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The Global Burden of Disease (GBD) Study provides estimates of death and disability from eighty-seven risk factors, including some micronutrient deficiencies. To review methodological changes that led to large differences in the disease burden estimates for vitamin A and Zn deficiencies between the GBD 2017 and 2019 Studies. GBD publications were reviewed; additional information was provided by GBD researchers. Vitamin A deficiency prevalence is based on plasma retinol concentration, whereas the estimate for Zn deficiency prevalence uses dietary adequacy as a proxy. The estimated global prevalence of vitamin A deficiency for children aged 1-4 years in the year 2017 decreased from 0·20 (95 % CI 0·17, 0·24) in GBD 2017 to 0·16 (95 % CI 0·15, 0·19) in GBD 2019, while the global prevalence of Zn deficiency did not change between the two studies (0·09 (95 % CI 0·04, 0·17) and 0·09 (95 % CI 0·03, 0·18)). New to 2019 was that meta-analyses were performed using Meta Regression - Bayesian, Regularized, Trimmed, a method developed for GBD. Due to this and multiple other methodological changes, the estimated number of deaths due to vitamin A deficiency dropped from 233 000 (179 000-294 000) to 24 000 (3000-50 000) from GBD 2017 to 2019, and for Zn deficiency from 29 000 (1000-77 000) to 2800 (700-6500), respectively. The changes in the estimated disease burdens due to vitamin A and Zn deficiencies in the GBD reports from 2017 to 2019 are due primarily to changes in the analytical methods employed, so may not represent true changes in disease burden. Additional effort is needed to validate these results.

We use COVID-19 case and mortality data from 1 February 2020 to 21 September 2020 and a deterministic SEIR (susceptible, exposed, infectious and recovered) compartmental framework to model possible trajectories of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the effects of non-pharmaceutical interventions in the United States at the state level from 22 September 2020 through 28 February 2021. Using this SEIR model, and projections of critical driving covariates (pneumonia seasonality, mobility, testing rates and mask use per capita), we assessed scenarios of social distancing mandates and levels of mask use. Projections of current non-pharmaceutical intervention strategies by state—with social distancing mandates reinstated when a threshold of 8 deaths per million population is exceeded (reference scenario)—suggest that, cumulatively, 511,373 (469,578–578,347) lives could be lost to COVID-19 across the United States by 28 February 2021. We find that achieving universal mask use (95% mask use in public) could be sufficient to ameliorate the worst effects of epidemic resurgences in many states. Universal mask use could save an additional 129,574 (85,284–170,867) lives from September 22, 2020 through the end of February 2021, or an additional 95,814 (60,731–133,077) lives assuming a lesser adoption of mask wearing (85%), when compared to the reference scenario. A modeling study using case and mortality data from the first 8 months of the COVID-19 pandemic in the United States explores five potential future scenarios of social distancing mandates and mask use at the state level, with projections of the course of the epidemic through winter 2021.

Characterizing the potential health effects of exposure to risk factors such as red meat consumption is essential to inform health policy and practice. Previous meta-analyses evaluating the effects of red meat intake have generated mixed findings and do not formally assess evidence strength. Here, we conducted a systematic review and implemented a meta-regression—relaxing conventional log-linearity assumptions and incorporating between-study heterogeneity—to evaluate the relationships between unprocessed red meat consumption and six potential health outcomes. We found weak evidence of association between unprocessed red meat consumption and colorectal cancer, breast cancer, type 2 diabetes and ischemic heart disease. Moreover, we found no evidence of an association between unprocessed red meat and ischemic stroke or hemorrhagic stroke. We also found that while risk for the six outcomes in our analysis combined was minimized at 0 g unprocessed red meat intake per day, the 95% uncertainty interval that incorporated between-study heterogeneity was very wide: from 0–200 g d −1 . While there is some evidence that eating unprocessed red meat is associated with increased risk of disease incidence and mortality, it is weak and insufficient to make stronger or more conclusive recommendations. More rigorous, well-powered research is needed to better understand and quantify the relationship between consumption of unprocessed red meat and chronic disease. Using the burden of proof analytical tool, a meta-analysis found weak or no evidence of associations between unprocessed red meat consumption and increased risk of six cardiometabolic disease and cancer outcomes.

Previous research suggests a protective effect of vegetable consumption against chronic disease, but the quality of evidence underlying those findings remains uncertain. We applied a Bayesian meta-regression tool to estimate the mean risk function and quantify the quality of evidence for associations between vegetable consumption and ischemic heart disease (IHD), ischemic stroke, hemorrhagic stroke, type 2 diabetes and esophageal cancer. Increasing from no vegetable consumption to the theoretical minimum risk exposure level (306–372 g daily) was associated with a 23.2% decline (95% uncertainty interval, including between-study heterogeneity: 16.4–29.4) in ischemic stroke risk; a 22.9% (13.6–31.3) decline in IHD risk; a 15.9% (1.7–28.1) decline in hemorrhagic stroke risk; a 28.5% (−0.02–51.4) decline in esophageal cancer risk; and a 26.1% (−3.6–48.3) decline in type 2 diabetes risk. We found statistically significant protective effects of vegetable consumption for ischemic stroke (three stars), IHD (two stars), hemorrhagic stroke (two stars) and esophageal cancer (two stars). Including between-study heterogeneity, we did not detect a significant association with type 2 diabetes, corresponding to a one-star rating. Although current evidence supports increased efforts and policies to promote vegetable consumption, remaining uncertainties suggest the need for continued research. A meta-analysis using the Burden of Proof function identified modest evidence supporting a protective role of vegetable consumption against ischemic heart disease, stroke and esophageal cancer but not type 2 diabetes.

Micronutrient deficiency is one of the most recognized and critical forms of malnutrition. Generally, micronutrient deficiency is quantified by low levels of a micronutrient biomarker in the body, but key micronutrients often lack sensitive and specific biomarkers. Additionally, there is a shortage of data on micronutrient status, especially surveys that assess multiple biomarkers on the same population. To quantify multiple micronutrient inadequacy, and provide insights into micronutrient consumption patterns around the world, we estimate the prevalence of inadequate intake of iron, vitamin A and zinc, using a standardized set of nutrient requirement levels and a copula joint distribution approach. We found that a large proportion of the world is at risk of inadequate intake of key micronutrients, ranging from 60% of people in high-income locations to 94% of people in locations in South Asia. Globally, 5.9 billion people have dietary inadequacy of at least one of the three micronutrients examined. There is higher prevalence of inadequate intake of vitamin A and zinc than iron, likely because dietary recall surveys and requirement levels do not distinguish between the differential absorption of heme and non-heme iron. By assessing the prevalence of multiple micronutrient inadequacy rather than a single micronutrient, we revealed that a much higher number of people are at risk for micronutrient inadequacy than the 2 billion previously thought. Our findings highlight the need for better data on micronutrient status indicators across geographically diverse populations. Further research is warranted to define the relationship between inadequacy and deficiency, which has implications on the management and planning of nutrition interventions.

Little is known about health care spending variation across the US for recent years. To estimate health spending by state and payer, we combined data from the government's State Health Expenditure Accounts, which have estimates through 2014, with other primary data on spending. In 2019 state-specific per person spending ranged from $7,250 to $14,500. After adjustment for inflation, annualized per person spending growth for each state ranged from 1.0 percent in Washington, D.C., to 4.2 percent in South Dakota between 2013 and 2019. The factors that explained the most variation across states were incomes (25.3 percent) and consumer prices (21.7 percent). Medicaid expansion was associated with increases in total spending per person, although the median of spending in expansion states showed slower growth in out-of-pocket spending than the median in nonexpansion states. Contemporary estimates of state health spending are valuable for tracking divergent expenditure trajectories in the US and assessing the associated factors.

A Correction to this paper has been published: https://doi.org/10.1038/s41591-020-01181-w