Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Population Health Metrics
Published in: Population Health Metrics 1/2003

Open Access 01-12-2003 | Review

Comparative quantification of health risks: Conceptual framework and methodological issues

Authors: Christopher JL Murray, Majid Ezzati, Alan D Lopez, Anthony Rodgers, Stephen Vander Hoorn

Published in: Population Health Metrics | Issue 1/2003

Login to get access

Abstract

Reliable and comparable analysis of risks to health is key for preventing disease and injury. Causal attribution of morbidity and mortality to risk factors has traditionally been conducted in the context of methodological traditions of individual risk factors, often in a limited number of settings, restricting comparability.
In this paper, we discuss the conceptual and methodological issues for quantifying the population health effects of individual or groups of risk factors in various levels of causality using knowledge from different scientific disciplines. The issues include: comparing the burden of disease due to the observed exposure distribution in a population with the burden from a hypothetical distribution or series of distributions, rather than a single reference level such as non-exposed; considering the multiple stages in the causal network of interactions among risk factor(s) and disease outcome to allow making inferences about some combinations of risk factors for which epidemiological studies have not been conducted, including the joint effects of multiple risk factors; calculating the health loss due to risk factor(s) as a time-indexed "stream" of disease burden due to a time-indexed "stream" of exposure, including consideration of discounting; and the sources of uncertainty.
Appendix
Available only for authorised users
Literature
1.
Preston SH: Mortality Patterns in National Populations: with Special Reference to Recorded Causes of Death. New York: Academic Press 1976.
2.
Murray CJL, Lopez AD: Global Mortality, Disability, and The Contribution of Risk Factors: Global Burden of Disease Study. Lancet 1997, 349: 1436-1442.PubMed
3.
Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr: Mortality from Tobacco in Developed Countries. Lancet 1992, 339: 1268-1278.PubMed
4.
McGinnis JM, Foege WH: Actual Causes of Death in the United States. JAMA 1993, 270: 2207-2212.PubMed
5.
Single E, Robson L, Rehm J, Xie X: Morbidity and Mortality Attributable to Alcohol, Tobacco, and Illicit Drug Use in Canada. American Journal of Public Health 1999, 89: 385-390.PubMedPubMedCentral
6.
Smith KR, Corvalan CF, Kjellstrom T: How Much Global Ill Health is Attributable to Environmental Factors. Epidemiology 1999, 10: 573-584.PubMed
7.
Smith KR: The National Burden of Disease from Indoor Air Pollution in India. Proc Natl Acad Sci USA 2000, 97: 13286-13293.PubMedPubMedCentral
8.
Leigh J, Macaskill P, Kuosma E, Mandryk J: Global Burden of Disease and Injury due to Occupational Factors. Epidemiology 1999, 10: 626-631.PubMed
9.
Kunzli N, Kaiser R, Medina S, Studnicka M, Chanel O, Filliger P, Herry M, Horak F Jr, Puybonnieux-Texier V, Quenel P, et al.: Public-Health Impact of Outdoor and Traffic-Related Air Pollution: a European Assessment. Lancet 2000, 356: 795-801.PubMed
10.
Willet WC: Balancing Life-Style and Genomics Research for Disease Prevention. Science 2002, 296: 695-698.
11.
Manton KG, Singer BH, Suzman RM: Forecasting the Health of Elderly Populations. New York: Springer-Verlag 1993.
12.
Manton KG, Stallard E, Singer BH: Methods for Projecting the Future Size and Health Status of the US. Elderly Populations. In: Studies in the Economics of Aging (Edited by: Wise DA). Chicago: University of Chicago Press 1994.
13.
Yashin AI, Manton KG, Stallard E: Dependent Competing Risks: A Stochastic Process Model. Journal of Mathematical Biology 1986, 24: 119-140.PubMed
14.
Robins JM: A New Approach to Causal Inference in Mortality Studies with Sustained Exposure Periods – Application to Control of the Healthy Worker Survival Effect. Mathematical Modelling 1986, 7: 1393-1512.
15.
Robins JM: Addendum to "A New Approach to Causal Inference in Mortality Studies with Sustained Exposure Periods – Application to Control of the Healthy Worker Survival Effect". Computers and Mathematics with Applications 1987, 14: 917-921.
16.
Robins JM, Greenland S: Estimability and Estimation of Expected Years of Life Lost due to a Hazardous Exposure. Statistics in Medicine 1991, 10: 79-93.PubMed
17.
Robins JM, Greenland S, Fu-Chang H: Estimation of the Causal Effect of a Time-Varying Exposure on the Marginal Mean of a Repeated Binary Outcome. Journal of American Statistical Association 1999, 94: 687-700.
18.
Robins JM: Association, Causation, and Marginal Structural Models. Synthese 1999, 121: 151-179.
19.
Robins JM: Marginal Structural Models versus Structural Nested Models as Tools for Causal Inference. In: Statistical Models in Epidemiology (Edited by: Halloran E). New York: Springer Verlag 1999.
20.
Murray CJL, Lopez AD: On the Comparable Quantification of Health Risks: Lessons from the Global Burden of Disease. Epidemiology 1999, 10: 594-605.PubMed
21.
Murray CJL: Rethinking DALYs. In: The Global Burden of Disease (Edited by: Murray CJL, Lopez AD). Cambridge, MA: Harvard School of Public Health (on behalf of the World Health Organization and the World Bank) 1996.
22.
Murray CJL, Salomon J, Mathers CD, Lopez AD, Lozano R (eds.): Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications. Geneva: World Health Organization 2002.
23.
Mathers CD, Ezzati M, Lopez AD, Murray CJL, Rodgers AD: Causal Decomposition of Summary Measures of Population Health. In: Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications (Edited by: Murray CJL, Salomon J, Mathers CD, Lopez AD). Geneva: World Health Organization 2002.
24.
World Health Organization (WHO): International Statistical Classification of Disease and Related Health Problems, Tenth Edition. Geneva: World Health Organization 1992.
25.
Maldonado G, Greenland S: Estimating Causal Effects. International Journal of Epidemiology 2002, 31: 422-429.PubMed
26.
Rothman KJ: Causes. American Journal of Epidemiology 1976, 104: 587-592.PubMed
27.
Levin ML: The Occurrence of Lung Cancer in Man. Acta Unio Internationalis Contra Cancrum 1953, 9: 531-541.PubMed
28.
MacMahon B, Pugh TF: Epidemiology: Principles and Methods. Boston: Little Brown and Company 1970.
29.
Cole P, MacMahon B: Attributable Risk Percent in Case-Control Studies. British Journal of Preventive and Social Medicine 1971, 25: 242-244.PubMedPubMedCentral
30.
Miettinen OS: Proportion of Disease Caused or Prevented by a Given Exposure, Trait or Intervention. American Journal of Epidemiology 1974, 99: 325-332.PubMed
31.
Ouellet BL, Romeder JM, Lance JM: Premature Mortality Attributable to Smoking and Hazardous Drinking in Canada. American Journal of Epidemiology 1979, 109: 451-463.PubMed
32.
Eide GE, Heuch I: Attributable Fractions: Fundamental Concepts and Their Visualization. Statistical Methods in Medical Research 2001, 10: 159-193.PubMed
33.
Uter W, Pfahlberg A: The Application of Methods to Quantify Attributable Risk in Medical Practice. Statistical Methods in Medical Research 2001, 10: 231-237.PubMed
34.
Greenland S: Bias in Methods for Deriving Standardized Morbidity Ratio and Attributable Fraction Estimates. Statistics in Medicine 1984, 3: 131-141.PubMed
35.
Rockhill B, Newman B, Weinberg C: Use and misuse of population attributable fractions. American Journal of Public Health 1998, 88: 15-19.PubMedPubMedCentral
36.
Greenland S, Robins JM: Conceptual Problems in the Definition and Interpretation of Attributable Fractions. American Journal of Epidemiology 1988, 128: 1185-1197.PubMed
37.
Drescher K, Becher H: Estimating the Generalized Impact Fraction from Case-Control Data. Biometrics 1997, 53: 1170-1176.PubMed
38.
Walter SD: Prevention of Multifactorial Disease. American Journal of Epidemiology 1980, 112: 409-416.PubMed
39.
Greenland S: Causality Theory for Policy Uses of Epidemiological Measures. In: Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications (Edited by: Murray CJL, Salomon J, Mathers CD, Lopez AD). Geneva: World Health Organization 2002.
40.
Powles J, Day N: Interpreting the Global Burden of Disease. Lancet 2002, 360: 1342-1343.PubMed
41.
Puddey IB, Rakic V, Dimmitt SB, Beilin LJ: Influence of Pattern of Drinking on Cardiovascular Disease and Cardiovascular Risk Factors – a Review. Addiction 1999, 94: 649-663.PubMed
42.
Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, Comparative Risk Assessment Collaborative Group: Selected Major Risk Factors and Global and Regional Burden of Disease. Lancet 2002, 360: 1347-1360.PubMed
43.
MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J: Blood Pressure, Stroke, and Coronary Heart Disease. Part I, Prolonged Differences in Blood Pressure: Prospective Observational Studies Corrected for the Regression Dilution Bias. Lancet 1990, 335: 765-774.PubMed
44.
Chen Z, Peto R, Collins R, MacMahon S, Lu J, Li W: Serum Cholesterol Concentration and Coronary Heart Disease in Population with Low Cholesterol Concentrations. British Medical Journal 1991, 303: 276-282.PubMedPubMedCentral
45.
Eastern Stroke and Coronary Heart Disease Collaborative Research Group: Blood Pressure, Cholesterol, and Stroke in Eastern Asia. Lancet 1998, 352: 1801-1807.
46.
Prospective Studies Collaboration: Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 45,000 people in 45 prospective cohorts. Lancet 1995, 346: 1647-1653.
47.
Carvalho JJ, Baruzzi RG, Howard PF, Poulter N, Alpers MP, Franco LJ, Marcopito LF, Spooner VJ, Dyer AR, Elliott P: Blood pressure in four remote populations in the INTERSALT Study. Hypertension 1989, 14: 238-246.PubMed
48.
He J, Klag MJ, Whelton PK, Chen JY, Mo JP, Qian MC, MP S, He GQ: Migration, blood pressure pattern, and hypertension: the Yi Migrant Study. American Journal of Epidemiology 1991, 134: 1085-1101.PubMed
49.
He J, Tang YC, Tell GS, Mo PS, He GQ: Effect of migration on blood pressure: the Yi People Study. Epidemiology 1991, 2: 88-97.PubMed
50.
Barnes R: Comparisons of blood pressure and blood cholesterol levels in New Guineans and Ausralians. Medical Journal of Australia 1965, 1: 611-617.PubMed
51.
Mann GV, Shaffer RD, Anderson RS, Sandstead HH: Cardiovascular disease in the Masai. Journal of Atherosclerosis 1964, 289-312.
52.
LaRosa JC, He J, Vupputuri S: Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. Journal of American Medical Association 1999, 282: 2340-2346.
53.
Pignone M, Phillips C, Mulrow C: Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. British Medical Journal 2000, 321: 983-986.PubMedPubMedCentral
54.
Corrao G, Rubbiati L, Bagnardi V, Zambon A, Poikolainen K: Alcohol and Coronary Heart Disease: A Meta-Analysis. Addiction 2000, 95: 1505-1523.PubMed
55.
Yerushalmy J, Palmer CE: On the Methodology of Investigations of Etiologic Factors in Chronic Diseases. Journal of Chronic Disease 1959, 108: 27-40.
56.
Corvalan CF, Kjellstrom T, Smith KR: Health, Environment, and Sustainable Development: Identifying Links and Interactions to Promote Action. Epidemiology 1999, 10: 656-660.PubMed
57.
Evans AS: Causation and Disease: The Henle-Koch Postulates Revisited. Yale Journal of Biology and Medicine 1976, 49: 175-195.PubMedPubMedCentral
58.
Evans AS: Causation and Disease: A Chronological Journey. American Journal of Epidemiology 1978, 108: 249-258.PubMed
59.
Rothman KJ, Greenland S: Modern Epidemiology. Philadelphia: Lippincott-Raven 1998.
60.
Greenland S: Quantitative Methods in the Review of Epidemiologic Literature. Epidemiologic Reviews 1987, 9: 1-30.PubMed
61.
Patz JA, McGeehin MA, Bernard SM, Ebi KL, Epstein PR, Grambsch A, Gubler DJ, Reiter P, Romieu I, Rose JB, et al.: The Potential Health Impacts of Cimate Variability and Change for the United States: Executive Summary of the Report of the Health Sector of the US National Assessment. Environmental Health Perspectives 2000, 108: 367-376.PubMedPubMedCentral
62.
Rogers DJ, Randolph SE: The Global Spread of Malaria in a Future, Warmer World. Science 2000, 289: 1763-1766.PubMed
63.
64.
Craig MH, Snow RW, le Sueur D: A climate-based distribution model of malaria transmission in sub-Saharan Africa. Parasitology Today 1999, 15: 105-111.PubMed
65.
Martens P, Kovats RS, Nijhof S, de Vries P, Livermore MTJ, Bradley DJ, Cox J, McMichael AJ: Climate change and future populations at risk of malaria. Global Environmental Change-Human and Policy Dimensions 1999, 9: S89-S107.
66.
Rice AL, Sacco L, Hyder A, Black RE: Malnutrition as an Underlying Cause of Childhood Deaths Associated with Infectious Diseases in Developing Countries. Buletin of the World Health Organization 2000, 108: 367-376.
67.
Smith KR, Samet JM, Romieu I, Bruce N: Indoor Air Pollution in Developing Countries and Acute Lower Respiratory Infections in Children. Thorax 2000, 55: 518-532.PubMedPubMedCentral
68.
Foulkes MA, Davis CE: An index of tracking for longitudinal data. Biometrics 1981, 37: 439-446.
69.
Tate RB, Manfreda J, Krahn AD, Cuddy TE: Tracking of blood pressure over a 40-year period in the University of Manitoba Follow-up Study, 1948–1988. American Journal of Epidemiology 1995, 142: 946-954.PubMed
70.
Yong LC, Kuller LH, Rutan G, Bunker C: Longitudinal study of blood pressure: Changes and determinants from adolescence to middle age. The Dormont High School Follow-up Study, 1957–1963 to 1989–1990. American Journal of Epidemiology 1993, 138: 973-983.PubMed
71.
Manton KG, Dowd JE, Stallard E: The Effects of Risk Factors on Male and Female Cardiovascular Risks in Middle and Late Age. In: Forecasting the Health of Elderly Populations (Edited by: Manton KG, Singer BH, Suzman RM). New York: Springer-Verlag 1993.
72.
Robins JM: Causal Inference from Complex Longitudinal Data. In: Latent Variable Modeling and Applications to Causality. Lecture Notes in Statistics (120) (Edited by: Berkane M). New York: Springer Verlag 1997.
73.
Robins JM, Greenland S: Estimability and Estimation of Excess and Etiological Fractions. Statistics in Medicine 1989, 8: 845-859.PubMed
74.
Murray CJL, Acharya A: Age Weights and Discounting in Health Gaps Reconsidered. In: Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications (Edited by: Murray CJL, Salomon J, Mathers CD, Lopez AD, Lozano R). Geneva: World Health Organization 2002.
75.
Kneese AV: The Faustian Bargain. In: The RFF Reader in Environment and Resource Management (Edited by: Oates WE). Washington, DC: Resources for the Future (RFF) 1999.
76.
Lind RC, ed.: Discounting for Time and Risk in Energy Policy. Baltimore: Johns Hopkins University Press for Resources for the Future 1982.
77.
Portney PR, Weyant JP, eds: Discounting and Intergenerational Equity. Washington, DC: Resources for the Future 1999.
78.
Howarth RH: Climate Change and Overlapping Generations. Contemporary Economic Policy 1996, 14: 100-111.
79.
Schelling TC: Intergenerational Discounting. Energy Policy 1995, 23: 395-401.
80.
Toman MA: Reconciling Philosophy and Economics in Long-Term Discounting. In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
81.
Solow RM: Foreword. In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
82.
Parfit D: Reasons and Persons. New York: Oxford University Press 1984.
83.
Murray CJL, Lopez AD, eds.: The Global Burden of Disease. Cambridge, MA: Harvard School of Public Health (on behalf of the World Health Organization and the World Bank) 1996.
84.
Anand S, Hansen K: Age Weights and Discounting in Disability-Adjusted Life Years: A Critical Review. In: Summary Measures of Population Health (Edited by: Geneva: World Health Organization). Murray CJL, Salomon J, Mathers CD, Lopez AD, Lozano R 2002.
85.
Koopmans TC: Stationary Ordinal Utility and Impatience. Econometrica 1960, 28: 287-309.
86.
Dasgupta P, Mäler K-G: Poverty, Institutions, and the Environmental Resource Base. In: Book Poverty, Institutions, and the Environmental Resource Base City: The World Bank 1994.
87.
Dasgupta P, Mäler K-G, Barrett S: Intergenerational Equity, Social Discount Rates, and Global Warming. In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
88.
Dasgupta P, Heal GM: The Optimal Depletion of Exhaustible Resources. Review of Economic Studies 1974., 41:
89.
Solow RM: Intergenerational Equity and Exhaustible Resources. The Review of Economic Studies 1974, 41: 29-45.
90.
Arrow KJ: Discounting, Morality, and Gaming. In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
91.
Solow RM: The Economics of Resources or the Resources of Economics. The American Economic Review 1974, 64: 1-14.
92.
Montgomery WD: A Market-Based Discount Rate: Comments on Bradford. In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
93.
Weitzman ML: Just Keep Discounting, But... In: Discounting and Intergenerational Equity (Edited by: Portney PR, Weyant JP). Washington, DC: Resources for the Future 1999.
94.
Graham JD, Green LC, Roberts MJ: In Search of Safety: Chemicals and Cancer Risk. Cambridge: Harvard University Press 1988.
95.
Kay D, Pruess AM, Corvalan CF: Methodology for Assessment of Environmental Burden of Disease. ISEE Session on Environmental Burden of Disease. In: Book Methodology for Assessment of Environmental Burden of Disease. ISEE Session on Environmental Burden of Disease City: World Health Organization (WHO) 2000.
96.
Ezzati M, Saleh H, Kammen DM: The Contributions of Emissions and Spatial Microenvironments to Exposure to Indoor Air Pollution from Biomass Combustion in Kenya. Environmental Health Perspectives 2000, 108: 833-839.PubMedPubMedCentral
97.
Peto R: Influence of Dose and Duration of Smoking on Lung Cancer Rates. Lyon, France: International Agency for Research on Cancer 1986.
98.
Hill AB: The Environment and Disease: Association or Causation? Proceedings of the Royal Society of Medicine 1965, 58: 295-300.PubMedPubMedCentral
99.
National Research Council (NRC): Science and Judgment in Risk Assessment. Washington, DC: National Academy Press 1994.
100.
Robins JM, Greenland S: Comment on "Causal Inference without Counterfactuals" by A.P. Dawid. Journal of American Statistical Association – Theory and Methods 2000, 95: 477-482.
101.
Law MR, Wald NJ, Thompson SG: By How Much and How Quickly Does Reduction in Serum Cholesterol Concentration Lower Risk of Ischaemic Heart Disease? British Medical Journal 1994, 308: 367-373.PubMedPubMedCentral
102.
Horton R: Common Sense and Figures: The Rhetoric of Validity in Medicine (Bradford Hill Memorial Lecture 1999). Statistics in Medicine 2000, 19: 3149-3164.PubMed
103.
Horwitz RI, Viscoli CM, Clemens JD, Sadock RT: Developing Improved Observational Methods for Evaluating Therapeutic Evidence. American Journal of Medicine 1990, 89: 630-638.PubMed
104.
Horwitz RI, Singer BH, Viscoli CM, Makuch RW: Can Treatment That Is Helpful on Average be Harmful to Some Patients? A Study of the Conflicting Information Needs of Clinical Inquiry and Drug Regulation. Journal of Clinical Epidemiology 1996, 49: 395-400.PubMed
105.
Horwitz RI, Singer BH, Makuch RW, Viscoli CM: Clinical versus Statistical Considerations in the Design and Analysis of Clinical Research. Journal of Clinical Epidemiology 1998, 51: 305-307.PubMed
106.
Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C: Threats to Applicability of Randomised Trials: Exclusion and Selective Participation. Journal of Health Services Research and Policy 1999, 4: 112-121.PubMed
107.
Britton A, McKee M: The Relationship between Alcohol and Cardiovascular Disease in Eastern Europe: Explaining the Paradox. Journal of Epidemiology and Community Health 2000, 54: 328-332.PubMedPubMedCentral
108.
Thun MJ, Apicella LF, Henley SJ: Smoking vs Other Risk Factors as the Cause of Smoking-Attributable Mortality: Confounding in the Courtroom. Journal of American Medical Association 2000, 284: 706-712.
109.
Morgan MG, Henrion M: Uncertainty: A Guide to Dealing with Uncertainty in Quantitative Risk and Policy Analysis. Cambridge: Cambridge University Press 1990.
Metadata
Title
Comparative quantification of health risks: Conceptual framework and methodological issues
Authors
Christopher JL Murray
Majid Ezzati
Alan D Lopez
Anthony Rodgers
Stephen Vander Hoorn
Publication date
01-12-2003
Publisher
BioMed Central
Published in
Population Health Metrics / Issue 1/2003
Electronic ISSN: 1478-7954
DOI
https://doi.org/10.1186/1478-7954-1-1

Other articles of this Issue 1/2003

Population Health Metrics 1/2003 Go to the issue

Research

Autoregression as a means of assessing the strength of seasonality in a time series

Editorial

Introduction of article-processing charges for Population Health Metrics

Research

A generic model for the assessment of disease epidemiology: the computational basis of DisMod II

Research

Estimating the prevalence of breast cancer using a disease model: data problems and trends

Research

How do Zimbabweans value health states?

Research

A longitudinal analysis of the risk factors for diabetes and coronary heart disease in the Framingham Offspring Study