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- Lozano, Rafael, et al.
(författare)
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Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017
- 2018
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Ingår i: The Lancet. - : Elsevier. - 1474-547X .- 0140-6736. ; 392:10159, s. 2091-2138
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Tidskriftsartikel (refereegranskat)abstract
- Background: Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of “leaving no one behind”, it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990–2017, projected indicators to 2030, and analysed global attainment. Methods: We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0–100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. Findings: The global median health-related SDG index in 2017 was 59·4 (IQR 35·4–67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6–14·0) to a high of 84·9 (83·1–86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030. Interpretation: The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains—curative interventions in the case of NCDs—towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions—or inaction—today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.
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| 5. |
- Zendehdel, Kazem
(författare)
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Risk indicators for esophageal cancer : some medical conditions and tobacco-related indicators
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Because of little progress in the prognosis and survival of esophageal cancer patients, the early diagnosis and prevention have been prioritized. Alcohol consumption and tobacco smoking are the main risk factors of squamous cell carcinoma, and high body mass index and gastroesophageal reflux are strongly linked to adenocarcinoma of the esophagus. However underlying mechanisms for the observed associations between these risk factors and esophageal cancer are not fully understood. This thesis was aimed to shed further light on the etiology of this cancer through a series of epidemiological studies. An inverse relation between H. pylori infection and the risk of esophageal adenocarcinoma, and a positive link with the risk of squamous cell carcinoma is suggested. We identified retrospective cohorts of patients hospitalized for gastric and duodenal ulcers both strongly linked to H. pylori infection between 1965 and 2003 through the Swedish Inpatient Register. We found a 70% excess risk of esophageal adenocarcinoma in duodenal ulcer patients (SIR=1.7 95% CI 1.1-2.5) compared to the general Swedish population. This finding was plausible because duodenal ulcer is associated with hyperacidity and gastroesophageal reflux, a strong risk factor for esophageal adenocarcinoma. However, it was not consistent with the reported inverse relationship between H. pylori and adenocarcinoma of the esophagus. On the other hand, gastric ulcer patients exhibited 80% higher risk of squamous cell carcinoma (SIR=1.8 95% CI 1.4-2.3), supporting the postulated hypothesis in which bacterial overgrowth in an atrophic stomach may lead to the generation of Nnitroso compounds, a suspected risk factor for esophageal squamous cell carcinoma. In a large cohort study among achalasia patients, we found a strong association between achalasia and risk of esophageal cancer (SIR=10.5 95% CI 7.0-15.9). The excess risk was evident for both adenocarcinoma and squamous cell carcinoma, particularly among men. We also found that the risk of esophageal cancer was high among both operated and unoperated achalasia patients. However, there was some indication that the risk of squamous cell carcinoma may decrease among patients undergoing esophagogastric myotomy. This study showed that achalasia surgery does not increase the risk of esophageal adenocarcinoma. Scandinavian moist snuff (snus) is increasing in Sweden. There are strong forces from tobacco lobbies to encourage snus use as a safer alternative to smoking and to lift the ban put on snus use in most Euopean countries. Using information from 336,381 male Swedish construction workers, we studied the associations between snus use and tobacco smoking and the risk of esophageal cancer. In an analysis among smokers, we found no convincing evidence to support that additional snus use among smokers may decrease the risk of esophageal adenocarcinoma and squamous cell carcinoma compared to those who were only smoking. Moreover, the risk of esophageal squamous cell carcinoma was 3.5-fold higher among never-smoking snus users compared to never-users of any tobacco (95% CI 1.6-7.6). The latter analysis was restricted to never smokers to discard the confounding by smoking appropriately. We therefore concluded that snus cannot be considered an entirely safe alternative to smoking and should not be marketed as a means for harm reduction until strong evidence is able to refute its carcinogenicity. Strong associations between tobacco smoking and the risks of esophageal adenocarcinoma (RR=2.3 95%CI 1.4-3.7) and squamous cell carcinoma (RR=5.2, 95% CI 3.1-8.6) were also noted. Finally, in a population based case-control study we studied the association between polymorphisms of some tobacco-metabolizing genes (GSTP, GSTT1 and GSTM1) and the risk of esophageal cancer. Although there were no associations between these polymorphisms and the risk of adenocarcinoma, the variant GSTP1 Val105 was associated with an increased risk of squamous cell carcinoma (OR=1.7, 95% CI 1.0-2.9). The association tended to be stronger among smokers and homozygotes with the variant allele. Together with the combined literature, we concluded that carriage of the variant GSTP1 Val105 allele may be associated with the risk of both histological types of esophageal cancer among Caucasian populations.
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