Background: Worrying changes in life expectancy trends have been observed recently in the UK, largely attributed to austerity policies introduced over the last decade. To incorporate changes to quality, rather than just length of, life, our aim was to describe trends in healthy life expectancy (HLE) for the relevant period. Methods: In the absence of available long-term trends, we calculated new estimates of HLE for Scotland for the period 1995–2019, using standard HLE methodologies based on mortality and national survey data, and stratified by sex and socioeconomic deprivation. Results: Overall, male and female HLE increased markedly between 1995 and 2009, but then decreased by approximately 2 years between 2011 and 2019. A decline was observed for the most and least deprived groups, but this was larger for those living in the 20% most deprived areas, where the decrease was 3.5 years. Conclusions: Our findings are further evidence of changing levels of pre-pandemic population health in the UK. An increasing body of UK and international evidence have attributed these changes to UK Government austerity policies. There is an urgent need, therefore, to reverse cuts to social security and protect the income and health of the poorest across all of the UK.
BackgroundA criticism of Burden of Disease (BOD) estimates has been that they only provide evidence for national policy and aren't relevant for local needs. This has led to a growing call for BOD studies to provide more granular estimates for sub-national geographies, particularly within European countries, to help support local policy makers with evidence-based decision making.
AimTo develop local BOD estimates and investigate inequalities in BOD within and across local areas of Scotland.
MethodsEstimates of Years Lived with Disability (YLD), Years of Life Lost (YLL), DALYs (Disability-adjusted Life Years), prevalent cases and mortality counts were developed for 68 conditions. Morbidity estimates were calculated based on a three-year average of 5-year age-group, sex and deprivation decile rates per person (from the SBOD 2016 study) which were applied to 2016 mid-year local population estimates. Mortality estimates were based on a three-year average (2014-16) sourced from the National Records of Scotland register of deaths. Direct age-standardised rates and numbers were produced for regions (3), NHS boards (14) and local authorities (32) by age-group and sex.
ResultsAcross local authorities the male rate of all-cause DALYs ranged from 20,996 (per 100,000 population) to 33,442 and the female rate of all-cause DALYs ranged from 19,889 to 27,684. Inequalities in age-group (15-24; 25-44; 45-64; and 65+ years) differences between all-cause DALYs rates in the area with the highest and lowest rates ranged from 58.4% to 98.0% in males. Comparable estimates were slightly lower for females, but inequalities in rates were wider (41.4% to 87.4%).
ConclusionInequalities in BOD across areas highlight the need for action at all levels. These local estimates provide a huge opportunity to work towards and beyond the 2020 vision of the Scottish Government by ensuring that we have the right workforce and services to achieve a healthier Scotland.
BackgroundIncreasingly Burden of Disease (BOD) measures are being used to influence policy decisions because they summarise health loss in an equitable manner. An important part of producing non-fatal BOD estimates are severity distributions (SDs). The Global Burden of Disease (GBD) study use the same SDs across countries due to a lack of available data.
Aim To develop and assess the impact of national SDs compared with GBD worldwide severity distributions for 21 cancer types.
MethodsPatient-level records from the Scottish Cancer Registry for 21 cancers were obtained and linked to death registrations. We estimated prevalent cancer cases for 2016 and assigned each case to one of four phases (diagnosis and treatment; controlled; metastatic; and terminal) using GBD 2016 study definitions. SDs were calculated by considering relative proportions. The impact of choice of SDs was evaluated by comparing relative differences between weighted-average disability weights (DW) derived using GBD 2016 worldwide SDs with those derived from Scottish SDs.
ResultsFor the majority of cancers the most prevalent phase was the controlled phase, which contributed a higher proportion than the combined proportion from the other three phases across all cancers except mesothelioma. Differences in the composition of severity meant that most point-estimates of Scottish severity proportions were out-with the 95% uncertainty intervals. These differences resulted in overestimates of weighted-average DWs based on GBD 2016 worldwide SDs (17 out of 21 cancer types). The largest relative overestimates were for gallbladder and biliary tract cancer, oesophageal cancer and pancreatic cancer (71%, 32% and 31% higher respectively).
ConclusionThese findings illustrate a systematic bias introduced by using worldwide SDs. Current non-fatal BOD estimates should not be interpreted too precisely when comparing populations when they rely on data inputs from other countries. It is essential to ensure that any estimates are based upon country-specific data as far as possible.
ABSTRACTObjectivesThere have been a number of key changes in the clinical definition and diagnostic threshold of acute coronary syndromes in the last 10 years. We have characterised temporal and geographic changes in the incidence and outcomes following Acute Coronary Syndrome (ACS: Unstable Angina (UA), Non ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI)) between 2009 and 2013.
Approach65,137 hospitals stays were identified involving ACS (ICD-10: I20.0, I21 and I22) relating to 55,369 individuals identified through secondary care primary diagnosis records during 2009-2013. All prior and subsequent secondary care diagnoses from 1981-2014 were sourced for these patients and records were deterministically matched on a pseudo patient identifier to obtain the cause and date of death for purposes of follow-up. An incident ACS case was defined as such if the patient had not suffered an ACS in the five years prior to the hospital admission and all co-morbidities were derived from hospital diagnostic codes accompanying the ACS codes.
ResultsFor the entire cohort, patients with an incident ACS were predominantly male (61.5%) with mean age 68 (SD=13.7 years). Co-morbidities included: 65.5% Other Ischaemic Heart Disease; 5.2% Stroke; 7.5% Peripheral Artery Disease; 14.8% Atrial Fibrillation; 42.0% Hypertension; 18.0% Diabetes Mellitus and 8.4% Chronic Kidney Disease.
The overall incidence of ACS in 2009 was 204/100,000 and fell by 8.1% to 188/100,000 in 2013. Subtypes of ACS comprised 9.4% UA, 50.9% NSTEMI, 29.0% STEMI and 10.8% MI unspecified in 2013.
In-hospital mortality following an incident ACS was 9.7% (95% CI: 9.2-10.3%) in 2009 and varied from 7.9 to 19.0% across the NHS boards. In 2013, in-hospital mortality was 8.5% (95% CI: 7.9-9.0%) ranging from 4.5 to 10.5% across the NHS boards. One-year mortality following an incident ACS in 2009 was 18.6% (95% CI: 17.9-19.4%) falling to 16.8% (95% CI: 16.1-17.5%) in 2013. Stratified by NHS board, the one-year mortality rate in 2009 varied from 16.9 to 28.0% and in 2013 ranged from 11.9 to 20.0% across the NHS boards.
ConclusionThese findings highlight the importance of a cohort based record linkage approach to routine healthcare datasets. While there appears to be changes in incidence of ACS and its subtypes and changes in mortality over time, these findings reflect significant changes in clinical practice with respect to definition and diagnosis. Cautious interpretation is needed combined with further research to fully understand the epidemiological implications of our findings.
BackgroundSBOD2015 was the first endeavour to produce burden of disease estimates in Scotland using linkage of routine health records. In 2017, the study highlighted disparities in burden due to morbidity and mortality with respect to age and gender for 132 conditions, diseases and injuries.
ObjectivesThe aim of SBOD2016 is to report on socioeconomic inequalities to provide further evidence to support preventable public health.
MethodsMorbidity estimates were estimated using an extensive range of administrative datasets to provide a transparent and systematic approach to describe non-fatal population health loss. Combining these estimates with the Global Burden of Disease 2016 study's relative assessment of severity and disability for each condition, we were able to calculate the Years Lived with Disability (YLD). Death registrations were used alongside life expectancy data to calculate the Years of Life Lost to premature mortality (YLL) as a measure of fatal burden.
FindingsPreliminary findings show a three-fold increase in the burden of disease between individuals living in the most deprived areas compared to the least deprived areas. The profile of diseases contributing the largest burden also varies between the most and least deprived areas.
ConclusionsBy combining information on fatal burden with the burden of living in less than ideal health (non-fatal burden), planners and policymakers have a better idea of the contribution that different diseases, conditions and injuries make to the total burden of disease and how this varies by levels of deprivation. This in turn provides information to support decisions about where prevention and service activity should be focused. It also provides a way of looking at the proportion of the burden that can be explained by a range of exposures in the population such as poverty or smoking.
BackgroundRecent evidence shows that after several decades of gains in life expectancy, Scotland has firmly entered a period of slow-down. Trend data show that the prevalence of morbidity continues to increase resulting in a frailer and more vulnerable population. Burden of Disease (BOD) studies measure the causes of health loss and their attribution to risk factor exposure and are essential to tackling current and future population needs for care workforce and services in an efficient manner.
AimTo assess the current and projected health loss in Scotland between 2019 and 2040, based on different scenarios for change in risk factors and the impact and cost-effectiveness of evidence-based interventions on those risk factors.
Methods and AnalysisEstimates of Years Lived with Disability (YLD), Years of Life Lost (YLL) and DALYs (Disability-adjusted Life Years) will be developed for 132 conditions for Scotland using routine data sources and linkage techniques. These estimates will be linked to risk factors using attributable fractions from the Global Burden of Disease (GBD) 2017 study. Scenario-modelling will be carried out based on three scenarios: continuation; worsening; and improvements of secular trends. Cost-effective interventions will be identified and their results will be assessed in the context of Scottish BOD estimates (current & projected) and evidence on the costs and potential impact of those interventions.
Dissemination Findings from Scottish BOD estimates along with information on costs and effectiveness will help direct resources to interventions and policies with the most potential to reduce disease burdens and improve population health. Results will be disseminated through pre-print publications, scientific publications, grey literature, social media and conference or workshop presentations both nationally and internationally throughout the European Burden of Disease Network and associated events.
OBJECTIVE: Gains in life expectancy have faltered in several high-income countries in recent years. Scotland has consistently had a lower life expectancy than many other high-income countries over the past 70 years. We aim to compare life expectancy trends in Scotland to those seen internationally and to assess the timing and importance of any recent changes in mortality trends for Scotland. SETTING: Austria, Croatia, Czech Republic, Denmark, England and Wales, Estonia, France, Germany, Hungary, Iceland, Israel, Japan, Korea, Latvia, Lithuania, Netherlands, Northern Ireland, Poland, Scotland, Slovakia, Spain, Sweden, Switzerland and USA. METHODS: We used life expectancy data from the Human Mortality Database (HMD) to calculate the mean annual life expectancy change for 24 high-income countries over 5-year periods from 1992 to 2016. Linear regression was used to assess the association between life expectancy in 2011 and mean life expectancy change over the subsequent 5 years. One-break and two-break segmented regression models were used to test the timing of mortality rate changes in Scotland between 1990 and 2018. RESULTS: Mean improvements in life expectancy in 2012–2016 were smallest among women (<2 weeks/year) in Northern Ireland, Iceland, England and Wales, and the USA and among men (<5 weeks/year) in Iceland, USA, England and Wales, and Scotland. Japan, Korea and countries of Eastern Europe had substantial gains in life expectancy over the same period. The best estimate of when mortality rates changed to a slower rate of improvement in Scotland was the year to 2012 quarter 4 for men and the year to 2014 quarter 2 for women. CONCLUSIONS: Life expectancy improvement has stalled across many, but not all, high-income countries. The recent change in the mortality trend in Scotland occurred within the period 2012–2014. Further research is required to understand these trends, but governments must also take timely action on plausible contributors.
To date in Cyprus, there is no dedicated "Quality Improvement" body or Public Health authority. The long-awaited general healthcare system (known as GeSy or GHS) has been completed, mid-stream of the COVID-19 pandemic. A recently proposed resilience plan in response to the lessons learnt from the pandemic was put forward by the Government of the Republic of Cyprus to strengthen the capacity of the GHS and support public health defense. The negotiator of GeSy and Health Minister 2015–2018 also provided his view that the health system needs a holistic transformation of service provision. Recognizing failures and thinking from a syndemogenesis perspective how the envisioned patient-centric healthcare delivery can be achieved, we propose that the public health response could also be linked to a politico-economic one in shielding GeSy. We make such case for a syndemic strategy (simultaneous management of COVID-19 and pre-existing epidemics on the island) and the development of the five-district model where each main district hospital is to complement the activities of the GHS through developing: 1. A training Center for training and sharing of best practices for COVID-19 and other public emergencies. 2. A public health body. 3. A quality improvement institute. 4. A commissioning center on planning and streamlining healthcare services. 5. A clinical trial platform. The rationale is based on the management literature and use of existing resources and capabilities for transforming the GeSy and generating value. ; peer-reviewed
ABSTRACT
ObjectivesThe gap between a population's actual and ideal health can be quantified by Disability-Adjusted Life Years (DALY). This metric combines the Years Lived with Disability (YLD) and Years of Life Lost (YLL). When supplemented by a Comparative Risk Assessment (CRA) it can depict the magnitude of disease burden and the effect that modifiable exposures contribute. We aim to utilise routine healthcare records to quantify the burden and potential reduction in DALY caused by stroke.
ApproachHospital stays involving a stroke diagnosis (ICD-9: 430-431, 433-34, 436; ICD-10: I60-61, I63-64) were identified through secondary care primary diagnoses from 1981-2013 and used to derive the incidence of acute stroke and the point-prevalence of chronic stroke. Disability weights for each health state of stroke sequelae were sourced from the Global Burden of Disease 2013 study and used to derive YLD. YLL for each death was calculated using Scotland-specific life tables for deaths where stroke was the underlying cause.
Eight waves of the Scottish Health Survey (SHES) from 1995-2012 were linked to secondary care and mortality records. Risk factors were identified from SHES then mapped to levels in the Dahlgren and Whitehead model and Population Attributable Fractions (PAFs) were calculated for each risk factor that was a significant casual risk of stroke from a Cox-proportional hazard regression model.
ResultsStroke was responsible for 47,836 DALY in Scotland during 2013 which was a reduction of 33.3% from 2000. The proportion of YLD contributing to DALY was 7.6% in 2000 rising to 14.4% in 2013. The main reasons for the changing profile of DALY are due to the large reduction in mortality and influence of the rising prevalence of chronic stroke. Stroke mortality reduced 34.3% during the period 2000-2013 from 7,013 deaths in 2000 to 4,610 in 2013, whilst chronic prevalence increased from 46,184 in 2000 to 59,367 in 2013.
Between 23.5 to 38.8% of excess first stroke incidence can be explained by education, social class and area deprivation, which were all significant predictors of stroke after adjusting for confounding. Altering the exposure distribution for each independent risk factor to its theoretical minimum risk exposure level could potentially reduce the DALY by between 9,615 to 15,882 in 2013.
ConclusionThis study highlights the benefit of using linked administrative health records to quantify the burden of stroke on the population and how public health interventions to tackle inequalities would be a method of reducing strokes in Scotland.
In: Santos , J V , Gorasso , V , Souza , J , Wyper , G M A , Grant , I , Pinheiro , V , Viana , J , Ricciardi , W , Haagsma , J A , Devleesschauwer , B , Plass , D & Freitas , A 2021 , ' Risk factors and their contribution to population health in the European Union (EU-28) countries in 2007 and 2017 ' , European Journal of Public Health , vol. 31 , no. 5 , pp. 958-967 . https://doi.org/10.1093/eurpub/ckab145
BACKGROUND: The Global Burden of Disease (GBD) study has generated a wealth of data on death and disability outcomes in Europe. It is important to identify the disease burden that is attributable to risk factors and, therefore, amenable to interventions. This paper reports the burden attributable to risk factors, in deaths and disability-adjusted life years (DALYs), in the 28 European Union (EU) countries, comparing exposure to risks between them, from 2007 to 2017. METHODS: Retrospective descriptive study, using secondary data from the GBD 2017 Results Tool. For the EU-28 and each country, attributable (all-cause) age-standardized death and DALY rates, and summary exposure values are reported. RESULTS: In 2017, behavioural and metabolic risk factors showed a higher attributable burden compared with environmental risks, with tobacco, dietary risks and high systolic blood pressure standing out. While tobacco and air quality improved significantly between 2007 and 2017 in both exposure and attributable burden, others such as childhood maltreatment, drug use or alcohol use did not. Despite significant heterogeneity between EU countries, the EU-28 burden attributable to risk factors decreased in this period. CONCLUSION: Accompanying the improvement of population health in the EU-28, a comparable trend is visible for attributable burden due to risk factors. Besides opportunities for mutual learning across countries with different disease/risk factors patterns, good practices (i.e. tobacco control in Sweden, air pollution mitigation in Finland) might be followed. On the opposite side, some concerning cases must be highlighted (i.e. tobacco in Bulgaria, Latvia and Estonia or drug use in Czech Republic).
Erratum in: Wyper GMA, Assunção R, Cuschieri S, Devleesschauwer B, Fletcher E, Haagsma JA, Hilderink HBM, Idavain J, Lesnik T, Von der Lippe E, Majdan M, Milicevic MS, Pallari E, Peñalvo JL, Pires SM, Plaß D, Santos JV, Stockton DL, Thomsen ST, Grant I. Arch Public Health. 2020 Jun 18;78:57. doi:10.1186/s13690-020-00437-8. eCollection 2020. "[This corrects the article DOI:10.1186/s13690-020-00433-y.]." ; Background: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. Methods: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. Results: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. Conclusion: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create composite indicators of vulnerability for rapid assessments, in this case to severe health consequences from COVID-19. Countries with available results for sub-national regions within their country, or national burden of disease studies that also use sub-national levels for burden quantifications, should consider using non-fatal burden of disease estimates to estimate geographical vulnerability to COVID-19. ; This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Journal open access publications fees upon acceptance of this article in a peer-reviewed journal will be reimbursed under the COST action CA18218 (European Burden of Disease Network) ; info:eu-repo/semantics/publishedVersion
In: Wyper , G M A , Assunção , R , Cuschieri , S , Devleeschauwer , B , Fletcher , E , Haagsma , J A , Hilderink , H B M , Idavain , J , Lesnik , T , Von Der Lippe , E , Majdan , M , Milicevic , M S , Pallari , E , Peñalvo , J L , Pires , S M , Plaß , D , Santos , J V , Stockton , D L , Thomsen , S T & Grant , I 2020 , ' Population vulnerability to COVID-19 in Europe : A burden of disease analysis ' , Archives of Public Health , vol. 78 , no. 1 , 47 . https://doi.org/10.1186/s13690-020-00433-y
Background: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. Methods: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. Results: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. Conclusion: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create ...
Background: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. Methods: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. Results: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. Conclusion: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create composite indicators of vulnerability for rapid assessments, in this case to severe health consequences from COVID-19. Countries with available results for sub-national regions within their country, or national burden of disease studies that also use sub-national levels for burden quantifications, should consider using non-fatal burden of disease estimates to estimate geographical vulnerability to COVID-19. ; peer-reviewed
Information is increasingly digital, creating opportunities to respond to pressing issues about human populations in near real time using linked datasets that are large, complex, and diverse. The potential social and individual benefits that can come from data-intensive science are large, but raise challenges of balancing individual privacy and the public good, building appropriate socio-technical systems to support data-intensive science, and determining whether defining a new field of inquiry might help move those collective interests and activities forward. A combination of expert engagement, literature review, and iterative conversations led to our conclusion that defining the field of Population Data Science (challenge 3) will help address the other two challenges as well. We define Population Data Science succinctly as the science of data about people and note that it is related to but distinct from the fields of data science and informatics. A broader definition names four characteristics of: data use for positive impact on citizens and society; bringing together and analyzing data from multiple sources; finding population-level insights; and developing safe, privacy-sensitive and ethical infrastructure to support research. One implication of these characteristics is that few people possess all of the requisite knowledge and skills of Population Data Science, so this is by nature a multi-disciplinary field. Other implications include the need to advance various aspects of science, such as data linkage technology, various forms of analytics, and methods of public engagement. These implications are the beginnings of a research agenda for Population Data Science, which if approached as a collective field, can catalyze significant advances in our understanding of trends in society, health, and human behavior.
BACKGROUND: The number of individuals living with dementia is increasing, negatively affecting families, communities, and health-care systems around the world. A successful response to these challenges requires an accurate understanding of the dementia disease burden. We aimed to present the first detailed analysis of the global prevalence, mortality, and overall burden of dementia as captured by the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, and highlight the most important messages for clinicians and neurologists. METHODS: GBD 2016 obtained data on dementia from vital registration systems, published scientific literature and surveys, and data from health-service encounters on deaths, excess mortality, prevalence, and incidence from 195 countries and territories from 1990 to 2016, through systematic review and additional data-seeking efforts. To correct for differences in cause of death coding across time and locations, we modelled mortality due to dementia using prevalence data and estimates of excess mortality derived from countries that were most likely to code deaths to dementia relative to prevalence. Data were analysed by standardised methods to estimate deaths, prevalence, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs; computed as the sum of YLLs and YLDs), and the fractions of these metrics that were attributable to four risk factors that met GBD criteria for assessment (high body-mass index [BMI], high fasting plasma glucose, smoking, and a diet high in sugar-sweetened beverages). FINDINGS: In 2016, the global number of individuals who lived with dementia was 43·8 million (95% uncertainty interval [UI] 37·8-51·0), increased from 20.2 million (17·4-23·5) in 1990. This increase of 117% (95% UI 114-121) contrasted with a minor increase in age-standardised prevalence of 1·7% (1·0-2·4), from 701 cases (95% UI 602-815) per 100 000 population in 1990 to 712 cases (614-828) per 100 000 population in 2016. More women than men had dementia in 2016 (27·0 million, 95% UI 23·3-31·4, vs 16.8 million, 14.4-19.6), and dementia was the fifth leading cause of death globally, accounting for 2·4 million (95% UI 2·1-2·8) deaths. Overall, 28·8 million (95% UI 24·5-34·0) DALYs were attributed to dementia; 6·4 million (95% UI 3·4-10·5) of these could be attributed to the modifiable GBD risk factors of high BMI, high fasting plasma glucose, smoking, and a high intake of sugar-sweetened beverages. INTERPRETATION: The global number of people living with dementia more than doubled from 1990 to 2016, mainly due to increases in population ageing and growth. Although differences in coding for causes of death and the heterogeneity in case-ascertainment methods constitute major challenges to the estimation of the burden of dementia, future analyses should improve on the methods for the correction of these biases. Until breakthroughs are made in prevention or curative treatment, dementia will constitute an increasing challenge to health-care systems worldwide. FUNDING: Bill & Melinda Gates Foundation. ; AA received financial support from the Department of Science and Technology, Government of India, (New Delhi, India) through the INSPIRE Faculty program. MSBS received Australian Government Research and Training Program funding for post-graduates to study at the Australian National University (Canberra, ACT, Australia). FC acknowledges support from the European Union (FEDER funds POCI/01/0145/FEDER/007728 and POCI/01/0145/FEDER/007265) and National Funds (FCT/MEC, Fundação para a Ciência e a Tecnologia and Ministério da Educação e Ciência) under the Partnership Agreements PT2020 UID/MULTI/04378/2013 and PT2020 UID/QUI/50006/2013. EC is supported by an Australian Research Council Future fellowship (FT3 140100085). AK was supported by the Miguel Servet contract financed by the CP13/00150 and PI15/00862 projects, integrated into the National R + D + I and funded by the ISCIII (General Branch Evaluation and Promotion of Health Research) and the European Regional Development fund (ISCIII-FEDER). MOO is supported by grant U54HG007479 from the National Institutes of Health. TCR is a member of the Alzheimer Scotland Dementia Research Centre (University of Edinburgh, Edinburgh, UK) and is supported by Alzheimer Scotland. RT-S was partly supported by grant number PROMETEOII/2015/021 from Generalitat Valenciana and the national grant PI17/00719 from ISCIII-FEDER. TW acknowledges academic support from University of Rajarata (Mihintale, Sri Lanka). ; Sí