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Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk–outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk–outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk–outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51–12·1) deaths (19·2% [16·9–21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12–9·31) deaths (15·4% [14·6–16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253–350) DALYs (11·6% [10·3–13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0–9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10–24 years, alcohol use for those aged 25–49 years, and high systolic blood pressure for those aged 50–74 years and 75 years and older. Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Bill & Melinda Gates Foundation.

More remains unknown than known about how to optimize multiple health behaviour change. After reviewing the prevalence and comorbidities among major chronic disease risk behaviours for adults and youth, we consider the origins and applicability of high-risk and population strategies to foster multiple health behaviour change. Findings indicate that health risk behaviours are prevalent, increase with age and co-occur as risk behaviour clusters or bundles. We conclude that both population and high-risk strategies for health behaviour intervention are warranted, potentially synergistic and need intervention design that accounts for substitute and complementary relationships among bundled health behaviours. To maximize positive public health impact, a pressing need exists for bodies of basic and translational science that explain health behaviour bundling. Also needed is applied science that elucidates the following: (1) the optimal number of behaviours to intervene upon; (2) how target behaviours are best selected (e.g. greatest health impact; patient preference or positive effect on bundled behaviours); (3) whether to increase healthy or decrease unhealthy behaviours; (4) whether to intervene on health behaviours simultaneously or sequentially and (5) how to achieve positive synergies across individual-, group- and population-level intervention approaches.

The present study examines links between civic engagement (voting, volunteering, and activism) during late adolescence and early adulthood, and socioeconomic status and mental and physical health in adulthood. Using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health, a propensity score matching approach is used to rigorously estimate how civic engagement is associated with outcomes among 9,471 adolescents and young adults (baseline Mage = 15.9). All forms of civic engagement are positively associated with subsequent income and education level. Volunteering and voting are favorably associated with subsequent mental health and health behaviors, and activism is associated with more healthrisk behaviors and not associated with mental health. Civic engagement is not associated with physical health.

Background Adolescent health-risk behaviors are prevalent and tend to co-occur. This study aimed to identify patterns of health-risk behaviors among Chinese adolescents during the COVID-19 pandemic and explore the effects of individual and social factors on health-risk patterns. Methods This cross-sectional study investigated 1607 adolescents from four high schools in 2021 through stratified cluster random sampling. Latent class analysis was conducted to identify patterns of health-risk behaviors and logistic regression was used to examine the risk and protective factors of latent class membership. Results Four latent classes were identified: “Low risk” (81.6%), “Problematic Internet use” (7.8%), “Alcohol use” (8.5%), and “High risk” (2.1%). Relative to the “Low risk”, adolescents with higher levels of sensation seeking, deviant peer affiliation, and childhood abuse were more likely to be assigned to the “Problematic Internet use” class, while those with high degrees of parental monitoring and school connectedness were less likely to be in the “Problematic Internet use” class. Those with higher levels of sensation seeking and deviant peer affiliation, lower scores of parental monitoring and school connectedness were more likely to be assigned to the “Alcohol use” class, compared to the “Low risk”. Students in the “High risk” class were more likely to report higher levels of sensation seeking, deviant peer affiliation, and childhood abuse, but lower degrees of parental monitoring and school connectedness than the “Low risk” class. Conclusions This study identified patterns of multiple risk behaviors among Chinese high school students during the COVID-19 pandemic and found that multi-level individual and social factors affected latent classes of adolescent health-risk behaviors. These findings provide clues for designing effective interventions to reduce health-risk behaviors among adolescents.

The aim of this study was to build a detailed, integrative profile of the correlates of young adults' feelings of loneliness, in terms of their current health and functioning and their childhood experiences and circumstances. Data were drawn from the Environmental Risk Longitudinal Twin Study, a birth cohort of 2232 individuals born in England and Wales in 1994 and 1995. Loneliness was measured when participants were aged 18. Regression analyses were used to test concurrent associations between loneliness and health and functioning in young adulthood. Longitudinal analyses were conducted to examine childhood factors associated with young adult loneliness. Lonelier young adults were more likely to experience mental health problems, to engage in physical health risk behaviours, and to use more negative strategies to cope with stress. They were less confident in their employment prospects and were more likely to be out of work. Lonelier young adults were, as children, more likely to have had mental health difficulties and to have experienced bullying and social isolation. Loneliness was evenly distributed across genders and socioeconomic backgrounds. Young adults' experience of loneliness co-occurs with a diverse range of problems, with potential implications for health in later life. The findings underscore the importance of early intervention to prevent lonely young adults from being trapped in loneliness as they age.

Background Although experiences of violence are detrimental and may occur throughout the lifespan, few studies have examined the long-term health correlates of violence in both childhood and adulthood. Objective To examine the association of exposure to child maltreatment (CM) as well as severe violence in adulthood with mental and physical health problems and health-related risk behaviors in adulthood. Methods The study was cross-sectional and applied a novel survey instrument among a random sample of 10 337 Swedish women and men aged 18–74. Logistic regression was applied to calculate odds ratios. Results Exposure to 0, 1, 2 or 3 or more types of CM showed graded associations for depression, anxiety, self-harm and PTSD in adulthood. Irritable bowel syndrome, fibromyalgia and obesity showed modest correlations. No significant associations were found between CM and ischemic heart disease (IHD), type 2 diabetes or cancer, although the ORs were in line with several previous ACE studies. When exposure to severe violence in adulthood was added to CM, odds ratios increased dramatically for mental health problems and health-related risk behaviors, suggesting that revictimization may moderate or mediate this relationship. Conclusions The results underscore the importance of studying violence exposure in a life-course perspective and suggest that the relationship between childhood adversities and long-term physical health problems in adulthood may be affected by the traumatic effects of revictimization in adult life. This points to the importance of early identification of child maltreatment and provision of robust services to protect children, treat symtoms of trauma, and enhance resilience to decrease the risk of poor health outcomes.

Adverse childhood experiences (ACEs) have been associated with poor health status later in life. The objective of the present study was to examine the relationship between ACEs and health-related behaviors, chronic diseases, and mental health in adults. A cross-sectional study was performed with 1501 residents of Macheng, China. The ACE International Questionnaire (ACE-IQ) was used to assess ACEs, including psychological, physical, and sexual forms of abuse, as well as household dysfunction. The main outcome variables were lifetime drinking status, lifetime smoking status, chronic diseases, depression, and posttraumatic stress disorder. Multiple logistic regression models were used to examine the associations between overall ACE score and individual ACE component scores and risk behaviors/comorbidities in adulthood after controlling for potential confounders. A total of 66.2% of participants reported at least one ACE, and 5.93% reported four or more ACEs. Increased ACE scores were associated with increased risks of drinking (adjusted odds ratio [AOR] = 1.09, 95% confidence intervals [CI]: 1.00-1.09), chronic disease (AOR = 1.17, 95% CI: 1.06-1.28), depression (AOR = 1.37, 95% CI: 1.27-1.48), and posttraumatic stress disorder (AOR = 1.32, 95% CI: 1.23-1.42) in adulthood. After adjusting for confounding factors, the individual ACE components had different impacts on risk behavior and health, particularly on poor mental health outcomes in adulthood. ACEs during childhood were significantly associated with risk behaviors and poor health outcomes in adulthood, and different ACE components had different long-term effects on health outcomes in adulthood.

Health risk behaviors continue to disproportionately affect Hispanic youth. Despite the existence of successful family and school-based interventions, there is a need for developing and testing individually-based preventive interventions that are easily accessed and widely disseminated. Therefore, this study aimed to develop a prototype (proof of concept) for an individual-level mobile application (app), informed by Hispanic parents and adolescents, to prevent/reduce drug use and sexual risk behaviors among Hispanic youth. An iterative user-centered approach was used to inform the development of the app prototype via focus groups with 66 participants (n = 46 adolescents, n = 20 parents). A coding team analyzed data from the focus groups and identified major themes. The coding team summarized interview data into sub-categories that yielded five intervention modules for Hispanic adolescents, three more than originally proposed (i.e., drug use and sexual risk behaviors): (1) effective communication, (2) depression, (3) sexual health, (4) drug use, and (5) mindfulness. A mobile application for health risk behaviors can be used as an additional preventive tool to decrease the existing behavioral health disparities among Hispanic youth. Incorporating a user-centered approach to inform development is important for including the needs and voices of this population.

Tobacco and cannabis use, alcohol consumption and inactivity are health risk behaviors (HRB) of crucial importance for health and wellbeing. The impact of the COVID-19 pandemic on university students’ engagement in HRB has yet received limited attention. We investigated whether HRB changed during the COVID-19 pandemic, assessed factors associated with change and profiles of HRB changes in university students. A web-based survey was conducted in May 2020, including 5021 students of four German universities (69% female, the mean age of 24.4 years (SD = 5.1)). Sixty-one percent of students reported consuming alcohol, 45.8% binge drinking, 44% inactivity, 19.4% smoking and 10.8% cannabis use. While smoking and cannabis use remained unchanged during the COVID-19 pandemic, 24.4% reported a decrease in binge drinking while 5.4% reported an increase. Changes to physical activity were most frequently reported, with 30.6% reporting an increase and 19.3% reporting a decrease in vigorous physical activity. Being female, younger age, being bored, not having a trusted person and depressive symptoms were factors associated with a change in HRB. Five substance use behavior profiles were identified, which also remained fairly unchanged. Efforts to promote student health and wellbeing continue to be required, also in times of the COVID-19 pandemic.

Risk-behaviors are a major contributor to the leading causes of morbidity among adolescents and young people; however, their association with pathological Internet use (PIU) is relatively unexplored, particularly within the European context. The main objective of this study is to investigate the association between risk-behaviors and PIU in European adolescents. This cross-sectional study was conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). Data on adolescents were collected from randomized schools within study sites across eleven European countries. PIU was measured using Young’s Diagnostic Questionnaire (YDQ). Risk-behaviors were assessed using questions procured from the Global School-Based Student Health Survey (GSHS). A total of 11,931 adolescents were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89 ± 0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviors. The significant association observed between PIU and risk-behaviors, combined with a high rate of co-occurrence, underlines the importance of considering PIU when screening, treating or preventing high-risk behaviors among adolescents.