol use is associated with a lower risk constituted an increasing portion of the cause distribution in this age group, resulting in a higher TMREL and NDE than in individuals aged 15–39 years. The global TMREL among individuals aged 40–64 years in 2020 was 0·527 (0·400–1·00) standard drinks per day among males and 0·562 (0·400–0·800) standard drinks per day among females. The global NDE in 2020 was 1·69 (0·800–3·20) standard drinks per day among males and 1·82 (1·00–3·10) standard drinks per day among females. As in the younger age group, the differences in the TMREL and the NDE between females and males aged 40–64 years were not statistically significant.
Among individuals aged 65 years and older, the major causes of disease burden were cardiovascular diseases. In 2020, ischaemic heart disease was responsible for 31·5% (95% UI 30·3–32·7) of all alcohol-related DALYs among males and 29·7% (28·2–31·2) among females, intracerebral haemorrhage was responsible for 11·6% (10·9–12·4) of all alcohol-related DALYs among males and 10·9% (10·1–11·8) among females, and ischaemic stroke was responsible for 14·2% (13·5–14·9) of all alcohol-related DALYs among males and 16·0% (15·2–16·7) among females. As a result, in this population the TMREL was higher than in the younger age groups and was estimated to be 0·636 (0·500–1·00) standard drinks per day among males and 0·656 (0·500–1·00) standard drinks per day among females, whereas the NDE was estimated to be 3·19 (1·50–5·20) standard drinks per day among males and 3·51 (1·70–5·50) standard drinks per day among females. The differences in the TMREL and the NDE between males and females aged 65 years and older were not significant.
The distribution of the causes of disease burden for a given age group varied substantially across regions, resulting in regional variations in TMRELs and NDEs, particularly in individuals aged 40 years and older. For example, among individuals aged 55–59 years in north Africa and the Middle East, 30·7% (95% UI 27·3–34·6) of alcohol-related DALYs were due to cardiovascular disease, 12·6% (11·0–14·3) were due to cancers, and 0·37% (0·27–0·55) were due to tuberculosis. By contrast, in this same age group in central sub-Saharan Africa, 20·1% (17·2–23·8) of alcohol-related DALYs were due to cardiovascular disease, 9·80% (8·31–11·7) were due to cancers, and 10·1% (6·03–14·1) were due to tuberculosis. As a result, the TMRELs for this age group were 0·876 (0·500–2·00) standard drinks per day in north Africa and the Middle East and 0·596 (0·300–2·00) standard drinks per day in central sub-Saharan Africa. The NDEs also varied, with an NDE of 3·89 (1·50–5·90) standard drinks per day in north Africa and the Middle East and 1·53 (0·600–4·70) standard drinks per day in central sub-Saharan Africa. The TMRELs and NDEs for each region by age and sex for 1990, 2000, 2010, and 2020 are shown in appendix 2 (pp 3–31).
The distribution of the major causes of DALYs varied slightly between sexes, with injuries making up a larger share of distributions for males than for females. This resulted in mean TMRELs and NDEs that were larger among females compared to males of the same region, age, and year. When taking uncertainty into account, these differences were not significant. However, a larger proportion of males compared to females consume alcohol, and their average level of consumption is also significantly higher. As a result, young males stood out as the group with the highest level of harmful alcohol consumption (figure 4).
Figure 4Proportion of the population consuming harmful amounts of alcohol, defined as consumption in excess of the mean non-drinker equivalence level, by sex and age group, in 2020
Globally, 1·03 billion (95% UI 0·851–1·19) males (35·1% [29·1–40·7] of the male population aged ≥15 years) and 312 million (199–432) females (10·5% [6·72–14·6] of the female population aged ≥15 years) consumed alcohol in amounts exceeding the NDE in 2020; the number and proportion of people consuming alcohol in excess of the NDE, along with the percentage change since 1990 in the proportion of people consuming alcohol in excess of the NDE, by age group, sex, and location is reported in table 1. Since 1990, the global proportion of drinkers consuming alcohol in excess of the NDE has not changed significantly. Although the proportion of the population consuming harmful amounts of alcohol stayed at the same level over the past three decades, the number of people consuming harmful amounts of alcohol increased from 983 million (718–1190) in 1990 to 1·34 billion (1·06–1·62) in 2020, driven by population growth. Overall, among individuals consuming harmful amounts of alcohol in 2020, 76·9% (73·0–81·3) were male.
Table 1Number and proportion of population consuming in excess of the non-drinker equivalence, and percentage change since 1990 by country, age group, and sex, for 2020
Data in parentheses are 95% uncertainty intervals. All data are presented to three significant figures.
Harmful consumption was predominantly concentrated among individuals aged 15–39 years, who had the lowest TMRELs and NDEs (figure 4). Of the 1·34 billion (95% UI 1·06–1·62) individuals consuming alcohol in excess of the NDE in 2020, 59·1% (54·3–65·4) were aged 15–39 years. Of these, 75·5% (70·3–80·7) were male (595 million [489–658]). Australasia (83·2% [71·1–86·9]), western Europe (79·3% [67·1–84·5]), and central Europe (78·3% [68·1–83·5]) had the highest percentages of males aged 15–39 years consuming harmful amounts of alcohol (table 1). Among females in the same age group, Australasia (77·7% [65·3–82·0]), western Europe (64·3% [44·3–73·6]), and southern Latin America (59·0% [42·0–67·8]) had the highest rates of harmful alcohol consumption. By contrast, only 6·55% (4·79–8·43) of individuals consuming alcohol in excess of the NDE globally were older than 65 years (appendix 2 pp 54–83). Between 1990 and 2019, 14 countries had significant increases in the prevalence of harmful alcohol consumption, 55 countries had significant decreases, and in 135 countries the prevalence did not change significantly (table 1).
Importantly, these results were not sensitive to our approach to constructing the weighted attributable-cause relative risk curves that are used to calculate the TMREL and NDE. The TMREL and NDE for each of the sensitivity scenarios are shown in appendix 2 (pp 39–41). By including additional risk to health from alcohol use disorders and alcoholic cardiomyopathy, which are 100% attributable to alcohol use, the TMREL decreased by an average of 0·058 (95% UI 0·00–0·30) standard drinks per day in scenario A (for alcohol use disorder and alcoholic cardiomyopathy, relative risks linearly increase with consumption to a maximum relative risk of three at four standard drinks per day, at which point they plateau through ten standard drinks), 0·092 (0·00–0·50) standard drinks per day in scenario B (relative risks linearly increase with consumption to a maximum of five, at four standard drinks per day for alcohol use disorder and alcoholic cardiomyopathy), and 0·146 (0·00–0·60) standard drinks per day in scenario C (relative risks linearly increase with consumption to a maximum of 10, at four standard drinks per day for alcohol use disorder and alcoholic cardiomyopathy), whereas the NDE decreased by an average of 0·188 (0·00–0·90) standard drinks per day in scenario A, 0·310 (0·00–1·30) standard drinks per day in scenario B, and 0·508 (0·00–2·10) standard drinks per day in scenario C. The greatest differences were observed in males in eastern Europe, where alcohol use disorder is especially prevalent, as well as in individuals aged 30–54 years, among whom DALY rates from alcohol use disorder are the greatest (appendix 2 pp 39–41; Bryazka D, unpublished).
Our results were not sensitive to the changes in relative risk estimates for the five updated outcomes, compared to the entire set of relative risk estimates published in GBD 2016 (appendix 2 pp 43–53).
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
The global, age-standardised, both-sexes TMREL based on the full set of GBD 2016 relative risk estimates and GBD 2020 DALY rates was 0·534 (95% UI 0·00–1·00) standard drinks per day, compared to 0·511 (0·400–0·700) standard drinks per day based on the GBD 2020 relative risk estimates and GBD 2020 DALY rates, whereas the previously published global, age-standardised, both-sexes TMREL was 0·00 (0·00–0·80) standard drinks per day in 2016 based on GBD 2016 relative risk estimates and GBD 2016 DALY rates (table 2).
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Table 2Global, age-standardised, both-sexes theoretical minimum risk exposure level and non-drinker equivalence estimates based on various iterations of GBD estimates
Data in parentheses are 95% uncertainty intervals. Data are reported to three significant figures. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. DALY=disability-adjusted life-year. NA=not applicable.
Discussion
We show that the estimation of the health effects associated with alcohol use requires consideration of both the relationship between alcohol consumption and disease outcomes, and the observed disease rates in each population. We found that the population-level health risks associated with low levels of alcohol consumption varied across regions and were greater for younger populations than for older populations. Although we did not find significant differences in the risks of ill health by sex or by year, we did find that males made up 76·9% (95% UI 73·0–81·3) of the population consuming harmful amounts of alcohol in 2020. Notably, 1·03 billion (0·851–1·19) males and 312 million (199–432) females drank harmful amounts of alcohol in excess of the NDE in 2020. Harmful use of alcohol was particularly concentrated in males aged 15–39 years, primarily in Australasia, western Europe, and central Europe. These findings highlight the need for tailored guidelines that discourage alcohol consumption among young people, as well as alcohol control policies and interventions that are targeted especially towards young males.
Understanding the variation in the level of alcohol consumption that minimises the risk of ill health for populations can aid in setting effective consumption guidelines, supporting alcohol control policies, monitoring progress in reducing harmful alcohol use, and designing public health risk messaging.
3
Wood AM
Kaptoge S
Butterworth AS
et al.
Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.
,
16
WHO Global status report on alcohol and health 2018.
,
34
Rehm J
Crépault J-F
Wettlaufer A
Manthey J
Shield K
What is the best indicator of the harmful use of alcohol? A narrative review.
,
35
Chisholm D
Moro D
Bertram M
et al.
Are the “best buys” for alcohol control still valid? An update on the comparative cost-effectiveness of alcohol control strategies at the global level.
,
36
Brand DA
Saisana M
Rynn LA
Pennoni F
Lowenfels AB
Comparative analysis of alcohol control policies in 30 countries.
,
37
Ferreira-Borges C
Esser MB
Dias S
Babor T
Parry CDH
Alcohol control policies in 46 African countries: opportunities for improvement.
,
38
Burton R
Henn C
Lavoie D
et al.
A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective.
,
39
Howard SJ
Gordon R
Jones SC
Australian alcohol policy 2001–2013 and implications for public health.
,
40
Neufeld M
Ferreira-Borges C
Gil A
Manthey J
Rehm J
Alcohol policy has saved lives in the Russian Federation.
Most alcohol consumption guidelines for the general population combine recommendations to avoid alcohol use with the definition of lower-risk alcohol consumption thresholds, which tend to vary between 8 g and 42 g of alcohol per day for females, and between 10 g and 52 g of alcohol per day for males.
41
Governmental standard drink definitions and low-risk alcohol consumption guidelines in 37 countries.
Generally, thresholds are one standard drink greater for men than for women, and some lower-risk thresholds are framed in units of weekly consumption that come with a recommendation to avoid alcohol entirely for several days of the week.
In our analysis, the population-specific TMRELs ranged between 0 (95% UI 0–0) and 0·603 (0·400–1·00) standard drinks per day among individuals aged 15–39 years across world regions, and the NDEs ranged between 0 (0–0) and 1·75 (0·698–4·30) standard drinks per day among individuals aged 15–39 years across world regions in 2020. Even if a conservative approach is taken and the lower bound of the uncertainty interval is used to set policy recommendations rather than the mean, this implies that the recommended level of alcohol consumption in existing low consumption recommendations is too high for younger populations. Our estimates, based on currently available evidence, also do not support low consumption guidelines that differ by sex. Given the known difficulties associated with translating evidence into changes in consumer behaviour, clear messaging around updates to drinking guidelines will be crucial to ensure the full improvements are realised.
One key distinction between this study and existing recommendations on alcohol consumption is that our estimates focus on minimising health loss across all alcohol-attributable outcomes in a population. Thresholds exist for different purposes; in terms of injury prevention, several countries have moved to a zero-tolerance threshold that is consistent with evidence of the entirely harmful effect of alcohol consumption on injuries. Furthermore, individual-level as opposed to population-level risk minimisation will depend on individual-level factors, including comorbid conditions and the use of pharmaceuticals, which are more prevalent among older populations. Our results for older adults should be interpreted in the context of their additional uncertainty.
42
Moore AA
Whiteman EJ
Ward KT
Risks of combined alcohol/medication use in older adults.
,
43
Ryan M
Merrick EL
Hodgkin D
et al.
Drinking patterns of older adults with chronic medical conditions.
Approaches to minimising individual-level risk are beyond the scope of this study and need to take into consideration not only alcohol use and specific health outcomes, but also interactions between environmental, genetic, and behavioural factors, as well as the societal and health system context of individuals.
Broadly, this analysis highlights the need to consider the existing prevalence of diseases and injuries for specific populations when determining the total harms posed by a risk factor. Although the biological effects of alcohol are unlikely to change across populations, except in the case of specific genetic interactions such as variants in alcohol dehydrogenase, disease rates vary substantially across regions, age, sex, and time.
44
The genetics of alcohol metabolism: role of alcohol dehydrogenase and aldehyde dehydrogenase variants.
For example, alcohol use poses a greater risk to population health in areas with a high prevalence of tuberculosis than in areas with low prevalence. Although this consideration is perhaps most important for setting effective policy recommendations for risks with both harmful and protective relationships with disease, such as alcohol use and red meat consumption, it has implications for all risk factors. As countries navigate the epidemiological transition and their background rates of disease evolve from infectious diseases and injuries to non-communicable diseases, policy recommendations will need to evolve as well.
It is important to consider our findings in the context of those published by the GBD 2016 Alcohol Collaborators in 2018.
1
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Compared to that report, the analysis presented here includes three major changes: we updated five of the relative risk curves; we weighted the relative risk curves using DALY rates estimated as part of GBD 2020 rather than GBD 2016; and we estimated the TMREL separately for each region, age, sex, and year. Although the GBD 2016 Alcohol Collaborators found that the global, age-standardised, both-sexes TMREL was zero standard drinks per day, computing the global TMREL with the first two of these updates, we found that the global TMREL was still quite low, at 0·511 (95% UI 0·400–0·700) standard drinks per day. Re-estimating the TMREL with updated 2020 DALY weights but the former relative risk curves suggests a global TMREL of 0·534 (0–1·00) standard drinks per day. Region-specific, age-specific, and sex-specific differences between these approaches are summarised in appendix 2 (pp 45–55). Importantly, the differences across TMREL by region and age hold even with the relative risk curves estimated in 2016. The more nuanced analysis in the present study, where we explored the risks to ill health by age and region, represents a major step forward in our understanding of how to minimise health loss due to alcohol consumption across the world.
One challenge associated with using observational studies to measure the causal effect of alcohol consumption on health is the potential for the introduction of various forms of bias, including reverse causation, selection bias, and residual confounding. Mendelian randomisation is a method that attempts to mitigate bias by using genetic variation as a proxy for risk exposure.
5
Millwood IY
Walters RG
Mei XW
et al.
Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China.
,
6
van de Luitgaarden IAT
van Oort S
Bouman EJ
et al.
Alcohol consumption in relation to cardiovascular diseases and mortality: a systematic review of Mendelian randomization studies.
Although a small number of Mendelian randomisation studies have been done on alcohol use to date, a recent meta-analysis reported that those done on cardiovascular disease and diabetes had varied in their findings, with 67% of studies on cardiovascular disease and 75% of studies on diabetes reporting a null association with alcohol.
6
van de Luitgaarden IAT
van Oort S
Bouman EJ
et al.
Alcohol consumption in relation to cardiovascular diseases and mortality: a systematic review of Mendelian randomization studies.
However, only five of 24 studies examined whether alcohol had a non-linear relationship with these health outcomes. As additional Mendelian randomisation studies from diverse populations are increasingly published, they have the potential to improve the evidence base, and estimates should be regularly revised to reflect new evidence.
This study had various limitations that should be taken into account when interpreting the findings. First, we did not incorporate patterns of drinking, and therefore did not distinguish between individuals who infrequently engage in heavy episodic drinking and those who consume the same amount of alcohol over several days.
45
Chrystoja BR
Rehm J
Manthey J
Probst C
Wettlaufer A
Shield KD
A systematic comparison of the global comparative risk assessments for alcohol.
Manthey and colleagues
46
Manthey J
Shield KD
Rylett M
Hasan OSM
Probst C
Rehm J
Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study.
estimated that in 2018, 20% of adults engaged in heavy episodic drinking—the consumption of 60 g or more of alcohol on a single occasion—over the past month. Second, due to a paucity of studies reporting a dose–response relationship between the risk of alcohol use and incidence of and mortality from alcohol use disorders, the burden of alcohol use disorders was not included in the TMREL calculation. As shown by the sensitivity analyses, which used conservative hypothetical relative risk curves for alcohol use disorder and alcoholic cardiomyopathy, inclusion of these diseases results in slightly lower estimates of TMREL and NDE, particularly among males in eastern Europe and in individuals aged 30–54 years globally. The decreases in the TMREL and NDE in the sensitivity scenarios were found to be quite small, since the risk of these two conditions is likely to be concentrated at higher levels of consumption and in younger adults, resulting in minimal impact on estimates of the TMREL and NDE. Third, although we attempted to adjust for the impacts of confounding and bias in our meta-regressions, it is possible that relative risk estimates did not account and adjust for all sources of bias, including measurement bias and selection bias, as well as the potential impacts of reverse causality. Fourth, studies reporting the relative risks of alcohol use were based on self-reported alcohol consumption, which is subject to social desirability and recall biases. Fifth, we did not consider differences in risk by type or quality of alcohol. Sixth, the weights used within the weighted alcohol-attributable relative risk curve used DALY estimates that could be due to alcohol use. However, this limitation would only have had a marginal effect on estimates of the TMREL and NDE. Seventh, our estimates of the proportion of the population consuming alcohol in excess of the NDE were derived from alcohol consumption data collected through 2019. Because of delays in routine data collection on risk factors caused by the COVID-19 pandemic, we forecasted our estimates to obtain a time series through 2020. As a result, the estimates do not reflect changes in consumption patterns associated with the pandemic.
47
Grossman ER
Benjamin-Neelon SE
Sonnenschein S
Alcohol consumption during the COVID-19 pandemic: a cross-sectional survey of US adults.
Last, our results did not include health conditions with burgeoning evidence indicating a relationship with alcohol use, such as major depressive disorder, generalised anxiety disorder, or dementia, given the current scarcity of sufficient evidence to support a meta-analysis and the potential for reverse causality. Inclusions of these outcomes would possibly reduce estimates of the TMREL and NDE.
In conclusion, the relationship between moderate alcohol use and health is complex and has raised a great deal of controversy in the scientific literature. Given that the available evidence suggests that low levels of alcohol consumption are associated with a lower risk of some disease outcomes and an increased risk of others, alcohol consumption recommendations should take into account the full epidemiological profile that includes the background rates of disease within populations. The findings of this study support the development of tailored guidelines and recommendations on alcohol consumption by age and across regions and highlight that existing low consumption thresholds are too high for younger populations in all regions. Additionally, our results suggest that guidelines should not incorporate sex-specific recommendations, given the absence of variation in TMREL and NDE by sex across geographies and locations. Finally, recognising that the majority of the world’s population consuming harmful amounts of alcohol are young adults and predominantly young males, in order to minimise health loss due to alcohol consumption it is important to prioritise interventions targeted at these demographic groups.
GBD 2020 Alcohol Collaborators
Dana Bryazka, Marissa B Reitsma, Max G Griswold, Kalkidan Hassen Abate, Cristiana Abbafati, Mohsen Abbasi-Kangevari, Zeinab Abbasi-Kangevari, Amir Abdoli, Mohammad Abdollahi, Abu Yousuf Md Abdullah, E S Abhilash, Eman Abu-Gharbieh, Juan Manuel Acuna, Giovanni Addolorato, Oladimeji M Adebayo, Victor Adekanmbi, Kishor Adhikari, Sangeet Adhikari, Qorinah Estiningtyas Sakilah Adnani, Saira Afzal, Wubetu Yimam Agegnehu, Manik Aggarwal, Bright Opoku Ahinkorah, Araz Ramazan Ahmad, Sajjad Ahmad, Tauseef Ahmad, Ali Ahmadi, Sepideh Ahmadi, Haroon Ahmed, Tarik Ahmed Rashid, Chisom Joyqueenet Akunna, Hanadi Al Hamad, Md Zakiul Alam, Dejene Tsegaye Alem, Kefyalew Addis Alene, Yousef Alimohamadi, Atiyeh Alizadeh, Kasim Allel, Jordi Alonso, Saba Alvand, Nelson Alvis-Guzman, Firehiwot Amare, Edward Kwabena Ameyaw, Sohrab Amiri, Robert Ancuceanu, Jason A Anderson, Catalina Liliana Andrei, Tudorel Andrei, Jalal Arabloo, Muhammad Arshad, Anton A Artamonov, Zahra Aryan, Malke Asaad, Mulusew A Asemahagn, Thomas Astell-Burt, Seyyed Shamsadin Athari, Desta Debalkie Atnafu, Prince Atorkey, Alok Atreya, Floriane Ausloos, Marcel Ausloos, Getinet Ayano, Martin Amogre Ayanore, Olatunde O Ayinde, Jose L Ayuso-Mateos, Sina Azadnajafabad, Melkalem Mamuye Azanaw, Mohammadreza Azangou-Khyavy, Amirhossein Azari Jafari, Ahmed Y Azzam, Ashish D Badiye, Nasser Bagheri, Sara Bagherieh, Mohan Bairwa, Shankar M Bakkannavar, Ravleen Kaur Bakshi, Awraris Hailu Balchut/Bilchut, Tilxrnighausen, Fabio Barra, Amadou Barrow, Pritish Baskaran, Luis Belo, Derrick A Bennett, Isabela M Bensenor, Akshaya Srikanth Bhagavathula, Neeraj Bhala, Ashish Bhalla, Nikha Bhardwaj, Pankaj Bhardwaj, Sonu Bhaskar, Krittika Bhattacharyya, Vijayalakshmi S Bhojaraja, Bagas Suryo Bintoro, Elena A Elena Blokhina, Belay Boda Abule Bodicha, Archith Boloor, Cristina Bosetti, Dejana Braithwaite, Hermann Brenner, Nikolay Ivanovich Briko, Andre R Brunoni, Zahid A Butt, Chao Cao, Yin Cao, Rosario Cárdenas, Andre F Carvalho, Márcia Carvalho, Joao Mauricio Castaldelli-Maia, Giulio Castelpietra, Luis F S Castro-de-Araujo, Maria Sofia Cattaruzza, Promit Ananyo Chakraborty, Jaykaran Charan, Vijay Kumar Chattu, Akhilanand Chaurasia, Nicolas Cherbuin, Dinh-Toi Chu, Nandita Chudal, Sheng-Chia Chung, Chuchu Churko, Liliana G Ciobanu, Massimo Cirillo, Rafael M Claro, Simona Costanzo, Richard G Cowden, Michael H Criqui, Natália Cruz-Martins, Garland T Culbreth, Berihun Assefa Dachew, Omid Dadras, Xiaochen Dai, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Beniam Darge Daniel, Anna Danielewicz, Jiregna Darega Gela, Kairat Davletov, Jacyra Azevedo Paiva de Araujo, Antonio Reis de Sá-Junior, Sisay Abebe Debela, Azizallah Dehghan, Andreas K Demetriades, Meseret Derbew Molla, Rupak Desai, Abebaw Alemayehu Desta, Diana Dias da Silva, Daniel Diaz, Lankamo Ena Digesa, Mengistie Diress, Milad Dodangeh, Deepa Dongarwar, Fariba Dorostkar, Haneil Larson Dsouza, Bereket Duko, Bruce B Duncan, Kristina Edvardsson, Michael Ekholuenetale, Frank J Elgar, Muhammed Elhadi, Mohamed A Elmonem, Aman Yesuf Endries, Sharareh Eskandarieh, Azin Etemadimanesh, Adeniyi Francis Fagbamigbe, Ildar Ravisovich Fakhradiyev, Fatemeh Farahmand, Carla Sofia e Sá Farinha, Andre Faro, Farshad Farzadfar, Ali Fatehizadeh, Nelsensius Klau Fauk, Valery L Feigin, Rachel Feldman, Xiaoqi Feng, Zinabu Fentaw, Simone Ferrero, Lorenzo Ferro Desideri, Irina Filip, Florian Fischer, Joel Msafiri Francis, Richard Charles Franklin, Peter Andras Gaal, Mohamed M Gad, Silvano Gallus, Fabio Galvano, Balasankar Ganesan, Tushar Garg, Mesfin Gebrehiwot Damtew Gebrehiwot, Teferi Gebru Gebremeskel, Mathewos Alemu Gebremichael, Tadele Regasa Gemechu, Lemma Getacher, Motuma Erena Getachew, Abera Getachew Obsa, Asmare Getie, Amir Ghaderi, Mansour Ghafourifard, Alireza Ghajar, Seyyed-Hadi Ghamari, Lilian A Ghandour, Mohammad Ghasemi Nour, Ahmad Ghashghaee, Sherief Ghozy, Franklin N Glozah, Ekaterina Vladimirovna Glushkova, Justyna Godos, Amit Goel, Salime Goharinezhad, Mahaveer Golechha, Pouya Goleij, Mohamad Golitaleb, Felix Greaves, Michal Grivna, Giuseppe Grosso, Temesgen Worku Gudayu, Bhawna Gupta, Rajeev Gupta, Sapna Gupta, Veer Bala Gupta, Vivek Kumar Gupta, Nima Hafezi-Nejad, Arvin Haj-Mirzaian, Brian J Hall, Rabih Halwani, Tiilahun Beyene Handiso, Graeme J Hankey, Sanam Hariri, Josep Maria Haro, Ahmed I Hasaballah, Hossein Hassanian-Moghaddam, Simon I Hay, Khezar Hayat, Golnaz Heidari, Mohammad Heidari, Delia Hendrie, Claudiu Herteliu, Demisu Zenbaba Heyi, Kamal Hezam, Mbuzeleni Mbuzeleni Hlongwa, Ramesh Holla, Md Mahbub Hossain, Sahadat Hossain, Seyed Kianoosh Hosseini, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Guoqing Hu, Junjie Huang, Salman Hussain, Segun Emmanuel Ibitoye, Irena M Ilic, Milena D Ilic, Mustapha Immurana, Lalu Muhammad Irham, M Mofizul Islam, Rakibul M Islam, Sheikh Mohammed Shariful Islam, Hiroyasu Iso, Ramaiah Itumalla, Masao Iwagami, Roxana Jabbarinejad, Louis Jacob, Mihajlo Jakovljevic, Zahra Jamalpoor, Elham Jamshidi, Sathish Kumar Jayapal, Umesh Umesh Jayarajah, Ranil Jayawardena, Rime Jebai, Seyed Ali Jeddi, Alelign Tasew Jema, Ravi Prakash Jha, Har Ashish Jindal, Jost B Jonas, Tamas Joo, Nitin Joseph, Farahnaz Joukar, Jacek Jerzy Jozwiak, Mikk Jürisson, Ali Kabir, Robel Hussen Kabthymer, Bhushan Dattatray Kamble, Himal Kandel, Girum Gebremeskel Kanno, Neeti Kapoor, Ibraheem M Karaye, Salah Eddin Karimi, Bekalu Getnet Kassa, Rimple Jeet Kaur, Gbenga A Kayode, Mohammad Keykhaei, Himanshu Khajuria, Rovshan Khalilov, Imteyaz A Khan, Moien AB Khan, Hanna Kim, Jihee Kim, Min Seo Kim, Ruth W Kimokoti, Mika Kivimäki, Vitalii Klymchuk, Ann Kristin Skrindo Knudsen, Ali-Asghar Kolahi, Vladimir Andreevich Korshunov, Ai Koyanagi, Kewal Krishan, Yuvaraj Krishnamoorthy, G Anil Kumar, Narinder Kumar, Nithin Kumar, Ben Lacey, Tea Lallukka, Savita Lasrado, Jerrald Lau, Sang-woong Lee, Wei-Chen Lee, Yo Han Lee, Lee-Ling Lim, Stephen S Lim, Stany W Lobo, Platon D Lopukhov, Stefan Lorkowski, Rafael Lozano, Giancarlo Lucchetti, Farzan Madadizadeh, Áurea M Madureira-Carvalho, Soleiman Mahjoub, Ata Mahmoodpoor, Rashidul Alam Mahumud, Alaa Makki, Mohammad-Reza Malekpour, Narayana Manjunatha, Borhan Mansouri, Mohammad Ali Mansournia, Jose Martinez-Raga, Francisco A Martinez-Villa, Richard Matzopoulos, Pallab K Maulik, Mahsa Mayeli, John J McGrath, Jitendra Kumar Meena, Entezar Mehrabi Nasab, Ritesh G Menezes, Gert B M Mensink, Alexios-Fotios A Mentis, Atte Meretoja, Bedasa Taye Merga, Tomislav Mestrovic, Junmei Miao Jonasson, Bartosz Miazgowski, Ana Carolina Micheletti Gomide Nogueira de Sá, Ted R Miller, GK Mini, Andreea Mirica, Antonio Mirijello, Seyyedmohammadsadeq Mirmoeeni, Erkin M Mirrakhimov, Sanjeev Misra, Babak Moazen, Maryam Mobarakabadi, Marcello Moccia, Yousef Mohammad, Esmaeil Mohammadi, Abdollah Mohammadian-Hafshejani, Teroj Abdulrahman Mohammed, Nagabhishek Moka, Ali H Mokdad, Sara Momtazmanesh, Yousef Moradi, Ebrahim Mostafavi, Sumaira Mubarik, Erin C Mullany, Beemnet Tekabe Mulugeta, Efrén Murillo-Zamora, Christopher J L Murray, Julius C Mwita, Mohsen Naghavi, Mukhammad David Naimzada, Vinay Nangia, Biswa Prakash Nayak, Ionut Negoi, Ruxandra Irina Negoi, Seyed Aria Nejadghaderi, Samata Nepal, Sudan Prasad Prasad Neupane, Sandhya Neupane Kandel, Yeshambel T Nigatu, Ali Nowroozi, Khan M Nuruzzaman, Chimezie Igwegbe Nzoputam, Kehinde O Obamiro, Felix Akpojene Ogbo, Ayodipupo Sikiru Oguntade, Hassan Okati-Aliabad, Babayemi Oluwaseun Olakunde, Gláucia Maria Moraes Oliveira, Ahmed Omar Bali, Emad Omer, Doris V Ortega-Altamirano, Adrian Otoiu, Stanislav S Otstavnov, Bilcha Oumer, Mahesh P A, Alicia Padron-Monedero, Raffaele Palladino, Adrian Pana, Songhomitra Panda-Jonas, Anamika Pandey, Ashok Pandey, Shahina Pardhan, Tarang Parekh, Eun-Kee Park, Charles D H Parry, Fatemeh Pashazadeh Kan, Jay Patel, Siddhartha Pati, George C Patton, Uttam Paudel, Shrikant Pawar, Amy E Peden, Ionela-Roxana Petcu, Michael R Phillips, Marina Pinheiro, Evgenii Plotnikov, Pranil Man Singh Pradhan, Akila Prashant, Jianchao Quan, Amir Radfar, Alireza Rafiei, Pankaja Raghav Raghav, Vafa Rahimi-Movaghar, Azizur Rahman, Md Mosfequr Rahman, Mosiur Rahman, Amir Masoud Rahmani, Shayan Rahmani, Chhabi Lal Ranabhat, Priyanga Ranasinghe, Chythra R Rao, Drona Prakash Rasali, Mohammad-Mahdi Rashidi, Zubair Ahmed Ratan, David Laith Rawaf, Salman Rawaf, Lal Rawal, Andre M N Renzaho, Negar Rezaei, Saeid Rezaei, Mohsen Rezaeian, Seyed Mohammad Riahi, Esperanza Romero-Rodríguez, Gregory A Roth, Godfrey M Rwegerera, Basema Saddik, Erfan Sadeghi, Reihaneh Sadeghian, Umar Saeed, Farhad Saeedi, Rajesh Sagar, Amirhossein Sahebkar, Harihar Sahoo, Mohammad Ali Sahraian, KM Saif-Ur-Rahman, Sarvenaz Salahi, Hamideh Salimzadeh, Abdallah M Samy, Francesco Sanmarchi, Milena M Santric-Milicevic, Yaser Sarikhani, Brijesh Sathian, Ganesh Kumar Saya, Mehdi Sayyah, Maria Inês Schmidt, Aletta Elisabeth Schutte, Michaël Schwarzinger, David C Schwebel, Abdul-Aziz Seidu, Nachimuthu Senthil Kumar, SeyedAhmad SeyedAlinaghi, Allen Seylani, Feng Sha, Sarvenaz Shahin, Fariba Shahraki-Sanavi, Shayan Shahrokhi, Masood Ali Shaikh, Elaheh Shaker, Murad Ziyaudinovich Shakhmardanov, Mehran Shams-Beyranvand, Sara Sheikhbahaei, Rahim Ali Sheikhi, Adithi Shetty, Jeevan K Shetty, Damtew Solomon Shiferaw, Mika Shigematsu, Rahman Shiri, Reza Shirkoohi, K M Shivakumar, Velizar Shivarov, Parnian Shobeiri, Roman Shrestha, Negussie Boti Sidemo, Inga Dora Sigfusdottir, Diego Augusto Santos Silva, Natacha Torres da Silva, Jasvinder A Singh, Surjit Singh, Valentin Yurievich Skryabin, Anna Aleksandrovna Skryabina, David A Sleet, Marco Solmi, YONATAN SOLOMON, Suhang Song, Yimeng Song, Reed J D Sorensen, Sergey Soshnikov, Ireneous N Soyiri, Dan J Stein, Sonu Hangma Subba, Miklós Szócska, Rafael Tabarés-Seisdedos, Takahiro Tabuchi, Majid Taheri, Ker-Kan Tan, Minale Tareke, Elvis Enowbeyang Tarkang, Gebremaryam Temesgen, Worku Animaw Temesgen, Mohamad-Hani Temsah, Kavumpurathu Raman Thankappan, Rekha Thapar, Nikhil Kenny Thomas, Chalachew Tiruneh, Jovana Todorovic, Marco Torrado, Mathilde Touvier, Marcos Roberto Tovani-Palone, Mai Thi Ngoc Tran, Sergi Trias-Llimós, Jaya Prasad Tripathy, Alireza Vakilian, Rohollah Valizadeh, Mehdi Varmaghani, Shoban Babu Varthya, Tommi Juhani Vasankari, Theo Vos, Birhanu Wagaye, Yasir Waheed, Mandaras Tariku Walde, Cong Wang, Yanzhong Wang, Yuan-Pang Wang, Ronny Westerman, Nuwan Darshana Wickramasinghe, Abate Dargie Wubetu, Suowen Xu, Kazumasa Yamagishi, Lin Yang, Gesila Endashaw E Yesera, Arzu Yigit, Vahit Yiğit, Ayenew Engida Ayenew Engida Yimaw, Dong Keon Yon, Naohiro Yonemoto, Chuanhua Yu, Siddhesh Zadey, Mazyar Zahir, Iman Zare, Mikhail Sergeevich Zastrozhin, Anasthasia Zastrozhina, Zhi-Jiang Zhang, Chenwen Zhong, Mohammad Zmaili, Yves Miel H Zuniga, Emmanuela Gakidou.
Affiliations
Institute for Health Metrics and Evaluation (D Bryazka BA, M B Reitsma BS, J A Anderson BS, R Feldman BS, E C Mullany BA, G T Culbreth PhD, X Dai PhD, Prof L Dandona MD, Prof R Dandona PhD, Prof V L Feigin PhD, Prof S I Hay FMedSci, Prof S S Lim PhD, Prof R Lozano MD, T Mestrovic PhD, A H Mokdad PhD, Prof C J L Murray DPhil, Prof M Naghavi PhD, G A Roth MD, R J D Sorensen PhD, Prof T Vos PhD, Prof E Gakidou PhD), Department of Health Metrics Sciences, School of Medicine (X Dai PhD, Prof R Dandona PhD, Prof S I Hay FMedSci, Prof S S Lim PhD, Prof R Lozano MD, A H Mokdad PhD, Prof C J L Murray DPhil, Prof M Naghavi PhD, G A Roth MD, Prof T Vos PhD, Prof E Gakidou PhD), Division of Cardiology (G A Roth MD), Department of Global Health (R J D Sorensen PhD), University of Washington, Seattle, WA, USA; Social and Economic Welfare Unit (M G Griswold MA), RAND Corporation, Santa Monica, CA, USA; Department of Nutrition and Dietetics (K H Abate PhD), Jimma University, Jimma, Ethiopia; Department of Juridical and Economic Studies (C Abbafati PhD), Department of Public Health and Infectious Diseases (M S Cattaruzza PhD), La Sapienza University, Rome, Italy; Social Determinants of Health Research Center (M Abbasi-Kangevari MD, Z Abbasi-Kangevari BSc, M Azangou-Khyavy MD, S Ghamari MD, Prof H Hassanian-Moghaddam MD, A Kolahi MD, M Rashidi MD), Department of Epidemiology (A Ahmadi PhD), School of Advanced Technologies in Medicine (S Ahmadi PhD), Department of Pharmacology (A Haj-Mirzaian MD), Obesity Research Center (A Haj-Mirzaian MD), Functional Neurosurgery Research Center (E Jamshidi PharmD), Department of Health & Community Medicine (A Kolahi MD), School of Medicine (S Nejadghaderi MD), Student Research Committee (S Rahmani MD), Medical Ethics and Law Research Center (M Taheri PhD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Non-Communicable Diseases Research Center (NCDRC) (Z Abbasi-Kangevari BSc, Z Aryan MD, S Azadnajafabad MD, M Azangou-Khyavy MD, Prof F Farzadfar DSc, S Ghamari MD, M Keykhaei MD, M Malekpour MD, S Momtazmanesh MD, S Rahmani MD, M Rashidi MD, N Rezaei PhD, M Varmaghani PhD), The Institute of Pharmaceutical Sciences (TIPS) (Prof M Abdollahi PhD), School of Pharmacy (Prof M Abdollahi PhD), Department of Epidemiology and Biostatistics (Y Alimohamadi PhD, M Mansournia PhD), Liver and Pancreatobiliary Diseases Research Center (S Alvand MD), Multiple Sclerosis Research Center (S Eskandarieh PhD, Prof M Sahraian MD), Department of Pathology (A Etemadimanesh MD), School of Medicine (N Hafezi-Nejad MD, M Mayeli MD, S Momtazmanesh MD, A Nowroozi BMedSc), Digestive Diseases Research Institute (S Hariri MD, H Salimzadeh PhD), Department of Psychiatry (R Jabbarinejad MD, S Shahrokhi MD), Students’ Scientific Research Center (SSRC) (M Keykhaei MD), Tehran Heart Center (E Mehrabi Nasab MD), Faculty of Medicine (E Mohammadi MD, E Shaker MD, P Shobeiri MD), Sina Trauma and Surgery Research Center (Prof V Rahimi-Movaghar MD), Endocrinology and Metabolism Research Institute (N Rezaei PhD), Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors (S SeyedAlinaghi PhD), Cancer Research Center (R Shirkoohi PhD), Cancer Biology Research Center (R Shirkoohi PhD), Department of Pharmacology, School of Medicine (M Zahir MD), Tehran University of Medical Sciences, Tehran, Iran; Zoonoses Research Center (A Abdoli PhD), Department of Public Health (Y Sarikhani PhD), Jahrom University of Medical Sciences, Jahrom, Iran; School of Planning, Faculty of Environment (A Abdullah MSc), School of Public Health and Health Systems (Z A Butt PhD), University of Waterloo, Waterloo, ON, Canada; Department of Botany (E S Abhilash PhD), Sree Narayana Guru College Chelannur, Kozhikode, India; Clinical Sciences Department (E Abu-Gharbieh PhD, Prof R Halwani PhD), College of Medicine (Prof R Halwani PhD), Mass Communication Department (A Makki PhD), Sharjah Institute for Medical Research (B Saddik PhD), University of Sharjah, Sharjah, United Arab Emirates; Department of Epidemiology and Population Health (Prof J M Acuna MD), Khalifa University, Abu Dhabi, United Arab Emirates; FIU Robert Stempel College of Public Health & Social Work (Prof J M Acuna MD), Department of Epidemiology (R Jebai MPH), Florida International University, Miami, FL, USA; Department of Internal Medicine (Prof G Addolorato MD), Catholic University of Rome, Rome, Italy; College of Medicine (O M Adebayo MD), Psychiatry Department (O O Ayinde MSc), Department of Medicine (A S Oguntade MSc), University College Hospital, Ibadan, Ibadan, Nigeria (O O Ayinde MSc); Department of Obstetrics and Gynecology (V Adekanmbi PhD), The Office of Health Policy & Legislative Affairs (W Lee PhD), University of Texas, Galveston, TX, USA; School of Public Health & Department of Community Medicine (K Adhikari PhD), Chitwan Medical College & Teaching Hospital, Bharatpur, Nepal; Public Health Section (K Adhikari PhD), Himalayan Environment and Public Health Network (HEPHN), Chitwan, Nepal; Biodesign Center for Environmental Health Engineering (S Adhikari MS), Arizona State University, Tempe, AZ, USA; Faculty of Medicine (Q E S Adnani PhD), Universitas Padjadjaran (Padjadjaran University), Bandung, Indonesia; Department of Community Medicine (Prof S Afzal PhD), King Edward Memorial Hospital, Lahore, Pakistan; Department of Public Health (Prof S Afzal PhD), Public Health Institute, Lahore, Pakistan; Public Health Department (W Y Agegnehu BHlthSci), Mizan-Tepi University, Mizan-Teferi, Ethiopia; Department of Internal Medicine (M Aggarwal MD), Department of Cardiovascular Medicine (M M Gad MD), Heart and Vascular Institute (M Zmaili MD), Cleveland Clinic, Cleveland, OH, USA; The Australian Centre for Public and Population Health Research (ACPPHR) (B O Ahinkorah MPH, E K Ameyaw MPhil), University of Technology Sydney, Sydney, NSW, Australia; College of Nursing (A R Ahmad PhD), International Relations & Diplomacy, Ranya – Al Sulaimaniyah, Iraq; Department of International Relations & Diplomacy (A R Ahmad PhD), Tishk International University, Erbil, Iraq; Department of Health and Biological Sciences (S Ahmad PhD), Abasyn University, Peshawar, Pakistan; Department of Epidemiology and Health Statistics (T Ahmad MS), Southeast University, Nanjing, China; Department of Epidemiology and Biostatistics (A Ahmadi PhD, A Mohammadian-Hafshejani PhD), Community-Oriented Nursing Midwifery Research Center (M Heidari PhD), Medical Plants Research Center, Basic Health Sciences Institute (R Sadeghian PhD), Department of Health in Disasters and Emergencies (R Sheikhi BHlthSci), Shahrekord University of Medical Sciences, Shahrekord, Iran; Department of Biosciences (H Ahmed PhD), COMSATS Institute of Information Technology, Islamabad, Pakistan; Department of Computer Science and Engineering (T Ahmed Rashid PhD), University of Kurdistan Hewler, Erbil, Iraq; Department of Public Health (C J Akunna DMD), The Intercountry Centre for Oral Health (ICOH) for Africa, Jos, Nigeria; Department of Public Health (C J Akunna DMD), Federal Ministry of Health, Garki, Nigeria; Geriatric and Long Term Care Department (H Al Hamad MD, B Sathian PhD), Rumailah Hospital (H Al Hamad MD), Hamad Medical Corporation, Doha, Qatar; Department of Population Sciences (M Alam MSS), University of Dhaka, Dhaka, Bangladesh; Department of Nursing (D T Alem MSc), Debre Markos University, Debremarkos, Ethiopia; Faculty of Health Sciences (K A Alene MPH), School of Public Health (G Ayano MSc, B A Dachew PhD, B Duko MPH, D Hendrie PhD, T R Miller PhD), Curtin University, Perth, WA, Australia; Wesfarmers Centre of Vaccines and Infectious Diseases (K A Alene MPH), Telethon Kids Institute, Perth, WA, Australia; Pars Advanced and Minimally Invasive Medical Manners Research Center (Y Alimohamadi PhD), Health Management and Economics Research Center (J Arabloo PhD), School of Medicine (M Dodangeh MD), Department of Medical Laboratory Sciences (F Dorostkar PhD), Preventive Medicine and Public Health Research Center (S Goharinezhad PhD), Minimally Invasive Surgery Research Center (A Kabir MD, S Salahi MD), The Five Senses Health Institute (S Rezaei MD), Trauma and Injury Research Center (M Taheri PhD), Department of Epidemiology (R Valizadeh PhD), Iran University of Medical Sciences, Tehran, Iran (F Pashazadeh Kan BSN); Department of Pharmacognosy (A Alizadeh MSc), Tehran University of Medical Sciences, tehran, Iran; Department of Disease Control (K Allel MSc), Department of Non-Communicable Disease Epidemiology (M Iwagami PhD), Department of Non-communicable Disease Epidemiology (S Trias-Llimós PhD), London School of Hygiene & Tropical Medicine, London, UK; Institute for Global Health (K Allel MSc), Department of Health Informatics (S Chung PhD), Department of Epidemiology and Public Health (Prof M Kivimäki PhD), Institute of Cardiovascular Science (A S Oguntade MSc), University College London, London, UK; Research Program of Epidemiology and Public Health (J Alonso MD), Pompeu Fabra University, Barcelona, Spain; Department of Experimental and Health Sciences (J Alonso MD), Biomedical Research Networking Center in Epidemiology and Public Health (CiberESP), Madrid, Spain; Research Group in Hospital Management and Health Policies (Prof N Alvis-Guzman PhD), Universidad de la Costa (University of the Coast), Barranquilla, Colombia; Research Group in Health Economics (Prof N Alvis-Guzman PhD), University of Cartagena, Cartagena, Colombia; School of Pharmacy (F Amare MSc), School of Public Health (B T Merga MPH), Department of Psychiatry (M T Walde MSc), Haramaya University, Harar, Ethiopia; Behavioral Sciences Research Center (S Amiri PhD), Baqiyatallah University of Medical Sciences, Tehran, Iran; Pharmacy Department (Prof R Ancuceanu PhD), Cardiology Department (C Andrei PhD), Internal Medicine Department (M Hostiuc PhD), Department of Legal Medicine and Bioethics (S Hostiuc PhD), Department of General Surgery (I Negoi PhD), Department of Anatomy and Embryology (R I Negoi PhD), Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Statistics and Econometrics (Prof T Andrei PhD, Prof M Ausloos PhD, Prof C Herteliu PhD, A Mirica PhD, A Otoiu PhD, A Pana MD, I Petcu PhD), Bucharest University of Economic Studies, Bucharest, Romania; Center of Biotechnology and Microbiology (M Arshad PhD), University of Peshawar, Peshawar, Pakistan; Department of Biophysics (A A Artamonov PhD), Russian Academy of Sciences, Moscow, Russia; Brigham and Women’s Hospital (Z Aryan MD), T.H. Chan School of Public Health (Prof T W Bärnighausen MD, P M S Pradhan MD), Harvard University, Boston, MA, USA; Department of Plastic Surgery (M Asaad MD), University of Texas, Houston, TX, USA; School of Public Health (M A Asemahagn PhD), Department of Health System and Health Economics (D D Atnafu MPH), Department of Psychiatry (M Tareke MSc), Department of Nursing (W A Temesgen PhD), Bahir Dar University, Bahir Dar, Ethiopia; School of Health and Society (Prof T Astell-Burt PhD, Z Ratan MSc), University of Wollongong, Wollongong, NSW, Australia; Menzies Centre for Health Policy (Prof T Astell-Burt PhD), Chapter of Addiction Medicine (Prof H Hassanian-Moghaddam MD), Sydney Medical School (S Islam PhD), Save Sight Institute (H Kandel PhD), NHMRC Clinical Trials Centre (R A Mahumud PhD), Department of Public Health (K Nuruzzaman PhD), University of Sydney, Sydney, NSW, Australia; Department of Immunology (S Athari PhD), Zanjan University of Medical Sciences, Zanjan, Iran; School of Medicine and Public Health (P Atorkey MPhil), University of Newcastle, Newcastle, NSW, Australia; Hunter New England Population Health, Wallsend, NSW, Australia (P Atorkey MPhil); Department of Forensic Medicine (A Atreya MD), Lumbini Medical College, Palpa, Nepal; Gastroenterology Department (F Ausloos MD), University of Liège, Liège, Belgium; School of Business (Prof M Ausloos PhD), University of Leicester, Leicester, UK; School of Indigenous Studies (G Ayano MSc), Medical School (Prof G J Hankey MD), University of Western Australia, Perth, WA, Australia; Department of Health Policy Planning and Management (M A a Ayanore PhD), Institute of Health Research (M Immurana PhD), Department of Population and Behavioural Sciences (E E Tarkang PhD), University of Health and Allied Sciences, Ho, Ghana; Department of Health Economics (M A a Ayanore PhD), Centre for Health Policy Advocacy Innovation & Research in Africa (CHPAIR-Africa), Accra, Ghana; Department of Psychiatry (Prof J L Ayuso-Mateos PhD), Universidad Autónoma de Madrid (Autonomous University of Madrid), Madrid, Spain; Biomedical Research Networking Center for Mental Health Network (CiberSAM) (Prof J L Ayuso-Mateos PhD), National School of Public Health (A Padron-Monedero PhD), Institute of Health Carlos III, Madrid, Spain; Department of Public Health (M M Azanaw MPH), Department of Midwifery (B G Kassa MSc), Debre Tabor University, Debre Tabor, Ethiopia; School of Medicine (A Azari Jafari MD, S Mirmoeeni MD), Shahroud University of Medical Sciences, Shahroud, Iran; Faculty of Medicine (A Y Azzam MBBCh), October 6 University, 6th October City, Egypt; Department of Forensic Science (A D Badiye MSc, N Kapoor MSc), Government Institute of Forensic Science, Nagpur, India; Research School of Population Health (N Bagheri PhD, Prof N Cherbuin PhD), Australian National University, Canberra, ACT, Australia; Health Research Institute (N Bagheri PhD), University of Canberra, Canberra, ACT, Australia; School of Medicine (S Bagherieh BSc), Department of Environmental Health Engineering (A Fatehizadeh PhD), Research Institute for Primordial Prevention of Non-Communicable Disease (S Hariri MD), Department of Biostatistics and Epidemiology (E Sadeghi PhD), Isfahan University of Medical Sciences, Isfahan, Iran; Centre for Community Medicine (M Bairwa MD), Department of Preventive Oncology (J K Meena MD), Department of Psychiatry (Prof R Sagar MD), All India Institute of Medical Sciences, New Delhi, India; Department of Forensic Medicine and Toxicology (S M Bakkannavar MD), Kasturba Medical College, Mangalore (R Holla MD), Department of Community Medicine (C R Rao MD), Manipal Academy of Higher Education, Manipal, India; Division of Reproductive Biology Maternal, Child Health & Nutrition (RBMCH&N) (R K Bakshi MD), Indian Council of Medical Research, New Delhi, India (Prof L Dandona MD); Department of Public Health (A H Balchut/Bilchut PhD, L Getacher MPH), Department of Psychiatry (A D Wubetu MSc), Debre Berhan University, Debre Berhan, Ethiopia; Heidelberg Institute of Global Health (HIGH) (Prof T W Bärnighausen MD, B Moazen MSc), Heidelberg University, Heidelberg, Germany; Academic Unit of Obstetrics and Gynecology (F Barra MD), Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) (Prof S Ferrero PhD), University Eye Clinic (L Ferro Desideri MD), University of Genoa, Genoa, Italy; Department of Public & Environmental Health (A Barrow MPH), University of The Gambia, Brikama, The Gambia; Epidemiology and Disease Control Unit (A Barrow MPH), Ministry of Health, Kotu, The Gambia; Department of Community Medicine and Family Medicine (P Baskaran MD, P Bhardwaj MD, Prof P R Raghav MD), Department of Anatomy (Prof N Bhardwaj MD), School of Public Health (P Bhardwaj MD), Department of Pharmacology (J Charan MD, R J Kaur PhD, S Singh DM, S B Varthya MD), Department of Surgical Oncology (Prof S Misra MCh), All India Institute of Medical Sciences, Jodhpur, India; Biological Sciences Department (L Belo PhD), Research Unit on Applied Molecular Biosciences (UCIBIO) (L Belo PhD, M Carvalho PhD), Department of Medicine (Prof N Cruz-Martins PhD), Laboratory of Toxicology (Prof D Dias da Silva PhD), Associated Laboratory for Green Chemistry (LAQV) (Á M Madureira-Carvalho PhD), Department of Chemistry (M Pinheiro PhD), University of Porto, Porto, Portugal; Nuffield Department of Population Health (D A Bennett PhD, B Lacey PhD), University of Oxford, Oxford, UK; Department of Internal Medicine (I M Bensenor PhD, Prof A R Brunoni PhD), Department of Psychiatry (Prof A R Brunoni PhD, Prof J Castaldelli-Maia PhD, Y Wang PhD), University of São Paulo, São Paulo, Brazil; Department of Social and Clinical Pharmacy (A S Bhagavathula PharmD), Charles University, Hradec Kralova, Czech Republic; Institute of Public Health (A S Bhagavathula PharmD), College of Medicine and Health Sciences (Prof M Grivna PhD), Family Medicine Department (M A Khan MSc), United Arab Emirates University, Al Ain, United Arab Emirates; Institutes of Applied Health Research and Translational Medicine (N Bhala PhD), Queen Elizabeth Hospital Birmingham, Birmingham, UK; Institute of Applied Health Research (N Bhala PhD), University of Birmingham, Birmingham, UK; Department of Internal Medicine (Prof A Bhalla MD), Post Graduate Institute of Medical Education and Research, Chandigarh, India; Neurovascular Imaging Laboratory (S Bhaskar PhD), NSW Brain Clot Bank, Sydney, NSW, Australia; Department of Neurology and Neurophysiology (S Bhaskar PhD), South West Sydney Local Heath District and Liverpool Hospital, Sydney, NSW, Australia; Department of Statistical and Computational Genomics (K Bhattacharyya MSc), National Institute of Biomedical Genomics, Kalyani, India; Department of Statistics (K Bhattacharyya MSc), University of Calcutta, Kolkata, India; Department of Anatomy (V S Bhojaraja MD), Department of Biochemistry (J K Shetty MD), Royal College of Surgeons in Ireland Medical University of Bahrain, Busaiteen, Bahrain; Department of Health Behaviour, Environment and Social Medicine (B Bintoro MD), Gadjah Mada University (Universitas Gadjah Mada), Sleman, Indonesia; Center of Health and Behavior and Promotion (B Bintoro MD), Universitas Gadjah Mada (Gadjah Mada University), Sleman, Indonesia; Valdman Institute of Pharmacology (E A E Blokhina MD), First Pavlov Medical University of St.Petersburg, St. Petersburg, Russia; Biomedical Sciences Department (B B A Bodicha MSc), School of Public Health, College of Medicine and Health Sciences (C Churko MPH, N B Sidemo MPH), College of Medicine and Health Sciences (B D Daniel MSc), Department of Comprehensive Nursing (L E Digesa MSc), Department of Epidemiology and Biostatistics (M A Gebremichael MPH), Health Informatics Department (B T Mulugeta MSc), Department of Midwifery (B Oumer MPH, G Temesgen MSc), School of Nursing, College of Medicine and Health Sciences (G E E Yesera MSc), Arba Minch University, Arba Minch, Ethiopia; Department of Internal Medicine (A Boloor MD), Department of Forensic Medicine and Toxicology, Kasturba Medical College Mangalore (H L Dsouza MD), Department of Community Medicine (N Joseph MD, N Kumar MD, R Thapar MD), Department of Obstetrics and Gynaecology (A Shetty MS), Manipal Academy of Higher Education, Mangalore, India; Department of Oncology (C Bosetti PhD), Department of Environmental Health Sciences (S Gallus DSc), Mario Negri Institute for Pharmacological Research, Milan, Italy; Department of Epidemiology (D Braithwaite PhD), University of Florida, Gainesville, FL, USA; Cancer Population Sciences Program (D Braithwaite PhD), University of Florida Health Cancer Center, Gainesville, FL, USA; Division of Clinical Epidemiology and Aging Research (Prof H Brenner MD), German Cancer Research Center, Heidelberg, Germany; Department of Epidemiology and Evidence-Based Medicine (Prof N I Briko DSc, E V Glushkova PhD, V A Korshunov PhD, P D Lopukhov PhD), Institute for Leadership and Health Management (S Soshnikov PhD), I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Al Shifa School of Public Health (Z A Butt PhD), Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan; Program in Physical Therapy (C Cao MPH), Washington University in St. Louis, St. Louis, MO, USA; Department of Surgery (Y Cao DSc), Washington University in St. Louis, Saint Louis, MO, USA; Department of Health Care (Prof R Cárdenas DSc), Metropolitan Autonomous University, Mexico City, Mexico; IMPACT Strategic Research Center (the Institute for Mental and Physical Health and Clinical Translation) (A F Carvalho MD), School of Medicine (V Gupta PhD), Deakin University, Geelong, VIC, Australia; Faculty of Health Sciences (M Carvalho PhD), University Fernando Pessoa, Porto, Portugal; Department of Medicine (G Castelpietra PhD), University of Udine, Udine, Italy; Department of Mental Health (G Castelpietra PhD), Healthcare Agency “Friuli Occidentale”, Pordenone, Italy; Department of Psychiatry (L F S Castro-de-Araujo PhD), School of Health Sciences (A Meretoja MD), Department of Pediatrics (Prof G C Patton MD), University of Melbourne, Melbourne, VIC, Australia; School of Population and Public Health (P A Chakraborty MPH, D P Rasali PhD), University of British Columbia, Vancouver, BC, Canada; Department of Community Medicine (V Chattu MD), Datta Meghe Institute of Medical Sciences, Sawangi, India; Saveetha Medical College (V Chattu MD), Saveetha University, Chennai, India; Department of Oral Medicine and Radiology (A Chaurasia MD), King George’s Medical University, Lucknow, India; Center for Biomedicine and Community Health (D Chu PhD), VNU-International School, Hanoi, Vietnam; Department of Medical Science (N Chudal Medical Student), Medical University of Vienna, Vienna, Austria; Health Data Research UK, London, UK (S Chung PhD); Adelaide Medical School (L G Ciobanu PhD), University of Adelaide, Adelaide, SA, Australia; School of Pharmacy and Medical Sciences (L G Ciobanu PhD), University of South Australia, Adelaide, SA, Australia; Department of Public Health (Prof M Cirillo MD, R Palladino MD), University of Naples Federico II, Naples, Italy; Department of Nutrition (Prof R M Claro PhD), Department of Maternal and Child Nursing and Public Health (Prof A C Micheletti Gomide Nogueira de Sá MSc), Federal University of Minas Gerais, Belo Horizonte, Brazil; Department of Epidemiology and Prevention (S Costanzo PhD), IRCCS Neuromed, Pozzilli, Italy; Department of Psychology (R G Cowden PhD), University of the Free State, Park West, South Africa; Department of Family Medicine and Public Health (Prof M H Criqui MD), University of California San Diego, La Jolla, CA, USA; Health sciences (Prof N Cruz-Martins PhD), Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Famalicão, Portugal; Department of Epidemiology (B A Dachew PhD), Department of Biochemistry (M Derbew Molla MSc), Department of Surgical Nursing (A A Desta MSc), Department of Human Physiology (M Diress MSc), Department of Clinical Midwifery (T W Gudayu MPH), School of Midwifery (A E A Yimaw MSc), University of Gondar, Gondar, Ethiopia; School of Public Health (O Dadras DrPH), Walailak University, Thai Buri, Thailand; Department of Global Public Health and Primary Care (O Dadras DrPH), University of Bergen, Bergen, Norway; IRCCS Istituto Ortopedico Galeazzi (Galeazzi Orthopedic Institute IRCCS) (G Damiani MD), University of Milan, Milan, Italy; Department of Dermatology (G Damiani MD), Case Western Reserve University, Cleveland, OH, USA; Department of Research (A Pandey PhD), Public Health Foundation of India, Gurugram, India (Prof L Dandona MD, Prof R Dandona PhD, G Kumar PhD); Department of Human Nutrition (A Danielewicz PhD), Uniwersytet Warmińsko-Mazurski w Olsztynie (University of Warmia and Mazury in Olsztyn), Olsztyn, Poland; Department of Public Health (J Darega Gela MPH), Ambo University, Ambo, Ethiopia; Health Research Institute (K Davletov PhD), Al Farabi Kazakh National University, Almaty, Kazakhstan; Department of Psychiatry (J A P de Araujo MD), Federal University of São Paulo, São Paulo, Brazil; Department of Psychiatry (J A P de Araujo MD), Centro de Estudos Clínica APICE, Salvador, Brazil; Department of Medical Clinic (Prof A R de Sá-Junior PhD), Department of Physical Education (Prof D A S Silva PhD), Federal University of Santa Catarina, Florianópolis, Brazil; School of Public Health (S Debela MPH), Salale University, Fiche, Ethiopia; Department of Epidemiology and Community Medicine (A Dehghan PhD), Non-Communicable Diseases Research Center (NCDRC), Fasa, Iran; Department of Neurosurgery (A K Demetriades MD), Global Health Governance Programme (J Patel), University of Edinburgh, Edinburgh, UK; Neurosurgery Department (A K Demetriades MD), National Health Service (NHS) Scotland, Edinburgh, UK; Division of Cardiology (R Desai MBBS), Atlanta Veterans Affairs Medical Center, Decatur, GA, USA; Center of Complexity Sciences (Prof D Diaz PhD), National Autonomous University of Mexico, Mexico City, Mexico; Faculty of Veterinary Medicine and Zootechnics (Prof D Diaz PhD), Autonomous University of Sinaloa, Culiacán Rosales, Mexico; Center of Excellence in Health Equity, Training and Research (D Dongarwar MS), Baylor College of Medicine, Houston, TX, USA; Forensic Medicine and Toxicology (H L Dsouza MD), Kasturba Medical College Mangalore, Mangalore, India; School of Public Health (B Duko MPH), Hawassa University, Hawassa, Ethiopia; Postgraduate Program in Epidemiology (Prof B B Duncan MD, Prof M I Schmidt MD), Federal University of Rio Grande do Sul, Porto Alegre, Brazil; College of Science, Health and Engineering (K Edvardsson PhD), La Trobe University, Bundoora, VIC, Australia; Department of Epidemiology and Medical Statistics (M Ekholuenetale MSc, A F Fagbamigbe PhD), Faculty of Public Health (M Ekholuenetale MSc), Department of Health Promotion and Education (S E Ibitoye MPH), University of Ibadan, Ibadan, Nigeria; School of Population and Global Health (Prof F J Elgar PhD), McGill University, Montreal, QC, Canada; Faculty of Medicine (M Elhadi MD), University of Tripoli, Tripoli, Libya; Egypt Center for Research and Regenerative Medicine (ECRRM), Cairo, Egypt (M A Elmonem PhD); Public Health Department (A Y Endries MPH), St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia; Population and Behavioural Sciences Division (A F Fagbamigbe PhD), University of St Andrews, St Andrews, UK; Head of the Laboratory of Experimental Medicine (I R Fakhradiyev PhD), Kazakh National Medical University, Almaty, Kazakhstan; Department of Literature and Humanities (F Farahmand BSc), Islamic Azad University, Kermanshah, Iran; Dissemination Division (C S e Farinha MSc), National Institute of Statistics, Lisbon, Portugal; Activity Planning and Control Unit (C S e Farinha MSc), Directorate-General of Health (DGS), Lisbon, Portugal; Department of Psychology (Prof A Faro PhD), Federal University of Sergipe, São Cristóvão, Brazil; Torrens University Australia, Adelaide, SA, Australia (N K Fauk MSc); Institute of Resource Governance and Social Change, Kupang, Indonesia (N K Fauk MSc); National Institute for Stroke and Applied Neurosciences (Prof V L Feigin PhD), Auckland University of Technology, Auckland, New Zealand; Research Center of Neurology, Moscow, Russia (Prof V L Feigin PhD); School of Population Health (X Feng PhD), School of Medicine (P K Maulik PhD), School of Public Health and Community Medicine (A E Peden PhD, Prof A E Schutte PhD), University of New South Wales, Sydney, NSW, Australia; National Institute of Environmental Health (X Feng PhD), Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology and Biostatistics (Z Fentaw MPH), Department of Environmental Health (M G D Gebrehiwot PhD), Department of Anatomy, College of Medicine and Health Sciences (C Tiruneh MSc), College of Medicine and Health Sciences School of Public Health Department of Public Health Nutrition (B Wagaye MPH), Wollo University, Dessie, Ethiopia; Psychiatry Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA; School of Health Sciences (I Filip MD), A.T. Still University, Mesa, AZ, USA; Institute of Public Health (F Fischer PhD), Charité Universitätsmedizin Berlin (Charité Medical University Berlin), Berlin, Germany; Department of Family Medicine and Primary Care (J M Francis PhD), University of the Witwatersrand, Johannesburg, South Africa; School of Public Health, Medical, and Veterinary Sciences (R C Franklin PhD), James Cook University, Douglas, QLD, Australia; Health Services Management Training Centre (P A Gaal PhD, T Joo MSc), Faculty of Health and Public Administration (M Szócska PhD), Semmelweis University, Budapest, Hungary; Department of Applied Social Sciences (P A Gaal PhD), Sapientia Hungarian University of Transylvania, Târgu-Mureş, Romania; Gillings School of Global Public Health (M M Gad MD), University of North Carolina Chapel Hill, Chapel Hill, NC, USA; Department of Biomedical and Biotechnological Sciences (Prof F Galvano PhD, G Grosso PhD), University of Catania, Catania, Italy; Neurorehabilitation and Robotics Laboratory, Department of Biomedical Engineering (B Ganesan PhD), Jockey Club School of Public Health and Primary Care (J Huang MD, C Zhong MD), The Chinese University of Hong Kong, Hong Kong, China; Department of Occupational Therapy (B Ganesan PhD), Mahatma Gandhi Occupational Therapy College, Jaipur, India; Department of Radiology (T Garg MBBS), King Edward Memorial Hospital, Mumbai, India; Department of Reproductive & Family Health (T G Gebremeskel MPH), Aksum University, Axum, Ethiopia; Medical Biochemistry Department (T R Gemechu MSc), Anatomy Department (D S Shiferaw MSc), Department of Biomedical Science (D S Shiferaw MSc), Madda Walabu University, Goba, Ethiopia; Department of Public Health (M E Getachew MPH), Wollega University, Nekemte, Ethiopia; School of Psychology (A Getachew Obsa MA), Addis Ababa University, Addis Ababa, Ethiopia; School of Nursing, College of Medicine and Health Sciences (A Getie MSc), Arba Minch University, Arbaminch, Ethiopia; Department of Addiction Studies (A Ghaderi PhD), Kashan University of Medical Sciences, Kashan, Iran; Department of Medical Surgical Nursing (M Ghafourifard PhD), Social Determinants of Health Research Center (S Karimi PhD), Anesthesiology and Critical Care Department (Prof A Mahmoodpoor MD), Tabriz University of Medical Sciences, Tabriz, Iran; Mount Auburn Hospital (A Ghajar MD), Harvard Medical School, Cambridge, MA, USA; Department of Epidemiology and Population Health (L A Ghandour PhD), American University of Beirut, Beirut, Lebanon; E-Learning Center, Faculty of Health (M Ghasemi Nour MD), Applied Biomedical Research Center (A Sahebkar PhD), Biotechnology Research Center (A Sahebkar PhD), Social Determinants of Health Research Center (M Varmaghani PhD), Mashhad University of Medical Sciences, Mashhad, Iran; School of Public Health (A Ghashghaee BSc), Qazvin University of Medical Sciences, Qazvin, Iran; Department of Radiology (S Ghozy MD), Mayo Clinic, Rochester, MN, USA; Department of Social and Behavioural Sciences (F N Glozah PhD), University of Ghana, Accra, Ghana; Department of Laboratories (J Godos PhD), Oasi Research Institute, Troina, Italy; Department of Gastroenterology (Prof A Goel DM), Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India; Health Systems and Policy Research (M Golechha PhD), Indian Institute of Public Health, Gandhinagar, India; Department of Genetics (P Goleij MSc), Sana Institute of Higher Education, Sari, Iran; Department of Nursing (M Golitaleb PhD), Arak University of Medical Sciences, Arak, Iran; Department of Primary Care and Public Health (F Greaves PhD, R Palladino MD, Prof S Rawaf MD), WHO Collaborating Centre for Public Health Education and Training (D L Rawaf MD), Imperial College London, London, UK; Health Improvement Directorate (F Greaves PhD), Academic Public Health England (Prof S Rawaf MD), Public Health England, London, UK; Department of Public Health and Preventive Medicine (Prof M Grivna PhD), Charles University, Prague, Czech Republic; Department of Public Health (B Gupta PhD), Torrens University Australia, Melbourne, VIC, Australia; Department of Preventive Cardiology (Prof R Gupta MD), Eternal Heart Care Centre & Research Institute, Jaipur, India; Department of Medicine (Prof R Gupta MD), Mahatma Gandhi University Medical Sciences, Jaipur, India; Toxicology Department (S Gupta MSc), Shriram Institute for Industrial Research, Delhi, Delhi, India; Department of Clinical Medicine (Prof V K Gupta PhD), Macquarie University, Sydney, NSW, Australia; Department of Radiology and Radiological Science (N Hafezi-Nejad MD, S Sheikhbahaei MD), Johns Hopkins University, Baltimore, MD, USA; NYU Shanghai, Shanghai, China (B J Hall PhD); School of Public Health (T B Handiso MPH), Wolaita Sodo University, Wolaita Sodo, Ethiopia; Department of Neurology (Prof G J Hankey MD), Sir Charles Gairdner Hospital, Perth, WA, Australia; Research Unit (J M Haro MD), University of Barcelona, Barcelona, Spain; Biomedical Research Networking Center for Mental Health Network (CiberSAM), Barcelona, Spain (J M Haro MD); Department of Zoology and Entomology (A I Hasaballah PhD), Al Azhar University, Cairo, Egypt; Institute of Pharmaceutical Sciences (K Hayat MS), University of Veterinary and Animal Sciences, Lahore, Pakistan; Department of Pharmacy Administration and Clinical Pharmacy (K Hayat MS), Xian Jiaotong University, Xian, China; Independent Consultant, Santa Clara, CA, USA (G Heidari MD); School of Business (Prof C Herteliu PhD), London South Bank University, London, UK; Public Health, Enviromental Health, Epidemiology and Health Education Department (D Z Heyi MPH), Madda Walabu University, Robe, Goba Town, Ethiopia; Department of Applied Microbiology (K Hezam PhD), Taiz University, Taiz, Yemen; Department of Microbiology (K Hezam PhD), Nankai University, Tianjin, China; School of Nursing and Public Health Medicine (M M Hlongwa PhD), University of KwaZulu-Natal, Durban, South Africa; Social and Environmental Health Research (M Hossain MPH), Nature Study Society of Bangladesh, Khulna, Bangladesh; Department of Health Promotion and Community Health Sciences (M Hossain MPH), Texas A&M University, College Station, TX, USA; Department of Public Health and Informatics (S Hossain MS), Jahangirnagar University, Dhaka, Bangladesh; Department of Interventional Cardiology (S Hosseini MD), Hamedan University of Medical Sciences, Hamadan, Iran; Pattern Recognition and Machine Learning Lab (M hosseinzadeh PhD), Gachon University, 1342 Seongnamdaero, Sujeonggu, Seongnam 13120, South Korea; Clinical Legal Medicine Department (S Hostiuc PhD), National Institute of Legal Medicine Mina Minovici, Bucharest, Romania; Department of Epidemiology and Health Statistics (Prof G Hu PhD), Central South University, Changsha, China; Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (S Hussain PhD), Institute of Biostatistics and Analyses (S Hussain PhD), Masaryk University, Brno, Czech Republic; Faculty of Medicine (I M Ilic PhD, Prof M M Santric-Milicevic PhD), School of Public Health and Health Management (Prof M M Santric-Milicevic PhD), Faculty of Medicine, Institute of Social Medicine (J Todorovic PhD), University of Belgrade, Belgrade, Serbia; Department of Epidemiology (Prof M D Ilic PhD), University of Kragujevac, Kragujevac, Serbia; Faculty of Pharmacy (L M Irham BPharm), University of Ahmad Dahlan, Yogyakarta, Indonesia; School of Psychology and Public Health (M Islam PhD), La Trobe University, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine (R M Islam PhD), Monash University, Melbourne, VIC, Australia; Institute for Physical Activity and Nutrition (S Islam PhD), Deakin University, Burwood, VIC, Australia; Public Health Department of Social Medicine (Prof H Iso MD), Graduate School of Medicine (Prof K Yamagishi MD), Osaka University, Suita, Japan; Department of Health Management (R Itumalla PhD), University of Hail, Hail, Saudi Arabia; Department of Health Services Research (M Iwagami PhD), Research and Development Center for Health Services (Prof K Yamagishi MD), University of Tsukuba, Tsukuba, Japan; Department of Physical Medicine & Rehabilitation (R Jabbarinejad MD), Northwestern University, Chicago, IL, USA; Research and Development Unit (L Jacob MD), Biomedical Research Networking Center for Mental Health Network (CiberSAM), Sant Boi de Llobregat, Spain; Faculty of Medicine (L Jacob MD), University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France; Institute of Advanced Manufacturing Technologies (Prof M Jakovljevic PhD), Peter the Great St. Petersburg Polytechnic University, St. Petersburg, Russia; Institute of Comparative Economic Studies (Prof M Jakovljevic PhD), Hosei University, Tokyo, Japan; Trauma Research Center (Z Jamalpoor PhD), Aja University of Medical Sciences, Tehran, Iran; Division of Pulmonary Medicine (E Jamshidi PharmD), Lausanne University Hospital (CHUV), Lausanne, Switzerland; Centre of Studies and Research (S Jayapal PhD), Ministry of Health, Muscat, Oman; Postgraduate Institute of Medicine (U U Jayarajah MD), Department of Physiology (R Jayawardena PhD), Department of Pharmacology (P Ranasinghe PhD), University of Colombo, Colombo, Sri Lanka; Department of Surgery (U U Jayarajah MD), National Hospital, Colombo, Sri Lanka; School of Exercise and Nutrition Sciences (R Jayawardena PhD), School of Public Health and Social Work (M T N Tran PhD), Queensland University of Technology, Brisbane, QLD, Australia; Department of Laboratory Sciences, School of Allied Medical Sciences (S Jeddi MSc), Abadan University of Medical Sciences, Abadan, Iran; Department of Public Health (A Jema MPH), Madda Walabu University, Bale Goba, Ethiopia; Department of Community Medicine (R P Jha MSc), Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, India; Department of Community Medicine (R P Jha MSc, B D Kamble MD), Banaras Hindu University, Varanasi, India; National Health System Resource Centre (H Jindal MD), Ministry of Health & Family Welfare, New Delhi, India; Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland (Prof J B Jonas MD); Department of Ophthalmology (Prof J B Jonas MD), Heidelberg University, Mannheim, Germany; Gastrointestinal and Liver Diseases Research Center (F Joukar PhD), Caspian Digestive Disease Research Center (F Joukar PhD), Guilan University of Medical Sciences, Rasht, Iran; Department of Family Medicine and Public Health (J J Jozwiak PhD), University of Opole, Opole, Poland; Institute of Family Medicine and Public Health (M Jürisson PhD), University of Tartu, Tartu, Estonia; School of Public Health (R H Kabthymer MSc, G G Kanno MSc), Dilla University, Dilla, Ethiopia; Department of Community Medicine and Family Medicine (B D Kamble MD), All India Institute of Medical Sciences, Hyderabad, India; Sydney Eye Hospital (H Kandel PhD), South Eastern Sydney Local Health District, Sydney, NSW, Australia; School of Health Professions and Human Services (I M Karaye MD), Hofstra University, Hempstead, NY, USA; International Research Center of Excellence (G A Kayode PhD), Institute of Human Virology Nigeria, Abuja, Nigeria; Julius Centre for Health Sciences and Primary Care (G A Kayode PhD), Utrecht University, Utrecht, Netherlands; Amity Institute of Forensic Sciences (H Khajuria PhD, B P Nayak PhD), Amity University, Noida, India; Department of Biophysics and Biochemistry (Prof R Khalilov PhD), Baku State University, Baku, Azerbaijan; Russian Institute for Advanced Study (Prof R Khalilov PhD), Moscow State Pedagogical University, Moscow, Russia; Department of Pediatrics (I A Khan MD), Rutgers University, New Brunswick, NJ, USA; Primary Care Department (M A Khan MSc), NHS North West London, London, UK; College of Medicine (H Kim BN), Ewha Womans University, Seoul, South Korea; Department of Preventive Medicine (J Kim MSc), Korea University, Seoul, South Korea; Department of Genomics and Digital Health (M Kim MD), Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Seoul, South Korea; Public Health Center (M Kim MD), Ministry of Health and Welfare, Wando, South Korea; Department of Nutrition (R W Kimokoti MD), Simmons University, Boston, MA, USA; Department of Public Health (Prof M Kivimäki PhD, Prof T Lallukka PhD), University of Helsinki, Helsinki, Finland; Community-based Services Development (V Klymchuk DSc), Mental Health for Ukraine Project, Lviv, Ukraine; Laboratory of Social Psychology (V Klymchuk DSc), Institute of Social and Political Psychology, Kyiv, Ukraine; Department of Disease Burden (A S Knudsen PhD), Norwegian Institute of Public Health, Bergen, Norway; Biomedical Research Networking Center for Mental Health Network (CIBERSAM) (A Koyanagi MD), San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain (A Koyanagi MD); Department of Anthropology (Prof K Krishan PhD), Panjab University, Chandigarh, India; Community Medicine Department (Y Krishnamoorthy MD), Employees’ State Insurance Model Hospital, Chennai, India; Department of Orthopaedics (Prof N Kumar MS), Medanta Hospital, Lucknow, India; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK (B Lacey PhD); Department of Otorhinolaryngology (S Lasrado MS), Father Muller Medical College, Mangalore, India; Department of Surgery (J Lau MPH, K Tan PhD), National University of Singapore, Singapore, Singapore; Pattern Recognition and Machine Learning Lab (Prof S Lee PhD), Gachon University, Seongnam, South Korea; Graduate School of Public Health (Y Lee PhD), Ajou University, Suwon-si, South Korea; Department of Medicine (L Lim MRCP), University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine and Therapeutics (L Lim MRCP), The Chinese University of Hong Kong, Shatin, China; Department of Professional and Medical Education (S W Lobo PhD), Meharry Medical College, Nashville, TN, USA; Department of Biomedical Sciences (S W Lobo PhD), Mercer University, Macon, GA, USA; Institute of Nutritional Sciences (Prof S Lorkowski PhD), Friedrich Schiller University Jena, Jena, Germany; Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Jena, Germany (Prof S Lorkowski PhD); School of Medicine (Prof G Lucchetti PhD), Federal University of Juiz de Fora, Juiz de Fora, Brazil; Department of Biostatistics and Epidemiology (F Madadizadeh PhD), Yazd University of Medical Sciences, Yazd, Iran; Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde (Institute for Research and Advanced Training in Health Sciences and Technologies) (Á M Madureira-Carvalho PhD), Instituto Universitário de Ciências da Saúde (University Institute of Health Sciences), Gandra, Portugal; Cellular and Molecular Biology Research Center, Health Research Institute (Prof S Mahjoub PhD), Department of Clinical Biochemistry (Prof S Mahjoub PhD), Babol University of Medical Sciences, Babol, Iran; Department of Psychiatry (N Manjunatha MD), National Institute of Mental Health and Neurosciences, Bengalore, India; Substance Abuse Prevention Research Center (B Mansouri PhD), Kermanshah University of Medical Sciences, Kermanshah, Iran; Psychiatry Department (J Martinez-Raga PhD), Hospital Universitario Doctor Peset, Valencia, Spain; Department of Medicine (J Martinez-Raga PhD, Prof R Tabarés-Seisdedos PhD), University of Valencia, Valencia, Spain; Teaching Department (Prof F A Martinez-Villa MSc), Mexican Institute of Social Security, Culiacan Rosales, Mexico; Burden of Disease Research Unit (R Matzopoulos PhD), Alcohol, Tobacco & Other Drug Research Unit (Prof C D H Parry PhD), Risk and Resilience in Mental Disorders Unit (Prof D J Stein MD), South African Medical Research Council, Cape Town, South Africa; School of Public Health and Family Medicine (R Matzopoulos PhD), University of Cape Town, Cape Town, South Africa; Research Division (P K Maulik PhD), The George Institute for Global Health, New Delhi, India; Queensland Brain Institute (Prof J J McGrath MD), The University of Queensland, Brisbane, QLD, Australia; National Centre for Register-based Research (Prof J J McGrath MD), Aarhus University, Aarhus, Denmark; Forensic Medicine Division (Prof R G Menezes MD), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; Department of Epidemiology and Health Monitoring (G B M Mensink PhD), Robert Koch Institute, Berlin, Germany; University Research Institute (A A Mentis MD), National and Kapodistrian University of Athens, Athens, Greece; Neurology Unit (A Meretoja MD), Helsinki University Hospital, Helsinki, Finland; University Centre Varazdin (T Mestrovic PhD), University North, Varazdin, Croatia; School of Public Health and Community Medicine (J Miao Jonasson PhD), University of Gothenburg, Gothenburg, Sweden; Center for Innovation in Medical Education (B Miazgowski MD), Pomeranian Medical University, Szczecin, Poland (B Miazgowski MD); Pacific Institute for Research & Evaluation, Calverton, MD, USA (T R Miller PhD); Global Institute of Public Health (Prof G Mini PhD), Ananthapuri Hospitals and Research Institute, Trivandrum, India; Women’s Social and Health Studies Foundation, Trivandrum, India (Prof G Mini PhD); Department of Medical Sciences (A Mirijello MD), IRCCS Casa Sollievo della Sofferenza General Hospital (IRCCS Home for the Relief of Suffering General Hospital), San Giovanni Rotondo, Italy; Internal Medicine Programme (Prof E M Mirrakhimov PhD), Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan; Department of Atherosclerosis and Coronary Heart Disease (Prof E M Mirrakhimov PhD), National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan; Institute of Addiction Research (ISFF) (B Moazen MSc), Frankfurt University of Applied Sciences, Frankfurt, Germany; Noncommunicable Disease Research Center (M Mobarakabadi MD), Hamadan University of Medical Sciences, Tehran, Iran; Department of Neurosciences (M Moccia PhD), Federico II University, Naples, Italy; Internal Medicine Department (Y Mohammad MD), Pediatric Intensive Care Unit (M Temsah MD), King Saud University, Riyadh, Saudi Arabia; Department of Epidemiology (S Nejadghaderi MD, E Shaker MD), Epidemiology Department (S Shahin MD), Department of International Studies (P Shobeiri MD), Non-Communicable Diseases Research Center (NCDRC), Tehran, Iran (E Mohammadi MD); Dental Basic Sciences Department (T A Mohammed MSc), University of Duhok, Duhok, Iraq; Oncology Department (N Moka MD), Appalachian Regional Healthcare, Hazard, KY, USA; Internal Medicine (N Moka MD), University of Kentucky, Lexington, KY, USA; Social Determinants of Health Research Center (Y Moradi PhD), Kurdistan University of Medical Sciences, Kurdistan, Iran; Department of Medicine (E Mostafavi PhD), Stanford Cardiovascular Institute (E Mostafavi PhD), Stanford University, Palo Alto, CA, USA; Department of Epidemiology and Biostatistics (S Mubarik MS, Prof C Yu PhD), School of Medicine (Z Zhang PhD), Wuhan University, Wuhan, China; Epidemiology, Family Medicine Unit 19 (E Murillo-Zamora PhD), Mexican Institute of Social Security, Colima, Mexico; Postgraduate Program in Medical Sciences (E Murillo-Zamora PhD), Universidad de Colima, Colima, Mexico; Department of Internal Medicine (J C Mwita MD, G M Rwegerera MD), University of Botswana, Gaborone, Botswana; Laboratory of Public Health Indicators Analysis and Health Digitalization (M Naimzada MD, S S Otstavnov PhD), Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Experimental Surgery and Oncology Laboratory (M Naimzada MD), Kursk State Medical University, Kursk, Russia; Suraj Eye Institute, Nagpur, India (V Nangia MD); Department of General Surgery (I Negoi PhD), Emergency Hospital of Bucharest, Bucharest, Romania; Cardio-Aid, Bucharest, Romania (R I Negoi PhD); Department of Community Medicine (S Nepal MD), Kathmandu University, Palpa, Nepal; National Centre for Suicide Research and Prevention (S P Neupane PhD), University of Oslo, Norway; Specialist Oral Health Center for Western Norway Department (S P Neupane PhD), Oral Health Center of Expertise in Rogaland, Rogland, Norway; Estia Health Blakehurst (S Neupane Kandel BSN), Estia Health, Sydney, NSW, Australia; Institute for Mental Health and Policy (Y T Nigatu PhD), Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Population Science (K Nuruzzaman PhD), Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh; Center of Excellence in Reproductive Health Innovation (CERHI) (C I Nzoputam MPH), University of Benin, Benin City, Nigeria; Centre for Rural Health (K O Obamiro PhD), University of Tasmania, Hobart, TAS, Australia; Translational Health Research Institute (F A Ogbo PhD), Western Sydney University, Sydney, NSW, Australia; Health Promotion Research Center (H Okati-Aliabad PhD, F Shahraki-Sanavi PhD), Zahedan University of Medical Sciences, Zahedan, Iran; Community Prevention and Care Services (B O Olakunde PhD), National AIDS Control Committee, Abuja, Nigeria; Cardiology Department (G M M Oliveira PhD), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Diplomacy and Public Relations Department (A Omar Bali PhD), University of Human Development, Sulaymaniyah, Iraq; Mass Communication Department (E Omer PhD), Ajman University, Dubai, United Arab Emirates; Health Systems Research Center (D V Ortega-Altamirano DrPH), National Institute of Public Health, Cuernavaca, Mexico; Department of Project Management (S S Otstavnov PhD), National Research University Higher School of Economics, Moscow, Russia; Department of Respiratory Medicine (Prof M P A DNB), Jagadguru Sri Shivarathreeswara Academy of Health Education and Research, Mysore, India; Department of Health Metrics (A Pana MD), Center for Health Outcomes & Evaluation, Bucharest, Romania; Privatpraxis, Heidelberg, Germany (S Panda-Jonas MD); Research Department (A Pandey MPH), Research Section (U Paudel PhD), Nepal Health Research Council, Kathmandu, Nepal; Research Department (A Pandey MPH), Public Health Research Society Nepal, Kathmandu, Nepal; Vision and Eye Research Institute (Prof S Pardhan PhD), Anglia Ruskin University, Cambridge, UK; Department of Health Administration and Policy (T Parekh MSc), George Mason University, Fairfax, VA, USA; Department of Medical Humanities and Social Medicine (Prof E Park PhD), Kosin University, Busan, South Korea; Department of Psychiatry (Prof C D H Parry PhD), Stellenbosch University, Cape Town, South Africa; School of Dentistry (J Patel), University of Leeds, Leeds, UK; Skills Innovation and Academic Network (SIAN) Institute (S Pati PhD), Association for Biodiversity Conservation and Research (ABC), Odisha, India; Population Health Theme (Prof G C Patton MD), Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Faculty of Humanities and Social Sciences (U Paudel PhD), Department of Community Medicine, Institute of Medicine (P M S Pradhan MD), Tribhuvan University, Kathmandu, Nepal; Department of Genetics (S Pawar PhD), Department of Internal Medicine (R Shrestha PhD), Yale University, New Haven, CT, USA; College of Public Health, Medical and Veterinary Sciences (A E Peden PhD), James Cook University, Townsville, NSW, Australia; Shanghai Mental Health Center (Prof M R Phillips MD), Shanghai Jiao Tong University, Shanghai, China; Department of Psychiatry (Prof M R Phillips MD), Department of Health and Behavior Studies (Prof I D Sigfusdottir PhD), Columbia University, New York, NY, USA; Research School of Chemistry and Applied Biomedical Sciences (E Plotnikov PhD), Tomsk Polytechnic University, Tomsk, Russia; Mental Health Research Institute (E Plotnikov PhD), Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia; Department of Biochemistry (Prof A Prashant PhD), Jagadguru Sri Shivarathreeswara University, Mysuru, India; School of Public Health (J Quan MD), University of Hong Kong, Hong Kong, China; College of Medicine (A Radfar MD), University of Central Florida, Orlando, FL, USA; Department of Immunology (Prof A Rafiei PhD), Molecular and Cell Biology Research Center (Prof A Rafiei PhD), Mazandaran University of Medical Sciences, Sari, Iran; Data Mining Research Unit (DaMRA) (A Rahman PhD), Charles Sturt University, Wagga Wagga, NSW, Australia; Department of Population Science and Human Resource Development (Prof M Rahman PhD, M Rahman DrPH), University of Rajshahi, Rajshahi, Bangladesh; Future Technology Research Center (A Rahmani PhD), National Yunlin University of Science and Technology, Yunlin, Taiwan (province of China); Research Department (C L Ranabhat PhD), Policy Research Institute, Kathmandu, Nepal; Health and Public Policy Department (C L Ranabhat PhD), Global Center for Research and Development, Kathmandu, Nepal; Data Analytic Services Department (D P Rasali PhD), British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Biomedical Engineering (Z Ratan MSc), Khulna University of Engineering and Technology, Khulna, Bangladesh; University College London Hospitals, London, UK (D L Rawaf MD); School of Health, Medical and Applied Sciences (L Rawal PhD), CQ University, Sydney, NSW, Australia; School of Medicine (Prof A M N Renzaho PhD), Translational Health Research Institute (Prof A M N Renzaho PhD), Western Sydney University, Campbelltown, NSW, Australia; Eye and Skull Base Research Centers (S Rezaei MD), Rassoul Akram Hospital, Tehran, Iran; Department of Epidemiology and Biostatistics (Prof M Rezaeian PhD), Department of Neurology (A Vakilian MD), Non-communicable Diseases Research Center (A Vakilian MD), Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Cardiovascular Diseases Research Center (S Riahi PhD, F Saeedi MD), Birjand University of Medical Sciences, Birjand, Iran; Clinical and Epidemiological Research in Primary Care (GICEAP) (E Romero-Rodríguez PhD), Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain; Research and Development (Prof U Saeed PhD), Islamabad Diagnostic Center Pakistan, Islamabad, Pakistan; Biological Production Division (Prof U Saeed PhD), National Institute of Health, Islamabad, Pakistan; Department of Development Studies (H Sahoo PhD), International Institute for Population Sciences, Mumbai, India; Health Systems and Population Studies Division (K Saif-Ur-Rahman MPH), International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of Public Health and Health Systems (K Saif-Ur-Rahman MPH), Nagoya University, Nagoya, Japan; Advanced Therapy Medicinal Products Department (S Salahi MD), Royan Institution, Tehran, Iran; Department of Entomology (A M Samy PhD), Ain Shams University, Cairo, Egypt; Department of Biomedical and Neuromotor Sciences (F Sanmarchi MD), University of Bologna, Bologna, Italy; Health Policy Research Center (Y Sarikhani PhD), Shiraz University of Medical Sciences, Shiraz, Iran; Faculty of Health & Social Sciences (B Sathian PhD), Bournemouth University, Bournemouth, UK; Department of Preventive and Social Medicine (G Saya MD), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India; Education Development Center (M Sayyah MD), Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; The George Institute for Global Health, Sydney, NSW, Australia (Prof A E Schutte PhD); Department of Methodology and Innovation in Prevention (M Schwarzinger MD), University Hospital of Bordeaux, France, Bordeaux, France; University of Bordeaux, Inserm UMR 1219-Bordeaux Population Health (M Schwarzinger MD), Inserm, Bordeaux, France; Department of Psychology (D C Schwebel PhD), School of Medicine (Prof J A Singh MD), University of Alabama at Birmingham, Birmingham, AL, USA; Department of Population and Health (A Seidu MPhil), University of Cape Coast, Cape Coast, Ghana; College of Public Health, Medical and Veterinary Sciences (A Seidu MPhil), James Cook University, Townsville, QLD, Australia; Department of Biotechnology (Prof N Senthil Kumar PhD), Mizoram University, Aizawl, India; National Heart, Lung, and Blood Institute (A Seylani BS), National Institute of Health, Rockville, MD, USA; Center for Biomedical Information Technology (F Sha PhD), Shenzhen Institutes of Advanced Technology, Shenzhen, China; Neuroimmunulogy Department (S Shahrokhi MD), Universal Scientific Research Network (USERN), Tehran, Iran; Independent Consultant, Karachi, Pakistan (M A Shaikh MD); Infectious Diseases Department (Prof M Z Shakhmardanov PhD), Department of Infectious Diseases and Epidemiology (A A Skryabina MD), Pirogov Russian National Research Medical University, Moscow, Russia; School of Medicine (M Shams-Beyranvand MSc), Alborz University of Medical Sciences, Karaj, Iran; National Institute of Infectious Diseases, Tokyo, Japan (M Shigematsu PhD); Finnish Institute of Occupational Health, Helsinki, Finland (R Shiri PhD); Public Health Dentistry Department (Prof K M Shivakumar PhD), Krishna Institute of Medical Sciences Deemed to be University, Karad, India; Department of Clinical Immunology and Hematology (V Shivarov PhD), Sofiamed University Hospital, Sofia, Bulgaria; Department of Genetics (V Shivarov PhD), Sofia University “St. Kliment Ohridiski”, Sofia, Bulgaria; Department of Psychology (Prof I D Sigfusdottir PhD), Reykjavik University, Reykjavik, Iceland; Portuguese Institute of Sport and Youth, Lisbon, Portugal (N T d Silva MPsych); Medicine Service (Prof J A Singh MD), US Department of Veterans Affairs (VA), Birmingham, AL, USA; Department No.16 (V Y Skryabin MD), Moscow Research and Practical Centre on Addictions, Moscow, Russia; Division of Injury Prevention (Prof D A Sleet PhD), The Bizzell Group, Atlanta, GA, USA; Rollins School of Public Health (Prof D A Sleet PhD), Emory University, Atlanta, GA, USA; Department of Psychiatry (M Solmi MD), University of Ottawa, Ottawa, ON, Canada; Department of Nursing (Y SOLOMON MSc), Dire Dawa University, Dire Dawa, Ethiopia; Taub Institute for Research on Alzheimer’s Disease and the Aging Brain (S Song PhD), Columbia University Medical Center, New York, NY, USA; Department of Land Surveying and Geo-Informatics (Y Song PhD), Hong Kong Polytechnic University, Hong Kong, China; Laboratory of Public Health Indicators Analysis and Health Digitalization (S Soshnikov PhD), Moscow Institute of Physics and Technology, Moscow, Russia; Hull York Medical School (I N Soyiri PhD), University of Hull, Hull City, UK; Department of Community Medicine and Family Medicine (Prof S H Subba MD), All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India; Carlos III Health Institute (Prof R Tabarés-Seisdedos PhD), Biomedical Research Networking Center for Mental Health Network (CiberSAM), Madrid, Spain; Cancer Control Center (T Tabuchi MD), Osaka International Cancer Institute, Osaka, Japan; HIV Health Promotion Division (E E Tarkang PhD), HIV/AIDS Prevention Research Network, Cameroon, Kumba, Cameroon; Department of Public Health and Community Medicine (Prof K R Thankappan MD), Central University of Kerala, Kasaragod, India; Gastroenterology Department (N K Thomas MD), PSG Institute of Medical Sciences and Research, Coimbatore, India; Psychiatry and Medical Psychology Department (M Torrado PhD), University of Lisbon, Lisbon, Portugal; Child and Adolescent Mental Health Services (CAMHS) (M Torrado PhD), Hospital Garcia de Orta, Almada, Portugal; Nutritional Epidemiology Research Team EREN (M Touvier PhD), National Institute for Health and Medical Research INSERM, Paris, France; Health, Medicine and Human Biology (M Touvier PhD), Sorbonne Paris Nord University, Bobigny, France; Department of Pathology and Legal Medicine (M R Tovani-Palone PhD), University of São Paulo, Ribeirão Preto, Brazil; Modestum LTD, London, UK (M R Tovani-Palone PhD); Health Informatic Department, Nursing and Midwifery Faculty (M T N Tran PhD), Hanoi Medical University, Ha Noi, Vietnam; Department of Community Medicine (J P Tripathy MD), All India Institute of Medical Sciences, Nagpur, India; UKK Institute, Tampere, Finland (Prof T J Vasankari MD); Faculty of Medicine and Health Technology (Prof T J Vasankari MD), Tampere University, Tampere, Finland; Infection Prevention & Control and Water, Sanitation and Hygiene Unit (B Wagaye MPH), Ethiopian Public Health Institute, Addis Ababa, Ethiopia; Foundation University Medical College (Prof Y Waheed PhD), Foundation University Islamabad, Islamabad, Pakistan; Department of Medicine (C Wang MPH), Vanderbilt University, Nashville, TN, USA; School of Population Health and Environmental Sciences (Y Wang PhD), King’s College London, London, UK; Competence Center of Mortality-Follow-Up of the German National Cohort (R Westerman DSc), Federal Institute for Population Research, Wiesbaden, Germany; Department of Community Medicine (N D Wickramasinghe MD), Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka; Department of Endocrinology, First Affiliated Hospital (Prof S Xu PhD), University of Science and Technology of China, Hefei, China; School of Medicine and Dentistry (Prof S Xu PhD), University of Rochester, Rochester, NY, USA; Cancer Epidemiology and Prevention Research (L Yang PhD), Alberta Health Services, Calgary, BC, Canada; Department of Oncology (L Yang PhD), University of Calgary, Calgary, AB, Canada; Department of Health Management (A Yigit PhD, V Yiğit PhD), Süleyman Demirel Üniversitesi (Süleyman Demirel University), Isparta, Turkey; Department of Pediatrics (D Yon MD), Kyung Hee University, Seoul, South Korea; Department of Neuropsychopharmacology (N Yonemoto PhD), National Center of Neurology and Psychiatry, Kodaira, Japan; Department of Public Health (N Yonemoto PhD), Juntendo University, Tokyo, Japan; Duke Global Health Institute (S Zadey MS), Duke University, Durham, NC, USA; Faculty of Medicine (M Zahir MD), Islamic Azad University, Tehran, Iran; Research and Development Department (I Zare BSc), Sina Medical Biochemistry Technologies, Shiraz, Iran; Department of Bioengineering and Therapeutic Sciences (Prof M S Zastrozhin PhD), University of California San Francisco, San Francisco, CA, USA; Addictology Department (Prof M S Zastrozhin PhD), Russian Medical Academy of Continuous Professional Education, Moscow, Russia; Peoples’ Friendship University of Russia, Moscow, Russia (A Zastrozhina PhD); Health Technology Assessment Unit (Y H Zuniga BS), Department of Health Philippines, Manila, Philippines; #MentalHealthPH, Inc., Quezon City, Philippines (Y H Zuniga BS).
Contributors
Please see appendix 1 (pp 50–55) for more detailed information about individual author contributions to the research, divided into the following categories: managing the overall research enterprise; writing the first draft of the manuscript; primary responsibility for applying analytical methods to produce estimates; primary responsibility for seeking, cataloguing, extracting, or cleaning data; designing or coding figures and tables; providing data or critical feedback on data sources; developing methods or computational machinery; providing critical feedback on methods or results; drafting the manuscript or revising it critically for important intellectual content; and managing the estimation or publications process. Members of the core research team for this topic area had full access to the underlying data used to generate estimates presented in this Article. All other authors had access to and reviewed estimates as part of the research evaluation process, which includes additional stages of formal review.
Data sharing
For access to the data used for this specific analysis before the full publication of GBD 2020, please contact Emmanuela Gakidou at [email protected] .
Declaration of interests
O M Adebayo reports grants or contracts from Merck Foundation and Servier Nigeria; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Merck Foundation; support for attending meetings or travel from Servier Nigeria; and a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Nigerian Association of Resident Doctors; all outside the submitted work. S Afzal reports honorary participation on the Institutional Review Board of King Edward Medical University (Lahore, Pakistan), the Quality Enhancement Cell at Fatima Jinnah Medical University (Lahore, Pakistan), and the Corona Expert Advisory Group (Pakistan); an unpaid leadership or fiduciary role in board, society, committee or advocacy group, with the Pakistan Society of Community Medicine & Public Health, Pakistan Association of Medical Editors, and Pakistan Society of Medical Infectious Diseases; all outside the submitted work. R Ancuceanu reports consulting fees from AbbVie; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AbbVie, B. Braun Medical, Sandoz, and Laropharm; all outside the submitted work. P Atorkey reports support for the present manuscript via funding from the School of Medicine and Public Health, The University of Newcastle (Callaghan, NSW, Australia), and infrastructure support from Hunter New England-Population Health and Hunger Medical Research Institute, Australia. M Ausloos reports a research grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI (project number: PN-III-P4-ID-PCCF-2016-0084, title: “Understanding and modelling time-space patterns of psychology-related inequalities and polarization”) outside the submitted work. T Bärnighausen reports grants from the European Union (Horizon 2020 and EIT Health), German Research Foundation (DFG), US National Institutes of Health, German Ministry of Education and Research, Alexander von Humboldt Foundation, Else-Kröner-Fresenius-Foundation, Wellcome Trust, Bill & Melinda Gates Foundation, KfW, Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization; consulting fees from KfW for the OSCAR initiative in Vietnam; participation on a Data Safety Monitoring Board or Advisory Board with National Institutes of Health (US)-funded study “Healthy Options” (PIs: Smith Fawzi, Kaaya) as Chair of the Data Safety and Monitoring Board, with the German National Committee on the “Future of Public Health Research and Education”, as chair of the scientific advisory board to the EDCTP Evaluation, as a member of the UNAIDS Evaluation Expert Advisory Committee, as a National Institutes of Health (US) Study Section Member on Population and Public Health Approaches to HIV/AIDS (PPAH), with the US National Academies of Sciences, Engineering, and Medicine’s Committee for the “Evaluation of Human Resources for Health in the Republic of Rwanda under the President’s Emergency Plan for AIDS Relief (PEPFAR)”, with the University of Pennsylvania Population Aging Research Center (PARC) as an External Advisory Board Member; leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Global Health Hub Germany (which was initiated by the German Ministry of Health) as a co-chair; all outside the submitted work. S M M Bhaskar reports grants or contracts from the NSW Ministry of Health, Australia; a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Rotary Club of Sydney as board director, with the International Rotary Fellowship of Healthcare Professionals (UK) as board director, with Global Health & Migration Hub Community, Global Health Hub Germany, Berlin as a chair or manager; all outside the submitted work. J M Castaldelli-Maia reports grants or contracts from Pfizer (Independent Grants for Learning and Change) and the French National Institute for Cancer (INCa); consulting fees from L’Oreal Mental Health Wellness International Board; all outside the submitted work. S Costanzo reports a research grant from the European Foundation for Alcohol Research (ERAB) (ID EA1767; 2018-2020); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from The Dutch Beer Institute Foundation – The Brewers of Europe as a member of the Organizing Committee and speaker for the 9th European Beer and Health Symposium (Bruxelles 2019), and for giving a lecture at the 13th European Nutrition Conference FENS 2019 (Dublin), sponsored by the Beer and Health Initiative (The Dutch Beer Institute foundation – The Brewers of Europe); all outside the submitted work. I Filip reports financial or non-financial support from the Avicenna Medical and Clinical Research Institute (California, USA). R C Franklin reports leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid with Kidsafe, Farmsafe, Royal Life Saving Society – Australia, and PHAA – Injury Prevention SIG outside the submitted work. C Herteliu reports research grants from the Romanian Ministry of Research Innovation and Digitalization, MCID (ID-585-CTR-42-PFE-2021, Jan 2022-Jun 2023, “Enhancing institutional performance through development of infrastructure and transdisciplinary research ecosystem within socio-economic domain – PERFECTIS”), the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI (PN-III-P4-ID-PCCF-2016-0084, October, 2018, to September, 2022, “Understanding and modelling time-space patterns of psychology-related inequalities and polarization”; PN-III-P2-2.1-SOL-2020-2-0351, June, 2020, to October, 2020, “Approaches within public health management in the context of COVID-19 pandemic”), and the Ministry of Labour and Social Justice, Romania (30/PSCD/2018, September, 2018, to June, 2019, “Agenda for skills Romania 2020-2025”), all outside the submitted work. J J Jozwiak reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Teva Pharmaceuticals, Amgen, Synexus, Boehringer Ingelheim, ALAB Laboratories, and Zentiva, outside the submitted work. M Kivimäki reports support for the present manuscript from the Wellcome Trust (221854/Z/20/Z), the UK Medical Research Council (MR/S011676/1), the US National Institute on Aging (R01AG056477), and the Academy of Finland (350426) in the form of research grants to their institution. K Krishan reports non-financial support from the UGC Centre of Advanced Study (Phase II), Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. S Lorkowski reports grants or contracts paid to his institution from Akcea Therapeutics Germany; consulting fees from Danone, Novartis Pharma, Swedish Orphan Biovitrum (SOBI), and Upfield; payment or honoraria for lectures, presentations, speaker’s bureaus, manuscript writing, or educational events from Akcea Therapeutics Germany, Amarin Germany, Amedes Holding, Amgen, Berlin-Chemie, Boehringer Ingelheim, Daiichi Sankyo Deutschland, Danone, Hubert Burda Media Holding, Janssen-Cilag, Lilly Deutschland, Novartis, Novo Nordisk, F Hoffmann-La Roche (Roche), Sanofi-Aventis, SYNLAB Holding Deutschland, and SYNLAB Akademie; support for attending meetings or travel from Amgen; and participation on a data safety monitoring board or advisory board for Akcea Therapeutics Germany, Amgen, Daiichi Sankyo Deutschland, Novartis, and Sanofi-Aventis; all outside the submitted work. A M Madureira-Carvalho reports grants or contracts from Instituto Universitário de Ciências da Saúde (Gandra, Portugal); consulting fees from Albert Labs and Eurox Pharma paid to her and her institution; a leadership or fiduciary role in a board, society, committee or advocacy group, paid or unpaid, with the Portuguese Association of Forensic Sciences (APCF); all outside the submitted work. A-F A Mentis reports grants or contracts from “MilkSafe: A novel pipeline to enrich formula milk using omics technologies”, a research co-financed by the European Regional Development Fund of the European Union and Greek national funds through the Operational Program Competitiveness, Entrepreneurship and Innovation, under the call RESEARCH – CREATE – INNOVATE (project code: T2EDK-02222), as well as from ELIDEK (Hellenic Foundation for Research and Innovation, MIMS-860); stock or stock options in a family winery; and support from BGI Group as a scientific officer; all outside the submitted work. C D H Parry reports grants or contracts from the South African Medical Research Council paid to their institution; consulting fees paid to them from the World Health Organization (WHO) and the University of Cape Town (Cape Town, South Africa); payment or honoraria for a lecture on alcohol & NCDs in 2020 from the University of Cape Town; support for attending meetings or travel from UCT African Union 2022, UN Office on Drugs & Crime 2019, and WHO meeting on alcohol in Uganda 2021; participation on a Data Safety Monitoring Board or Advisory Board with the UK SPECTRUM Project (multi university) Global Advisory Board, and the UN Office on Drugs & Crime WDR Scientific Advisory Board, both unpaid; all outside the submitted work. G A Roth reports support for the present manuscript from the Bill & Melinda Gates Foundation via a research grant to their institution. G A Roth reports grants or contracts from the American Heart Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute paid to their institution, outside the submitted work V Shivarov reports financial support from ICON plc. J A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, and Practice Point Communications, the National Institutes of Health, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel from the steering committee of OMERACT; participation on a Data Safety Monitoring Board or Advisory Board with the US Food and Drug Administration Arthritis Advisory Committee; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid, with OMERACT as a steering committee member, with the Veterans Affairs Rheumatology Field Advisory Committee as Chair (unpaid), and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis and editor and director (unpaid); stock or stock options in TPT Global Tech, Vaxart Pharmaceuticals, Aytu BioPharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals and Charlotte’s Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna Pharmaceuticals; all outside the submitted work.
Acknowledgments
Research reported in this publication was supported by the Bill & Melinda Gates Foundation. S Afzal acknowledges the support for intellectual contributions to this manuscript by the Department of Community Medicine and Epidemiology at King Edward Medical University, Lahore, Pakistan. T Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. L Belo acknowledges support from FCT in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of UCIBIO and the project LA/P/0140/2020 of i4HB. D Bennett is supported by the UK Medical Research Council Population Health Research Unit at the University of Oxford (Oxford, UK). M Carvalho acknowledges support from FCT in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of UCIBIO and the project LA/P/0140/2020 of i4HB. L Castro-de-Araujo was funded by the Medical Research Council (UK), Grant no. MR/T03355X/1 and by the National Institute of Mental Health Grant no. R01MH128911. FJ Elgar is supported by the Canada Research Chairs program. F Greaves acknowledges support from the NIHR Applied Research Collaboration for NW London. V K Gupta acknowledges funding support from the National Health and Medical Research Council (NHMRC), Australia. VB Gupta acknowledges funding support from the National Health and Medical Research Council (NHMRC), Australia. C Herteliu is partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. C Herteliu is partially supported by a grant from the Romanian Ministry of Research Innovation and Digitalization, MCID, project number ID-585-CTR-42-PFE-2021. S Hussain was supported by the Operational Programme Research, Development and Education –Project, Postdoc2MUNI “(No. CZ.02.2.69/0.0/0.0/18_053/0016952). S M S Islam is funded by the National Health and Medical Research Council and received funding from the National Heart Foundation of Australia. The Serbian part of this GBD-related contribution has been co-financed through Grant OI 175 014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. M Kivimaki was supported by the Wellcome Trust (221854/Z/20/Z), the UK Medical Research Council (MR/S011676/1), the US National Institute on Aging (R01AG056477), and the Academy of Finland (350426). K Krishan is supported by the UGC Centre of Advanced Study (Phase II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. B Lacey acknowledges support from the UK Biobank, funded largely by the UK Medical Research Council and Wellcome. S Lorkowski acknowledges institutional support from the Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD) Halle-Jena-Leipzig (Germany; German Federal Ministry of Education and Research; grant agreement number 01EA1808A). G Lucchetti received a productivity scholarship from the Brazilian National Council for Scientific and Technological Development — CNPq (Level 1D). J McGrath was supported by the Danish National Research Foundation (Niels Bohr Professor). J McGrath is employed by the Queensland Centre for Mental Health Research (Australia), which receives support from the Queensland Health Department. C Parry acknowleges the South African Medical Research Council. A Peden is supported by a National Health and Medical Research Council Emerging Leadership Fellowship (Grant ID: APP2009306). M R Phillips was supported in part by the Global Alliance for Chronic Diseases – National Natural Science Foundation of China (NSFC. No. 81761128031). M Pinheiro acknowledges FCT for funding through program DL 57/2016 – Norma transitória. A Rahman acknowledges the support from the Data Science Research Unit in Charles Sturt University (Bathurst, NSW, Australia). U Saeed would like to acknowledge the International Center of Medical Sciences Research (ICMSR), Islamabad, Pakistan. A M Samy acknowledges support from Ain Shams University (Cairo, Egypt) and the Egyptian Fulbright Mission Program. N Senthil Kumar acknowledges the DBT, New Delhi sponsored Advanced State Level Biotech Hub (BT/NER/143/SP44475/2021), Mizoram University (Aizawl, Mizoram, India) for facilitating this work. F Sha is supported by the Shenzhen Science and Technology Program (Grant No. KQTD20190929172835662). A Shetty acknowledges Kasturba Medical College (Mangalore, India) and Manipal Academy of Higher Education (Manipal, India) for all the academic support. R Shrestha acknowledges a career development award from the National Institutes of Health (K01DA051346). D Silva was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES)—Finance Code 001 and is supported in part by CNPq – Brazil (309589/2021-5). D Sleet acknowledges partial support from Veritas Management Group, Inc and The Bizzell Group, LLC. S Trias-Llimós acknowledges research funding from the Juan de la Cierva-Formación program of the Spanish Ministry of Science and Innovation (FJC-2019-039314-I).
Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
Supplementary Materials
References
1.
Griswold MG
Fullman N
Hawley C
et al.
Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
Lancet.2018; 392: 1015-1035
2.
Shield K
Manthey J
Rylett M
et al.
National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study.
Lancet Public Health.2020; 5: e51-e61
3.
Wood AM
Kaptoge S
Butterworth AS
et al.
Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies.
Lancet.2018; 391: 1513-1523
4.
Rehm J
Gmel Sr, GE
Gmel G
et al.
The relationship between different dimensions of alcohol use and the burden of disease-an update.
Addiction.2017; 112: 968-1001
5.
Millwood IY
Walters RG
Mei XW
et al.
Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China.
Lancet.2019; 393: 1831-1842
6.
van de Luitgaarden IAT
van Oort S
Bouman EJ
et al.
Alcohol consumption in relation to cardiovascular diseases and mortality: a systematic review of Mendelian randomization studies.
Eur J Epidemiol.2021; ()
7.
Liu Y
Nguyen N
Colditz GA
Links between alcohol consumption and breast cancer: a look at the evidence.
Womens Health.2015; 11: 65-77
8.
Imtiaz S
Shield KD
Roerecke M
Samokhvalov AV
Lönnroth K
Rehm J
Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease.
Eur Respir J.2017; 50: 50
9.
Taylor B
Irving HM
Kanteres F
et al.
The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together.
Drug Alcohol Depend.2010; 110: 108-116
10.
Roerecke M
Vafaei A
Hasan OSM
et al.
Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis.
Am J Gastroenterol.2019; 114: 1574-1586
11.
Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers.
BMC Med.2014; 12: 182
12.
Pietraszek A
Gregersen S
Hermansen K
Alcohol and type 2 diabetes. A review.
Nutr Metab Cardiovasc Dis.2010; 20: 366-375
13.
Ding C
O’Neill D
Bell S
Stamatakis E
Britton A
Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women.
BMC Med.2021; 19: 167
14.
Sherk A
Gilmore W
Churchill S
Lensvelt E
Stockwell T
Chikritzhs T
Implications of cardioprotective assumptions for national drinking guidelines and alcohol harm monitoring systems.
Int J Environ Res Public Health.2019; 16E4956
15.
Sherk A
Thomas G
Churchill S
Stockwell T
Does drinking within low-risk guidelines prevent harm? Implications for high-income countries using the international model of alcohol harms and policies.
J Stud Alcohol Drugs.2020; 81: 352-361
16.
Global status report on alcohol and health 2018.
17.
Corrao G
Bagnardi V
Zambon A
La Vecchia C
A meta-analysis of alcohol consumption and the risk of 15 diseases.
Prev Med.2004; 38: 613-619
18.
Xi B
Veeranki SP
Zhao M
Ma C
Yan Y
Mi J
Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults.
J Am Coll Cardiol.2017; 70: 913-922
19.
Alcohol consumption levels as compared with drinking habits in predicting all-cause mortality and cause-specific mortality in current drinkers.
Mayo Clin Proc.2021; 96: 1758-1769
20.
Patra J
Buckley C
Kerr WC
Brennan A
Purshouse RC
Rehm J
Impact of body mass and alcohol consumption on all-cause and liver mortality in 240 000 adults in the United States.
Drug Alcohol Rev.2021; 40: 1061-1070
21.
Habtemichael LH
Djekic D
Rosengren AR
et al.
Alcohol consumption in young men and risk of heart failure and all-cause mortality—a cohort study.
Eur Heart J.2021; 42 ()
22.
Fillmore KM
Stockwell T
Chikritzhs T
Bostrom A
Kerr W
Moderate alcohol use and reduced mortality risk: systematic error in prospective studies and new hypotheses.
Ann Epidemiol.2007; 17: S16-S23
23.
Wallach JD
Serghiou S
Chu L
et al.
Evaluation of confounding in epidemiologic studies assessing alcohol consumption on the risk of ischemic heart disease.
BMC Med Res Methodol.2020; 20: 64
24.
Dietary Guidelines Advisory Committee
Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and Secretary of Health and Human Services.
US Department of Agriculture, Agricultural Research Service, Washington, DC2020
25.
UK Chief Medical Officers’ Alcohol Guidelines Review. Summary of the proposed new guidelines.
26.
Alcool et santé: améliorer les connaissances et réduire les risques.
27.
Australian guidelines to reduce health risks from drinking alcohol.
National Health and Medical Research Council, Canberra2020
28.
Stockwell T
Zhao J
Panwar S
Roemer A
Naimi T
Chikritzhs T
Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality.
J Stud Alcohol Drugs.2016; 77: 185-198
29.
Why the relationship between level of alcohol-use and all-cause mortality cannot be addressed with meta-analyses of cohort studies.
Drug Alcohol Rev.2019; 38: 3-4
30.
Institute for Health Metrics and Evaluation
Protocol for the global burden of diseases, injuries, and risk factors study (GBD).
31.
Murray CJL
Aravkin AY
Zheng P
et al.
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.
Lancet.2020; 396: 1223-1249
32.
Stevens GA
Alkema L
Black RE
et al.
Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.
Lancet.2016; 388: e19-e23
33.
An integrative metaregression framework for descriptive epidemiology.
1st edn. University of Washington Press, Seattle, WA2015
34.
Rehm J
Crépault J-F
Wettlaufer A
Manthey J
Shield K
What is the best indicator of the harmful use of alcohol? A narrative review.
Drug Alcohol Rev.2020; 39: 624-631
35.
Chisholm D
Moro D
Bertram M
et al.
Are the “best buys” for alcohol control still valid? An update on the comparative cost-effectiveness of alcohol control strategies at the global level.
J Stud Alcohol Drugs.2018; 79: 514-522
36.
Brand DA
Saisana M
Rynn LA
Pennoni F
Lowenfels AB
Comparative analysis of alcohol control policies in 30 countries.
PLoS Med.2007; 4: e151
37.
Ferreira-Borges C
Esser MB
Dias S
Babor T
Parry CDH
Alcohol control policies in 46 African countries: opportunities for improvement.
Alcohol Alcohol.2015; 50: 470-476
38.
Burton R
Henn C
Lavoie D
et al.
A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective.
Lancet.2017; 389: 1558-1580
39.
Howard SJ
Gordon R
Jones SC
Australian alcohol policy 2001–2013 and implications for public health.
BMC Public Health.2014; 14: 848
40.
Neufeld M
Ferreira-Borges C
Gil A
Manthey J
Rehm J
Alcohol policy has saved lives in the Russian Federation.
Int J Drug Policy.2020; 80102636
41.
Governmental standard drink definitions and low-risk alcohol consumption guidelines in 37 countries.
Addiction.2016; 111: 1293-1298
42.
Moore AA
Whiteman EJ
Ward KT
Risks of combined alcohol/medication use in older adults.
Am J Geriatr Pharmacother.2007; 5: 64-74
43.
Ryan M
Merrick EL
Hodgkin D
et al.
Drinking patterns of older adults with chronic medical conditions.
J Gen Intern Med.2013; 28: 1326-1332
44.
The genetics of alcohol metabolism: role of alcohol dehydrogenase and aldehyde dehydrogenase variants.
Alcohol Res Health.2007; 30: 5-13
45.
Chrystoja BR
Rehm J
Manthey J
Probst C
Wettlaufer A
Shield KD
A systematic comparison of the global comparative risk assessments for alcohol.
Addiction.2021; 116: 2026-2038
46.
Manthey J
Shield KD
Rylett M
Hasan OSM
Probst C
Rehm J
Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study.
Lancet.2019; 393: 2493-2502
47.
Grossman ER
Benjamin-Neelon SE
Sonnenschein S
Alcohol consumption during the COVID-19 pandemic: a cross-sectional survey of US adults.
Complex relationship between health and moderate alcohol use
In The Lancet, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 Alcohol Collaborators1 provide a further study to systematically determine thresholds for low-risk alcohol consumption while considering background rates of disease. Overall, the authors estimated the amount of alcohol that minimises health risks to be between 0 (95% uncertainty interval 0–0) and 1·87 (0·50–3·30) standard drinks per day. Levels of zero, or very close to zero, were observed among individuals aged 15–39 years (ranging from 0 to 0·603 standard drinks per day), but higher levels were reported for individuals aged 40 years and older (ranging from 0·114 to 1·87 standard drinks per day).
RICHMOND, Australia (AP) — Hundreds of homes have been inundated in and around Australia’s largest city in a flood emergency that was causing trouble for 50,000 people, officials said Tuesday.
Emergency response teams made 100 rescues overnight of people trapped in cars on flooded roads or in inundated homes in the Sydney area, State Emergency Service manager Ashley Sullivan said.
Days of torrential rain have caused dams to overflow and waterways to break their banks, bringing a fourth flood emergency in 16 months to parts of the city of 5 million people.
Evacuation orders and warnings to prepare to abandon homes were given to 50,000 people, up from 32,000 on Monday, New South Wales Premier Dominic Perrottet said.
“This event is far from over. Please don’t be complacent, wherever you are. Please be careful when you’re driving on our roads. There is still substantial risk for flash flooding across our state,” Perrottet said.
The New South Wales state government declared a disaster across 23 local government areas overnight, activating federal government financial assistance for flood victims.
Emergency Services Minister Steph Cooke credited the skill and commitment of rescue crews for preventing any death or serious injury by the fourth day of the flooding emergency.
Parts of southern Sydney had been lashed by more than 20 centimeters (nearly 8 inches) of rain in 24 hours, more than 17% of the city’s annual average, Bureau of Meteorology meteorologist Jonathan How said.
Severe weather warnings of heavy rain remained in place across Sydney’s eastern suburbs on Tuesday. The warnings also extended north of Sydney along the coast and into the Hunter Valley.
The worst flooding was along the Hawkesbury-Nepean river system along Sydney’s northern and western fringes.
“The good news is that by tomorrow afternoon, it is looking to be mostly dry but, of course, we are reminding people that these floodwaters will remain very high well after the rain has stopped,” How said.
“There was plenty of rain fall overnight and that is actually seeing some rivers peak for a second time. So you’ve got to take many days, if not a week, to start to see these floodwaters start to recede,” How added.
Residents of Lansvale, in southwest Sydney, were surprised by the speed at which their area became inundated and the growing frequency of such flooding.
“Well, it happened in 1986 and ’88, then it didn’t happen for 28 years and, so, 2016 and 2020 and now it’s happened four times this year,” a Lansvale local identified only as Terry told Australian Broadcasting Corp. television of his home being flooded.
The wild weather and mountainous seas along the New South Wales coast thwarted plans to tow a stricken cargo ship with 21 crew members to the safety of open sea.
The ship lost power after leaving port in Wollongong, south of Sydney, on Monday morning and risked being grounded by 8-meter (26-foot) swells and winds blowing at 30 knots (34 mph) against cliffs.
An attempt to tow the ship with tugboats into open ocean ended when a towline snapped in an 11-meter (36-foot) swell late Monday, Port Authority chief executive Philip Holliday said.
The ship was maintaining its position Tuesday farther from the coast than it had been on Monday with two anchors and the help of two tugboats. The original plan had been for the ship’s crew to repair their engine at sea. The new plan was to tow the ship to Sydney when weather and sea conditions calmed as early as Wednesday, Holliday said.
“We’re in a better position than we were yesterday,” Holliday said. “We’re in relative safety.”
Perrottet described the tugboat crews’ response on Monday to save the ship as “heroic.”
“I want to thank those men and women who were on those crews last night for the heroic work they did in incredibly treacherous conditions. To have an 11-meter (36-foot) swell, to be undergoing and carrying out that work is incredibly impressive,” Perrottet said.
She has found some solace in online support groups that connect her with others who are trying to navigate recovery and career changes, she said.
“I drop a lot of balls all the time that I never used to,” said Ms. Bailey, whose work as a campaigns coordinator for a charity in London was not renewed last year after her contract ended. “I don’t really know where to go next. I can’t do the jobs I loved before.”
‘Another unequal burden’
Some countries in Western Europe have robust policies to protect those with disabilities, said Philippa Dunne, one of the authors of a report published by the Solve Long Covid Initiative, a nonprofit research and advocacy group.
In the United States, however, there are fewer protections. Since people who are unvaccinated may be at a higher risk for developing long Covid, according to the Centers for Disease Control and Prevention, companies in regions with low vaccination rates, like the South, may have more worker shortages than those in regions with higher vaccination rates, Ms. Dunne said.
“It’s going to be another unequal burden,” Ms. Dunne said. “The South already has a much higher rate of people on disability than the Northeast and the Midwest. That also is going to be made worse.”
A major logistical hurdle in the United States for employees with long Covid is qualifying for unemployment benefits. There is no single test for diagnosing it, and it is only vaguely defined, with so much still unknown. That can make it harder for people to be diagnosed and gain access to disability benefits. It can also complicate responses from employers, who are still navigating how to handle coronavirus-related work issues, including the fraught issue of whether Covid vaccinations should be mandatory for workers.
Katie Brennan, an adviser for the Society for Human Resource Management, said employers must consider their legal obligations to employees under the federal Family and Medical Leave Act and the Americans With Disabilities Act. With F.M.L.A., eligible employees are entitled up to 12 weeks off, and state protections may also be in place, she said.
For some, a headache means you may need to pop an aspirin. But many among us are affected by more persistent and serious head pain; a new study has now estimated the extent of this disorder worldwide, and the data are staggering.
A team led by epidemiologists from the Norwegian University of Science and Technology summarized epidemiological headache studies from 1961 to the end of 2020; the data included general headaches, migraines, and tension-type headaches, revealing that 52 percent of us suffer from some form of headache disorder each year.
The 357 publications reviewed mostly came from high-income countries. The team included studies that sampled participants not just from clinical studies, but from a broad range of settings including company employees, university students, and hospital staff.
Taken together, the authors estimate that global prevalence for migraines is 14 percent, and 26 percent for tension-type headaches.
“Each day, 15.8 percent of the world’s population had headache,” the authors grimly point out.
Researchers also found that all types of headaches were more common in females than in males, with migraines showing the largest difference (17 percent in females and 8.6 percent in males). Women were also more likely to report their headaches as an ongoing health issue, with 6 percent of females reporting they had a headache on 15 or more days per month, compared to 2.9 percent in males.
Many of the studies analyzed made their own estimates of global headache prevalence, but these tended to vary widely.
Modeling showed that 6 percent of the variation in migraine estimates could be explained by the different years the studies were published, with prevalence estimates increasing with more recent publications. However, there was no relationship between the publication date and other headache types.
While it appears that migraine is increasing, the team notes that’s not the only possible explanation.
“The apparent increase in migraine prevalence over time may be real, perhaps related to environmental, physical, behavioral or psychological changes, but more probably it has to do with methodological developments over the years, leading to better techniques of access and engagement and improved diagnostic instruments,” say the authors.
When the authors took into account methodological factors such as screening questions, sample size, publication year, and how diagnostic criteria were applied, they could explain 29.9 percent of the variation in migraine estimates, and less for other headache categories.
Due to most of the studies reviewed coming from high-income countries with good healthcare systems, the authors caution against generalizing these findings to every country. If more data could be gathered from middle and low-income countries, we would get a more accurate global estimate.
While there remains some uncertainty as to the exact figures of headache prevalence globally, the review, along with other research, consistently demonstrates that headache conditions create a huge burden worldwide.
The 2019 iteration of the Global Burden of Disease study found that migraine alone was the second highest cause of disability, and first among women under 50 years of age, highlighting headache disorders as a major public health concern globally.
“We found that the prevalence of headache disorders remains high worldwide and the burden of different types may impact many. We should endeavor to reduce this burden through prevention and better treatment,” says neurologist Lars Jacob Stovner, from the Norwegian University of Science and Technology.
“To measure the effect of such efforts, we must be able to monitor prevalence and burden in societies. Our study helps us understand how to improve our methods.”
The study was published in The Journal of Headache and Pain.
Cash-strapped Sri Lanka has sought to reschedule its huge Chinese debt burden in talks with visiting foreign minister Wang Yi, the president’s office said.
“The president pointed out that it would be a great relief if debt payments could be rescheduled in view of the economic crisis following the pandemic,” President Gotabaya Rajapaksa’s office said in a statement on Sunday.
China is Sri Lanka’s biggest bilateral lender and Wang’s visit comes after a warning from international ratings agencies that Rajapaksa’s government could be on the brink of default.
The island’s tourism-dependent economy has been hammered by the pandemic and its depleted foreign exchange reserves have led to food rationing at supermarkets and shortages of essential goods.
There was no immediate comment from the Chinese embassy in Colombo.
Sri Lanka’s foreign reserves dropped to just $1.5bn at the end of November – enough to pay for only about a month’s worth of imports.
The island’s main energy utility began rationing electricity on Friday after running out of foreign currency to import oil for its thermal generators.
China accounted for about 10% of Sri Lanka’s $35bn foreign debt to April 2021, government data shows. Officials said China’s total lending could be much higher when taking into account loans to state-owned enterprises and the central bank.
Sri Lanka has borrowed heavily from China for infrastructure, some of which ended up as white elephants. Unable to repay a $1.4bn loan for a port construction in southern Sri Lanka, Colombo was forced to lease the facility to a Chinese company for 99 years in 2017.
The United States and India warned that the Hambantota port, located along vital east-west international shipping routes, could give China a military toehold in the Indian Ocean. Both Colombo and Beijing have denied that Sri Lankan ports will be used for any military purposes.
Wang arrived in Sri Lanka on Saturday night after visiting the nearby Maldives, in the final leg of his first foreign tour of 2022 which has also taken him to Eritrea, Kenya and the Comoros.
China offered the Maldives infrastructure maintenance, medical aid and visa concessions as Beijing moved to strengthen its connections with the strategically placed archipelago.
The NFL and the NFL Players Association continue to discuss changes to their COVID-19 protocols that could ease the burden on vaccinated individuals, according to sources familiar with the discussions.
The two sides are working to test vaccinated players less frequently and address player concerns about the number of vaccinated, asymptomatic players who are being forced to miss games because of positive tests.
The changes, which could be announced in the coming days, sources say, include an alteration to the testing procedures for vaccinated individuals. Currently, teams are required to test vaccinated individuals once a week. The discussions seem aimed at a new procedure that would remove that requirement and instead move to spot testing of vaccinated individuals — perhaps a handful each day, chosen at random — while also imposing more stringent symptom checks, sources say. Basically, vaccinated people who don’t show symptoms might get tested every once in a while as part of the spot-testing program, but those who do show symptoms would be checked by team doctors and tested.
Unvaccinated players would still have to be tested every day, as they have been all year. The league and the union say their data shows unvaccinated individuals testing positive at a rate 10 times higher than vaccinated individuals.
The league and the players’ union also are discussing providing home tests for players who are interested in them.
Additionally, the NFLPA has been pushing for an in-season opt-out option for players who are uncomfortable with the change in testing procedures, though it’s unclear whether the league will agree to that.
The NFLPA has been under pressure in recent weeks from players who are upset because they feel they were effectively forced to get vaccinated (because of the far stricter rules that apply this year to unvaccinated individuals) and as a result of the proliferation of COVID-19 variants are now testing positive and missing games anyway. This has led to player dissatisfaction with other of the league’s COVID-19 mitigation strategies, such as mask wearing and physical distancing in team facilities. The hope is that adjusting the testing procedures to make them more targeted and strategic will address some of those concerns.
The NFL and NFLPA already altered their COVID-19 protocols Thursday to make it easier for asymptomatic, vaccinated players to return to play more quickly following a positive test. They also agreed to reschedule three of this weekend’s games as a result of high numbers of COVID-19 cases with the Cleveland Browns, Los Angeles Rams and the Washington Football Team.
As part of Thursday’s changes, all 32 teams were placed in the league’s enhanced COVID-19 protocols, which include mandatory mask wearing for everyone, vaccinated or not, at team facilities as well as a prohibition on indoor, in-person meetings and restrictions on the use of cafeterias and weight rooms at team facilities. A source familiar with the ongoing discussions said it was likely all teams would be removed from the enhanced protocols sometime in the coming week.
TOKYO — One of the toughest places to be a woman in Japan is within its royal family.
Nearly three decades ago, Empress Michiko lost the ability to speak after public carping about her supposed shortcomings as the wife of Emperor Akihito. Ten years later, Michiko’s daughter-in-law, the current Empress Masako, retreated from public duties to cope with depression after the media harangued her for failing to produce a male heir.
Earlier this month, the imperial household revealed that Michiko’s granddaughter, Princess Mako, 30, had suffered from post-traumatic stress disorder because of unrelenting public disapproval of her choice of a fiancé, Kei Komuro, a recent law school graduate whom she will marry on Tuesday.
“She felt like her dignity as a human being had been trampled on,” Princess Mako’s psychiatrist said in a news conference, adding that “she thinks of herself as somebody without value.”
Whether they marry into the monarchy or are born into it, Japan’s royal women are held to ruthless standards not only by the press and the public, but also by the court officials who manage their daily lives. With the emperor and his family standing as symbols of traditional Japan, the royal women are subjected to a concentrated version of the broader gender inequality in the country, where a conservative streak in society often still consigns women to rigid roles.
Although imperial women are not eligible to sit on the throne, the criticism they receive can be harsher than for the men of the family, who are protected in part by their proximity to the line of succession.
“In addition to working as a royal, you have to maintain beautiful fashion, and after getting married, your purpose is to give birth,” said Rika Kayama, a professor and psychiatrist at Rikkyo University in Tokyo.
“Are you being a good mother? People will ask,” she added. “Do you have a good relationship with your mother-in-law? How are you supporting the men in your life? So many jobs must be done perfectly without a hitch. I don’t think men in the imperial family are looked at this closely.”
Japan is slowly changing, with two women standing for prime minister during a recent governing party leadership election. And some corporations are making concerted efforts to elevate more women into positions of authority.
But in many ways Japanese society still treats women as second-class citizens. Married couples are not legally allowed to have separate last names, a system that in practice means most women take their husband’s names. Women are still underrepresented in management, in Parliament and at the country’s prestigious universities.
Women who protest their unfair treatment or advocate for equal rights are often censured for stepping out of line. The kind of criticism hurled at Princess Mako on social media echoes the treatment of women who have spoken out about sexual assault or even workplace rules about wearing high heels.
In the imperial family, the women are expected to adhere to the values of an earlier era.
“There’s this idea that the imperial family is sort of timeless and they are not part of modern society,” said Mihoko Suzuki, founding director of the Center for the Humanities at the University of Miami, who has written about women in monarchies. Traditionalists, she said, want to “project this older, more comforting, stable idea about gender roles onto the imperial family.”
After World War II, the emperor was stripped of his godlike status under the new, American-imposed constitution. And in many ways, the three generations of royal women reflect the evolution of Japan in the decades since.
As the nation shed the shackles of its wartime history, Michiko became the first commoner in centuries to marry into the family. Rather than handing her children over to court chamberlains to raise, she cared for them herself. Accompanying her husband, Akihito, as he traveled throughout Japan and internationally, she brought a human touch to the previously distant imperial family, kneeling to talk to victims of disasters and to people with disabilities.
But when she renovated the imperial residence or wore too many different outfits, the press griped. Rumors spread that court officials and her mother-in-law did not consider her deferential enough.
In 1963, after a molar pregnancy just four years into her marriage, she underwent an abortion and retreated for more than two months to a villa, as speculation spread that she had suffered a nervous breakdown. Thirty years later, she succumbed to severe stress and lost her voice, recovering it only after several months.
Her daughter-in-law, Masako, was a Harvard graduate with a promising career as a fast-rising diplomat in 1993 when she married Naruhito, then the crown prince. Many commentators hoped she might help modernize the fusty royal family and serve as a role model to Japan’s young working women.
Instead, her every move was analyzed for its potential effect on her ability to bear a child. After a miscarriage, she gave birth to a girl, Princess Aiko, disappointing those who wanted a male heir. Court officials, protective of her womb, limited her travel, leading her to withdraw from public duties. She issued a statement saying that she was suffering “accumulated exhaustion, mental and physical.”
The most recent case, involving Princess Mako, shows that segments of the public want her to rise to royal expectations even though she will be forced to leave the family upon her marriage. The public has savagely judged her choice to marry Mr. Komuro, assailing his mother’s finances (and by extension branding him a gold digger) and calling him unfit to be the spouse of an imperial daughter. Yet under Japanese law, Mako will lose her imperial standing once the marriage papers are filed.
Eight other princesses have married out of the family and been stripped of their monarchical status, though none have been subjected to attacks like those against Princess Mako.
“I find it very, very odd that the Japanese people believe that they should have a say in any shape or form in who she marries,” said Kenneth J. Ruoff, a historian and specialist in the Japanese imperial family at Portland State University.
Princess Mako’s father, Crown Prince Akishino, originally withheld approval of the marriage after the couple announced their engagement in 2017, saying he wanted the public to accept the match before he gave his blessing.
Some seem to have taken the crown prince’s words to heart.
He “said that they should get married with the blessing of the people, so even he said that we have the right to give input,” said Yoko Nishimura, 55, who was taking a walk inside the gardens of the Imperial Palace in Tokyo last week. “I think the Japanese feel like since the imperial family represents them in a way, we have the right to give our opinions.”
Crown Prince Akishino eventually relented, but the ceaseless commentary in the mainstream press and on social media took its toll.
Even as the couple have quietly prepared for a private registration of their marriage without royal pomp, the attacks have not stopped. In recent weeks, protesters have marched in Ginza, a popular shopping district, bearing signs reading “Do not pollute imperial household with this cursed marriage” and “Fulfill your responsibilities before you get married.”
A writer in Gendai Business, a weekly magazine, fulminated against Princess Mako’s choice, saying she would “expose Japan to shame internationally.” On Twitter, some have called her a “tax thief,” even though she has decided to renounce a royal dowry worth about $1.4 million. Others have accused the princess of faking her post-traumatic stress.
“The public will be suspicious of you if you announce in a few months that you have gotten better,” wrote one user on Twitter.
Comparisons to the British royal family are perhaps inevitable. Before her marriage to Prince Harry, Meghan Markle endured months of attacks because of her family’s background. Like Meghan and Harry, Princess Mako and Mr. Komuro, a graduate of Fordham Law School, are expected to flee to the United States, where Mr. Komuro works in a New York law office.
Both Harry and Meghan have spoken openly about the cost to their mental health. Prince Harry’s frankness about his depression over the death of his mother, Diana, who also suffered from depression and eating disorders, has helped open conversations about mental health in Britain.
Japan’s royal women, too, may inspire more discussion about mental health in a country where it is still a delicate topic.
“I don’t think the women in the imperial family have been public about their mental health issues in order to start a dialogue,” said Kathryn Tanaka, an associate professor of Japanese literature and culture at the University of Hyogo. “But I think it’s brave of them to acknowledge.”
