EUGLOREH project




13.2. Assessing priorities through estimation of the burden of disease

13.2.3. Burden of diseases attributable to specific health determinants.


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13.2.3. Burden of diseases attributable to specific health determinants.


Attributable fractions of total disease burden for the developed world (reference year 2000) were estimated as follows: 13.2% of total disease burden due to tobacco use, 10.9% attributable to hypertension, 7.4% and 7.4% to high cholesterol and obesity. Worldwide, these fractions were estimated to be 4.1%, 4.4%, 2.8%, 2.3%, respectively. Worldwide, childhood malnutrition attributed the highest disease burden, i.e. 9.5%. Estimations of environmental disease burden for the developed world range from 2-6%.


Table 13.4. Burden of disease in 2000 due to selected health determinants for Western Europe, Europe and worldwide


The first three determinants in Table 13.6 are typically associated to poverty in developing countries. Worldwide malnutrition, poor sanitation and indoor air pollution still produce a substantial burden of disease. Tobacco and alcohol use, physical inactivity and unhealthy diets are considered to be typical life-style choices, although one has to consider the important interaction with the social and physical environment. For instance, people do not choose to be born into families of lower socioeconomic status. Hypertension, unfavourable blood lipid composition and obesity are ‘endogenouscharacteristics that develop as a result of life-style, depending on a person’s genetic make-up. Finally, urban air pollution and occupational risks are typically the result of exposure to hazards that are produced collectively within societies.


Globally, an estimated 24% of the disease burden (healthy life years lost) and an estimated 23% of all premature mortality were due to environmental factors. Potentially sensitive groups at higher risk for damage or disease from environmental pollutants are children, people with existing health problems such as diabetes, respiratory disease, or heart disease and people with compromised immune systems, including those who have HIV/AIDS or are undergoing cancer chemotherapy. Poor or other disadvantaged populations who may live in more polluted environments are exposed to higher concentrations of pollutants. Children living in particularly adverse conditions, such as poor and abandoned children, street children and those who are exploited are at a higher risk of injuries due to environmental factors. Moreover, certain populations who live in increasingly agricultural regions, for example, agricultural workers and their families are especially vulnerable to poisoning from . A fetus can be exposed in uterus when their mothers use pesticides, work in sprayed fields, or work near spraying operations. According to a study made on children aged 0-4 years living in the WHO-Europe region (51 countries), 2-6 % of deaths from all causes were due to outdoor air pollution. Acute lower respiratory tract infections due to indoor air pollution accounted for 5% of all deaths and 3 % of DALYs (disability adjusted life years). Mild mental retardation resulting from lead exposure accounted for 4 % of DALYs.


In the Netherlands, lost DALYs have been calculated for 49 selected conditions. Table 13.7 presents a comparison of the health loss (in DALYs) due to unhealthy diet and unsafe food and that due to other lifestyle factors in perspective. A comparison is also carried out with the health loss due to a number of significant diseases. The comparison shows that the overall health loss due to an unhealthy diet is similar to that caused by smoking. The theoretical health gains which could be achieved merely by adopting a proper dietary composition (based on all five factors studied) is in second place and is of the same order as that of reducing obesity (shown here as “energy balance”), or of increasing physical activity. Moreover, it is shown that a proper dietary composition could provide health gains equivalent to the overall health loss due to the most common diseases in the Netherlands, including coronary heart diseases and depression. Table 13.7 also shows that the demonstrable health loss due to microbiological contamination of food is comparable to that due to a number of significant infectious diseases such as AIDS. In the case of chemical contamination, the health loss is lower than that of a number of major environmental factors. However, the health loss due to allergens and acrylamide is greater than that caused by various substances found in the environment. In the context of health protection, allergens must be considered separately, since most are normal constituents of certain foods that elicit greatly differing effects in different people.



Table 13.5. Annual health loss (in DALYs) due to dietary factors and energy balance, against other lifestyle factors, environmental factors and disease categories in the Netherlands.


Source: Van Kreil et al (2006)


DALYs lost







Dietary Factors

Microbiological contamination

Chemical contamination

Other lifestyle factors



Selection from Public Health Status Forecasts 2002


Unhealthy diet total  (1)



Three life-style factors combined (2) ,



Cardiovascular diseases, all cancers


5 dietary factors together, energy-balance (3)



Lack of physical activity


Coronary heart diseases,

Depression, lung cancer, diabetes, alcohol-dependency









Excess of trans fatty acids, too little fruit, vegetables and fish



Alcohol consumption (4)


Road traffic accidents, breast cancer


Excess of saturated fatty acids




Particulate matter in atmosphere

Schizophrenia, prostate cancer, influenza



Gastroenteritis caused by micro-organisms in food



Passive Smoking

Upper respiratory tract infections, HIV/AIDS (5), stomach and intestinal ulcers






Radon (interior)

Bacterial meningitis, bacterial STDs (5), tuberculosis



Campylobacter in food

Allergens acrylamide






STEC 0175 (5)

PAHs (5) other substances


Various substances



1.    Here, ‘unhealthy diet totalrelates to the overall health loss due to the dietary composition (the five modeled dietary factors together, in relation to cardiovascular diseases and the relevant types of cancer) plus the proportion of the health loss attributable to overweight (due to a positive energy balance)

2.    This relates to the combined effects of smoking, lack of physical activity or excessive alcohol consumptions on cardiovascular diseases, diabetes mellitus and the relevant types of cancer.

3.    Energy balance is the dietary factor which accounts for the development of overweight. The health loss due to overweight has been modeled using BMI as indicator. Overweight can also be caused by lack of physical activity, which falls under ‘ other lifestyle factors’ in this table

4.    It is assumed here that moderate alcohol consumption (one to three units per day for men and up to two for women) prevents cardiovascular diseases, as compared to total abstinence. The health loss due to alcohol dependency is shown in the seventh (right-hand) column.

5.    HIV/AIDS: Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome; STD: Sexually Transmitted Disease: STEC: Shiga-toxin-producing Escherichia coli; PAHs: Polycyclic Aromatic Hydrocarbons.