Calculating the global burden of disease due to low fruit and vegetable intake

	Karen Lock, Joceline Pomerleau and Martin McKee
	London School of Hygiene and Tropical Medicine

WHO Global Burden of Disease Study 1990

	Previous study (1990) only considered 10 risk factors for disease
	Malnutrition was only nutrition risk factor
	In discussions for the update –
	important to get more nutritional risk factors for non-communicable disease included

Comparative Risk Assessment, Global Burden of Disease study 2000

	New approach – comparative risk assessment
		Estimate contributions of 26 risk factors to global burden of disease using unified framework
		Physiological, lifestyle, environmental and occupational factors
	‘Nutrition-related’ risk factors included:
		low fruit and vegetables, obesity, high serum cholesterol
	Published in WHO World Health Report 2002:
	Reducing Risks, Promoting Healthy Life

Risk factors included

	Underweight
	Iron, Vitamin A, Zinc deficiency
	Tobacco
	Alcohol
	Illicit drugs
	Unsafe sex
	Lack of contraception
	High Blood Pressure
	Low fruit and vegetables
	Obesity (high BMI)
	High serum cholesterol
	Unsafe water, sanitation
	Outdoor air pollution
	Indoor smoke
	Climate change
	Occupational risks
	Childhood sexual abuse

General methods

	For 14 WHO regions, by age and sex
	Comprehensive reviews
		Prevalence of risk factor exposure
		Size of the ‘hazard’ or association (relative risk)
	Estimate contribution of RF to disease (attributable fraction)
		Applying potential impact fraction to burden of disease estimates in WHO GBD database
	Counterfactual analysis: using theoretical minimum exposure

Fruit and Vegetable intake

	Calculated average intake for each region (g/person/day)
	Combined national intake survey data in regions
	Where no surveys available: systematic extrapolation from FAO food balance sheets combined with survey data from other regions
		Assumptions about whether population distribution of intake similar in countries

Included intake surveys

	Data available for 26 countries within 9 WHO Regions
	Amr A: USA
	Amr B: Argentina, Mexico
	Emr B: Kuwait
	Eur A: Belgium, Denmark, Finland, France, Germany, Ireland, Israel, Italy, Norway, UK
	Eur B: Bulgaria
	Eur C: Estonia, Kazakhstan, Latvia, Lithuania, Russian Fed.
	Sear D: Bangladesh, India
	Wpr A: Australia, Japan, Singapore
	Wpr B: China
	No survey data: Afr D, Afr E, Amr D, Emr D, Sear B

Disease outcomes included

	Systematic reviews of 6 diseases
		Ischaemic heart disease
		Stroke
		Stomach, lung, oesophageal, colorectal cancer
	Fruit and vegetables treated as continuous variable
	Summary relative risks estimated using meta-analysis

Counterfactual distribution

	Theoretical ‘minimum exposure’
	= Maximum fruit and vegetable intake
	600g/ day
	Based on high intake populations, and level to which potential gains may continue given scientific evidence
	Provides a ‘vision’ potential health gains

Global attributable mortality and DALY in year 2000 due to low fruit and vegetable intake

Attributable mortality (000) due to leading global risk factors (Ezzati et al 2002)

Attributable DALY (000) due to leading global risk factors (Ezzati et al 2002)

Burden of disease due to leading risk factors in developed regions

Similar to previous estimates of the disease burden due to low fruit and vegetable intake

	DALY’s lost due to inadequate fruit and vegetable consumption :
	E.U (1997).: 3.5% (c.f. 1.1% for high saturated fat intake)
	Australia (1999): 2.8% (10% of all cancer deaths)
	New Zealand (2001): 2.4%

Key role of Nutrition in Global Burden of Disease

	15% GBD due to under nutrition
	BUT shows that significant burden of disease due to risk factors with dietary determinants including high cholesterol, obesity, F&V
	Patterns not uniform across regions – represents nutrition transition

Implications for Policy

	Puts fruit and vegetables as important nutritional risk factor on national and global policy agendas
		Confirms high public health cost of low fruit and vegetable intake for non-communicable disease
	1st direct comparison F&V with other leading risk factors in comparable way
		Unified framework allows comparison of risk factors from a variety of PH disciplines (with caveats)
		Both years of life and quality of life lost