For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.
Comprehensive, comparable, and timely estimates of demographic metrics-including life expectancy and age-specific mortality-are essential for evaluating, understanding, and addressing trends in population health. The COVID-19 pandemic highlighted the importance of timely and all-cause mortality estimates for being able to respond to changing trends in health outcomes, showing a strong need for demographic analysis tools that can produce all-cause mortality estimates more rapidly with more readily available all-age vital registration (VR) data. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is an ongoing research effort that quantifies human health by estimating a range of epidemiological quantities of interest across time, age, sex, location, cause, and risk. This study-part of the latest GBD release, GBD 2023-aims to provide new and updated estimates of all-cause mortality and life expectancy for 1950 to 2023 using a novel statistical model that accounts for complex correlation structures in demographic data across age and time. We used 24 025 data sources from VR, sample registration, surveys, censuses, and other sources to estimate all-cause mortality for males, females, and all sexes combined across 25 age groups in 204 countries and territories as well as 660 subnational units in 20 countries and territories, for the years 1950-2023. For the first time, we used complete birth history data for ages 5-14 years, age-specific sibling history data for ages 15-49 years, and age-specific mortality data from Health and Demographic Surveillance Systems. We developed a single statistical model that incorporates both parametric and non-parametric methods, referred to as OneMod, to produce estimates of all-cause mortality for each age-sex-location group. OneMod includes two main steps: a detailed regression analysis with a generalised linear modelling tool that accounts for age-specific covariate effects such as the Socio-demographic Index (SDI) and a population attributable fraction (PAF) for all risk factors combined; and a non-parametric analysis of residuals using a multivariate kernel regression model that smooths across age and time to adaptably follow trends in the data without overfitting. We calibrated asymptotic uncertainty estimates using Pearson residuals to produce 95% uncertainty intervals (UIs) and corresponding 1000 draws. Life expectancy was calculated from age-specific mortality rates with standard demographic methods. For each measure, 95% UIs were calculated with the 25th and 975th ordered values from a 1000-draw posterior distribution. In 2023, 60·1 million (95% UI 59·0-61·1) deaths occurred globally, of which 4·67 million (4·59-4·75) were in children younger than 5 years. Due to considerable population growth and ageing since 1950, the number of annual deaths globally increased by 35·2% (32·2-38·4) over the 1950-2023 study period, during which the global age-standardised all-cause mortality rate declined by 66·6% (65·8-67·3). Trends in age-specific mortality rates between 2011 and 2023 varied by age group and location, with the largest decline in under-5 mortality occurring in east Asia (67·7% decrease); the largest increases in mortality for those aged 5-14 years, 25-29 years, and 30-39 years occurring in high-income North America (11·5%, 31·7%, and 49·9%, respectively); and the largest increases in mortality for those aged 15-19 years and 20-24 years occurring in Eastern Europe (53·9% and 40·1%, respectively). We also identified higher than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 5-14 years (87·3% higher in GBD 2023 than GBD 2021 on average across countries and territories over the 1950-2021 period) and for females aged 15-29 years (61·2% higher), as well as lower than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 50 years and older (13·2% lower), reflecting advances in our modelling approach. Global life expectancy followed three distinct trends over the study period. First, between 1950 and 2019, there were considerable improvements, from 51·2 (50·6-51·7) years for females and 47·9 (47·4-48·4) years for males in 1950 to 76·3 (76·2-76·4) years for females and 71·4 (71·3-71·5) years for males in 2019. Second, this period was followed by a decrease in life expectancy during the COVID-19 pandemic, to 74·7 (74·6-74·8) years for females and 69·3 (69·2-69·4) years for males in 2021. Finally, the world experienced a period of post-pandemic recovery in 2022 and 2023, wherein life expectancy generally returned to pre-pandemic (2019) levels in 2023 (76·3 [76·0-76·6] years for females and 71·5 [71·2-71·8] years for males). 194 (95·1%) of 204 countries and territories experienced at least partial post-pandemic recovery in age-standardised mortality rates by 2023, with 61·8% (126 of 204) recovering to or falling below pre-pandemic levels. There were several mortality trajectories during and following the pandemic across countries and territories. Long-term mortality trends also varied considerably between age groups and locations, demonstrating the diverse landscape of health outcomes globally. This analysis identified several key differences in mortality trends from previous estimates, including higher rates of adolescent mortality, higher rates of young adult mortality in females, and lower rates of mortality in older age groups in much of sub-Saharan Africa. The findings also highlight stark differences across countries and territories in the timing and scale of changes in all-cause mortality trends during and following the COVID-19 pandemic (2020-23). Our estimates of evolving trends in mortality and life expectancy across locations, ages, sexes, and SDI levels in recent years as well as over the entire 1950-2023 study period provide crucial information for governments, policy makers, and the public to ensure that health-care systems, economies, and societies are prepared to address the world's health needs, particularly in populations with higher rates of mortality than previously known. The estimates from this study provide a robust framework for GBD and a valuable foundation for policy development, implementation, and evaluation around the world. Gates Foundation.
Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
Chronic kidney disease (CKD) is common and ranks among the leading causes of mortality and morbidity. This analysis aimed to present global CKD estimates using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to inform evidence-based policies for CKD identification and treatment. This analysis focused on adults aged 20 years and older over the period 1990 to 2023, from 204 countries and territories. Data sources used were published literature, vital registration systems, kidney failure treatment registries, and household surveys. Estimates of CKD burden, including deaths, incidence, prevalence, and disability-adjusted life-years (DALYs), were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool. A comparative risk assessment approach estimated the proportion of cardiovascular deaths attributable to impaired kidney function and estimated risk factors for CKD. Globally, in 2023, 788 million (95% uncertainty interval 743-843) people aged 20 years and older were estimated to have CKD, up from 378 million (354-407) in 1990. The global age-standardised prevalence of CKD in adults was 14·2% (13·4-15·2), a relative rise of 3·5% (2·7-4·1) from 1990. The region with the highest age-standardised prevalence was north Africa and the Middle East (18·0%; 16·9-19·4). Most people had stage 1-3 CKD, with a combined prevalence of 13·9% (13·1-15·0). In 2023, CKD was the ninth leading cause of death globally, accounting for 1·48 million (1·30-1·65) deaths, and the 12th leading cause of DALYs, with an age-standardised DALY rate of 769·2 (691·8-857·4) per 100 000. Impaired kidney function as a risk factor accounted for 11·5% (8·4-14·5) of cardiovascular deaths. High fasting plasma glucose, body-mass index, and systolic blood pressure were all leading risk factors for CKD DALYs. CKD is a major global health issue, with rising prevalence and increasing importance as a cause of death and as a risk factor for cardiovascular death. A better understating of aetiology, appropriate screening, and implementation programmes are needed to translate advances in CKD treatment into improved patient outcomes. Gates Foundation, Wellcome, US National Kidney Foundation, and US National Institute of Diabetes and Digestive and Kidney Diseases.
Due to the many health impacts of climate change, it is imperative to equip public health professionals with the skills and knowledge to work on climate mitigation and adaptation. However, it is unclear to what extent Masters of Public Health (MPH) include climate change and related subjects in their curricula. A survey was sent to MPH directors in the UK with questions about inclusion of climate change and related subjects in the curriculum. Russell group universities and those commissioned by NHS England Workforce, Training and Education were invited to take part. A total of 27 MPH courses were included (100% response rate). Climate change and related subjects were included in optional or core modules on other subjects, with health protection and health improvement being the most common. Two MPHs had only one lecture/seminar on climate change and one MPH did not cover these topics in the syllabus. The most common subject included in curricula was climate change (24, 89%). Most MPH directors wanted to increase the inclusion of climate change and planetary health in the curriculum (12, 55%) but could not do so due to lack of space within an already overloaded curriculum (10, 37%). Despite the recognition of the importance of climate change and health education by MPH course directors, the inclusion of those subjects in curricula remains variable and not as thorough as required given the importance of the topic. Addressing barriers is warranted to enable public health professionals to gain the required skills in climate mitigation and adaptation.
In 2019, the EAT-Lancet Commission introduced the Planetary Health Diet (PHD), aiming to enhance both human health and global environmental sustainability. Although a few indexes have been developed based on the PHD for different populations, there is currently no index tailored specifically for the South Asian population. This study aimed to develop and validate a Planetary Health Diet Index (PHDI) based on the EAT-Lancet PHD in a prospective South Asian cohort based in the United States. Analysis was conducted using cross-sectional dietary data obtained from a validated, ethnic-specific semiquantitative food frequency questionnaire administered to adults in the Mediators of Atherosclerosis in South Asians Living in America study at a baseline visit between 2010 and 2013. A total of 906 participants were enrolled at baseline, recruited from Chicago and the San Francisco Bay Area, in this community-based prospective cohort. Eligible participants were individuals of South Asian ancestry (defined as having 3 or more grandparents born in India, Pakistan, Nepal, Bangladesh, or Sri Lanka) with no history of cardiovascular disease, aged between 40 and 84 years, and proficient in English, Urdu, or Hindi. The analytic sample included a total of 891 participants without missing data or implausible energy intakes. The main outcome measure was the PHDI score and its associations with assessments of construct validity and internal reliability. Linear regression models were used to examine the construct validity of the PHDI, as well as correlations between the index and the Alternative Healthy Eating Index and the dietary carbon footprint. Analysis of variance was used to evaluate the concurrent-criterion validity and principal components analysis to assess multidimensionality. Pearson correlations were estimated between the PHDI components and energy, and Cronbach's coefficient α was determined to assess internal consistency. The PHDI was composed of 15 food components with intake ranges as prescribed by the 2019 EAT-Lancet PHD and scored proportionally 0 to 10 for a total possible score between 0 and 140. PHDI scores ranged from 51 to 119 out of 140 possible points, with a mean score of 89. PHDI was positively associated with plant-derived nutrients such as vegetable protein (P < .0001), total fiber (P < .0001), vitamins A (P < .006) and C (P < .012), and negatively associated with animal-sourced nutrients such as animal protein, cholesterol, and vitamin B12 (P < .0001 for all), amongst others. Concurrent criteria validity revealed significant differences among subgroups: current smokers scored lower (85) than nonsmokers (89) (P = .03); those with bachelor's degrees scored higher (89.3) than those without (85.4) (P < .0001); higher family income correlated with higher scores (89.7 vs 86.7; P < .0001); and participants with type 2 diabetes had higher scores (90.8) than those with prediabetes (88) (P = .002) or normal glycemia (88.4) (P < .008). Each 5-unit increase in PHDI score was associated with a higher Alternative Healthy Eating Index score (partial correlation: r = 0.7; P < .0001) and a 7% lower dietary carbon footprint (P < .001). Cronbach's α for internal reliability was .68. The findings provided support for both the construct validity and reliability of the PHDI in this cohort of American South Asians. This index is suitable for assessing diets in relation to the 2019 EAT-Lancet dietary guidelines.
Non-communicable diseases (NCDs) account for 70% of global mortality and are responsible for over 38 million deaths annually, with cardiovascular disease (CVD) constituting most of these fatalities. While traditional risk factors for CVD have long been recognized, there is growing evidence that a rising prevalence of ubiquitous environmental risk factors (ERFs) may play an increasingly significant role in the genesis and rising prevalence of NCDs. ERFs include many interconnected anthropogenic exposures with cumulative compound health impacts, including air pollution, noise exposure, artificial light at night, plastic pollution, chemical pollution and the various effects of climate change, such as heat extremes, desert storms, floods and wildfires. Urbanization has intensified the impact of many ERFs and created intense exposure environments, highlighting the urgency and the opportunity to address these for maximum public health benefit. Impactful intervention often requires regulatory and policy-driven efforts addressing the genesis of exposures and minimizes their health impact, particularly in vulnerable populations who may contribute the least but may be impacted the most. Solutions must involve the development of resiliency and adaptation measures to a changing world, where the probability of sudden catastrophic and cascading events is much more likely. Political will and international cooperation are essential in establishing and enforcing regulations that promote cleaner air and water, quieter and natural biodiverse environments, and sustainable infrastructure in urban, and rural medical facilities. Integration of planetary and environmental health into cardiovascular care will be vital in reducing the burden of NCDs globally. By addressing the root causes of environmental stressors, it is possible to reduce the incidence of CVDs and promote healthier, just and sustainable societies.
Addressing the adverse impacts of climate change on human health requires a global effort across multiple sectors. People living in low- and middle-income countries are particularly vulnerable to the health crises induced by climate change. Therefore, context specific solutions to tackle such challenges are essential to ensure preventive measures are in place for mitigating such risks. This protocol aims to outline an integrated, participatory approach to cocreate multisectoral interventions tailored to specific environmental and health challenges in Bangladesh, India, and Indonesia. This work is done as part of the Global Health Research Centre for Non-Communicable Diseases and Environmental Change, funded by the National Institute for Health and Care Research. The overall aim is to collaboratively design and assess interventions that deliver dual benefits for planetary and human health. To address the multisectoral nature of the challenges, this study will adopt a cocreation methodology that blends co-design and coproduction approaches. While the problem areas are specific to each context-tackling air pollution due to plastic burning in Indonesia, improving dietary diversity of public food procurement systems and managing extreme heat in India, and mitigating drinking water salinity in Bangladesh-the underlying cocreation framework is consistent and can be adapted to the needs of each study setting. The workflow consists of 4 key stages guided by an existing cocreation framework: planning, developing, evaluation, and reporting, with the 6 core elements of the Medical Research Council's complex intervention development framework embedded throughout the process. Drawing on the Double Diamond design process, the cocreation stage involves the following phases: codevelopment of a theory of change to explore potential context-specific interventions, short-listing of intervention components through gap analysis and prioritization, co-designing and coproducing selected intervention components, and assessing appropriateness and feasibility of intervention implementation. The cocreation process will be evaluated using the Research Quality Plus for Co‑Production framework to ensure methodological rigor and quality. Cocreation will take place over 6 months. Sampling and recruitment of cocreators (key stakeholders across sectors) have been completed in all 3 countries, with each cocreator group consisting of 20-30 members. We have developed the tools for the cocreation phase, informed by the findings from formative research, and received the necessary ethics approval to conduct these activities. We will generate a series of academic and nonacademic outputs on the cocreation process to disseminate the findings, as well as training materials for implementers to facilitate future adoption in similar settings. The cocreation of multisectoral interventions to tackle both environmental change and health is a comparatively new domain of implementation research. This protocol addresses the complex, multidimensional, and unique nature of such interventions by developing a structured and scientifically sound approach to be implemented in real-life settings. DERR1-10.2196/80368.
Exclusive breastfeeding is recommended as healthier and more sustainable than formula feeding. It produces less waste, requires fewer resources, and has a smaller environmental impact. Breastfeeding has some environmental impact related to increased maternal dietary needs and the use of feeding accessories. In light of the global climate emergency and suboptimal breastfeeding rates, targeted interventions are urgently needed to promote sustainable infant feeding practices. There are few studies that evaluate sustainability interventions in the postpartum period. The objective of this study is to evaluate the effectiveness of an educational and counseling intervention on breastfeeding and healthy maternal nutrition from an environmental perspective. A multicenter prospective intervention study is being conducted in 2 cohorts in primary care centers and hospitals in the north metropolitan area of Barcelona. The control group received standard obstetric care. The experimental group additionally received an educational intervention and health care support on breastfeeding and healthy and sustainable maternal nutrition. Pregnant women were monitored from 24 weeks of gestation to 6 months post partum. The rates of different types of breastfeeding, the women's diet, and the associated environmental impacts (climate change and water footprint) will be analyzed to assess the effectiveness of the intervention. The development of the educational and counseling intervention has been completed, including the creation of the Guide to Good Practices in Breastfeeding, Nutrition, and Sustainability. Health care professionals received targeted training. Recruitment of pregnant women was conducted from December 2023 to December 2024. Prenatal education sessions and specialized care pathways were designed and implemented. Breastfeeding-friendly spaces were adapted to support the participating centers. Data collection for monitoring breastfeeding practices, maternal diet, and environmental impact indicators (carbon footprint and water footprint), with the follow-up period of 6 months post partum, was extended until September 2025, with a complementary missing data collection in October 2025. Data cleaning for final analysis is expected to conclude by January 2026. This study hypothesizes that mothers who receive higher levels of education and counseling support will (1) breastfeed for a longer duration, (2) adopt healthier and more sustainable dietary practices, and (3) reduce environmental impacts associated with both infant feeding accessories and dietary choices. We expect an increase in the incidence and prevalence rates of breastfeeding and a shift toward a healthy and sustainable diet with low environmental impact. ClinicalTrials.gov NCT05729581; https://clinicaltrials.gov/study/NCT05729581. DERR1-10.2196/80358.
Planetary health education highlights the growing impact of climate change on human health - an urgent and relevant issue for healthcare providers that remains inadequately addressed in medical education. A student-led initiative at the University of Münster, Germany, has developed the "Klima-LIMETTE" (Engl.: "Climate-LIMETTE"), a course that teaches the health implications of climate change. It builds on the established infrastructure "LIMETTE" (Lernzentrum für individualisiertes medizinisches Tätigkeitstraining, Engl.: Learning center for individual medical skills training), that uses medical scenarios with simulated patients. Scenarios were developed based on current research on the effects of climate change on health with a focus in Germany. An additional blended e-learning course was designed to convey the knowledge needed for the case simulations and to promote a comprehensive understanding of planetary health. The "Klima-LIMETTE" was conducted twice as a pilot study with 32 students. The cases were evaluated to be realistic and relevant. Students ranked the "Klima-LIMETTE" as "good" or "very good" on a six-point Likert scale. Health-relevant climate information can be presented practically and theoretically in medical education. This course acts as a best-practice example of Planetary Health Education in medical teaching through interdisciplinary cooperation. The course is now implemented in the curriculum and jointly organized by four complementary institutes within the University of Münster. Die planetare Gesundheitslehre thematisiert die zunehmenden Auswirkungen des Klimawandels auf die menschliche Gesundheit – ein dringendes und relevantes Thema für Gesundheitsexpert:innen, das in der medizinischen Ausbildung noch nicht ausreichend behandelt wird. Eine von Studierenden geleitete Initiative an der Universität Münster hat die „Klima-LIMETTE“ entwickelt; einen Kurs, der die gesundheitlichen Auswirkungen des Klimawandels vermittelt. Sie baut auf der etablierten Infrastruktur „LIMETTE“ (Lernzentrum für individualisiertes medizinisches Tätigkeitstraining) auf, die medizinische Szenarien mit Schauspielpatient:innen darstellt. Die Szenarien wurden auf der Grundlage aktueller Forschung zu den Auswirkungen des Klimawandels auf die Gesundheit mit Schwerpunkt in Deutschland entwickelt. Ein zusätzlicher Blended-E-Learning-Kurs wurde konzipiert, um das für die Fallsimulationen benötigte Wissen zu vermitteln und ein umfassendes Verständnis der planetaren Gesundheit zu fördern. Die „Klima-LIMETTE“ wurde zweimal als Pilotstudie mit 32 Studierenden und zweimal curricular im neunten Semester durchgeführt. Die Fälle wurden als realistisch und relevant bewertet. Die Studierenden bewerteten die „Klima-LIMETTE“ auf einer sechsstufigen Likert-Skala mit „gut“ oder „sehr gut“. Gesundheitsrelevante Klimawandelfolgen können in der medizinischen Ausbildung praktisch und theoretisch vermittelt werden. Dieser Kurs dient als Best-Practice-Beispiel dafür, wie planetare Gesundheitslehre in der medizinischen Lehre durch interdisziplinäre Zusammenarbeit verankert werden kann. Der Kurs ist im Curriculum implementiert und wird von vier sich ergänzenden Instituten der Universität Münster gemeinsam organisiert.
Dementia prevention and climate action share a common imperative: safeguarding future generations' health. Despite evidence that nearly half of dementia cases could be prevented by addressing modifiable risk factors, current interventions focused mostly on individual behaviours have yielded mixed cognitive benefits. At the same time, climate change is introducing unprecedented environmental stressors, including air pollution, extreme heat exposure and degraded green spaces, that compound dementia risk. This study aimed to explore how midlife adults perceive the relationship between their daily environments, brain health-related behaviours and planetary health. Qualitative study using the photovoice method. Community setting in Auckland, Aotearoa New Zealand. 14 community-dwelling adults aged 40-65 years residing in Auckland, Aotearoa New Zealand. Participants took photographs and shared narratives to document how their daily environments nurture or threaten lifestyle factors related to brain health. The project involved a five-session participatory process, and data were analysed using reflexive thematic analysis informed by a planetary health framework. Reflexive thematic analysis, underpinned by a planetary health framework, revealed four inter-related themes: (1) nature as restorative and protective; (2) the mental burden of pollution, sensory overload and climate-driven landscape changes; (3) the protective role of social connection, community care and routines; (4) the co-benefits of education and mindful, eco-friendly behaviours. These findings underscore that midlife adults perceive their brain health as intertwined with ecological and social contexts. Dementia risk reduction strategies may therefore benefit from integrating planetary health perspectives that consider environmental conditions alongside social determinants of health. By centring lived experiences and diverse perspectives, photovoice generated context-rich insights that can guide research on more holistic approaches to dementia risk reduction.
The escalating climate crisis necessitates that health care and medical education adapt to the increasing health impacts of extreme weather events, rising temperatures, and shifting ecosystems. Patients and medical trainees are already confronting the health consequences of climate change, pollution, and environmental degradation, while health care systems grapple with effects on service delivery. These environmental challenges underscore the need for health care and medical education that is resilient and proactive in addressing emerging threats.Planetary health is a field inclusive of the effects of climate change and environmental degradation on human health and the broader systems that sustain life. Many U.S. medical schools have begun integrating planetary health into their curricula. However, without deliberate and scaffolded inclusion of planetary health education throughout graduate medical education, trainees may lack the ability to translate environmental determinants of health into actionable clinical strategies that improve patient outcomes and health care system resilience, as graduate medical education plays a pivotal role in shaping physicians' practice patterns. The Accreditation Council for Graduate Medical Education (ACGME), which sets the standard for routine graduate medical education, has the opportunity to help prepare trainees to meet societal needs and equip them for the challenges they will encounter in their medical practice.Incorporating planetary health into the Common Program Requirements would establish a training standard for planetary health, now widely recognized as fundamental to human health. Existing ACGME priorities, such as health equity, quality improvement, systems-based practice, and interdisciplinary collaboration, align with planetary health approaches. The ACGME's endorsement of planetary health education would ensure all residents acquire the skills and knowledge necessary to address the health consequences of climate change and are prepared to practice sustainable health care, thus fostering a health care workforce capable of meeting the needs of patients and delivering resilient, sustainable, and equitable care.
With increasing awareness that pollution, climate change and biodiversity loss threaten planetary health, nursing educators globally recognise their unique role in preparing the nursing workforce to engage in climate change mitigation and adaptation and build community climate resilience. While several nursing programs in high-income countries have begun integrating climate-related content, practical models from low- and middle-income settings remain scarce. In Indonesia, where no national standards require such content, this gap is particularly pronounced. To describe the development, implementation and evaluation of a novel elective subject, "Nursing Perspectives on Climate Change", designed to prepare nursing students to contribute to climate-resilient healthcare through sustainable clinical practices, health education, and community adaptation. A case study using the Design-Based Research framework. Universitas Indonesia. Bachelor-level students from nursing and other disciplines. The elective was developed for Bachelor of Nursing Program at a Faculty of Nursing, Universitas Indonesia using a six-phase design-based approach: Focus, Formulation, Contextualization, Definition, Implementation, and Evaluation. To evaluate student experience and learning outcomes, educators collected data from two cohorts: those enrolled in semester two of the academic year 2023/2024 and semester one of the academic year 2024/2025. Educators gathered data via university-administered learning evaluation surveys (N = 73) and semi-structured interviews (n = 12). Interview data were analysed thematically. Ethical approval was obtained from Universitas Indonesia no. ET207/UN2.F12.D1.2.1/PPM.00.02/2024. Students rated the subject highly across both cohorts, with scores of 5.8/6 during the implementation phase (n = 34, response rate 80 %) and 5.75/6 during the evaluation phase (n = 39, response rate 95 %). Three themes were identified from the interview data: 1) paradigm shift on attitudes to climate change; 2) the value of diverse and participatory teaching methods; 3) recognition of the nurse's role in interdisciplinary climate action. This subject represents one of the first documented, student-informed climate change electives in nursing education in the Asia-Pacific region. It offers a replicable, context-sensitive model for integrating climate competencies into nursing curricula, addressing a critical global implementation gap. The subject equips future nurses with the knowledge and skills to advocate for sustainability, lead climate adaptation in clinical settings, and support climate-resilient healthcare systems.
The Planetary Health Diet (PHD) integrates health and environmental sustainability, yet its association with chronic disease outcomes remains underexplored, particularly among women with a history of gestational diabetes (GD), who are at elevated risk of type 2 diabetes (T2D) and cardiovascular disease (CVD). To investigate the associations of adherence to the PHD with risks of T2D, CVD, and long-term weight change among women with a history of GD. This cohort study used data from the Nurses' Health Study II. A subset of participants with a history of GD was followed up from June 1991 to June 2021. Data were analyzed from February 1, 2024, to April 9, 2025. Adherence to the PHD was assessed using the Planetary Health Diet Index (PHDI), which was derived from food frequency questionnaires administered every 4 years. Cox proportional hazards regression models were used to assess hazard ratios (HRs) and 95% CIs for the risk of T2D and CVD. Associations between PHDI changes and concurrent 4-year weight changes were evaluated using multivariable marginal models with generalized estimating equations. During 120 465 person-years of follow-up among 4633 women with a history of GD (mean [SD] age, 38.9 [6.1] years), 90 incident CVD cases (38 myocardial infarction [MI] and 52 stroke) and 1053 incident T2D cases were observed. Women in the highest tertile of the PHDI had a 63% lower risk of MI (HR, 0.37; 95% CI, 0.16-0.86; P for trend = .01) compared with those in the lowest tertile, independent of body mass index (BMI) and other covariates. Higher PHDI was also associated with a lower risk of overall CVD and T2D; however, mediation analysis indicated that BMI accounted for 79.6% (95% CI, 16.5%-98.7%; P < .001) of the association with T2D and 15.1% (95% CI, 2.8%-52.5%; P = .02) of the association with CVD. Notably, decreasing PHDI was associated with greater weight gain (P for trend < .001), with the group experiencing the largest 4-year decrease in PHDI showing a mean weight gain of 2.3 (95% CI, 2.0-2.6) kg. In this cohort study of women with a history of GD, higher PHDI was associated with lower risk of myocardial infarction and better weight management. These findings also emphasize the importance of postpartum weight management to reduce the risk of progression from GD to T2D and CVD.
Ocean sustainability matters to everyone because planetary health depends on the ocean and a healthy ocean requires a sustainability transformation across society, land and sea. The ocean is a critical arena for addressing the triple planetary crisis of climate change, biodiversity loss, and pollution. Public engagement with ocean sustainability shows considerable potential to drive forward global sustainability action, as seen in contemporary concerns regarding marine plastic pollution rallying political leaders to develop a global plastics treaty. Despite this success, communities inland can still be much better connected to ocean sustainability and should be engaged to hold decision-makers to account for environmental and social progress alongside political interest in the growing ocean economy. Accessible and emotive messaging is required for public and political audiences, but delivery needs are complex, so we must ensure advances in public engagement are in tandem with translation into appropriate action. This Perspective recommends that we: (1) use a Rivers to Seas paradigm to better connect public support for ocean sustainability with land-based populations; (2) use accessible and emotive public messaging connected to detailed and complex delivery through principle-based approaches; and (3) create a UN Ocean Agency alongside the post-2030 sustainable development agenda to advance the changes needed.
Climate change is the greatest threat to global health, yet there are few foundational climate resources available for integration into medical school curricula. We describe an interactive session for equipping medical students with practical and empowering foundational climate-health competencies. We developed a 2-hour interactive lecture+ preceded by 30 minutes of required prep work. Knowledge was assessed using two-question quizzes. A postsession survey evaluated session effectiveness and self-assessed attitudes and preparedness. A total of 375 students participated; 164 completed all assessment and evaluation measures. The average knowledge quiz score after required prep was 80%. Of all students, 82% reported that more than half of the session's climate change mitigative strategies were new to them. Ratings of preparedness for five tasks linked to learning objectives significantly improved in all classes (p < .001), with 8%-58% of students before the session and 89%-100% of students after the session reporting being fairly/completely prepared. Qualitative responses also supported achievement of learning objectives. Rates of satisfaction with the required prep and lecture+ were 79% and 89%, respectively. Cited strengths included overall quality and the use of cases to highlight health care environmental impacts and opportunities for mitigation. This resource fills an urgent need for an integrable session for medical schools hoping to achieve action-oriented, foundational climate-health competencies. Key characteristics of this work include the diversity of the development team, ease and flexibility of session implementation, a focus on empowerment, and strong assessment and evaluation data supporting achievement of learning objectives.
This paper explores leadership in planetary health in an emerging grassroots organisation, Greener Practice. Greener Practice, formed in 2017, set out with the intention of creating the UK's Primary Care Sustainability hub and network. In the face of the evolving public health threat of the climate and ecological crisis, planetary health leadership has never been more necessary or urgent. There was a noticeable gap in leadership on this issue within Primary Care, with General Practice teams grossly underfunded, and climate action often seeming low on a list of burgeoning priorities. This article explores how visionary, nurturing and democratic leadership grew a grassroots movement. Through telling the story of Greener Practice's growth and development, I hope to share the lessons I have learned about our joint leadership of an emerging organisation. This paper is a reflection on my personal experience as a leader of an emerging grassroots organisation outside, but working alongside, existing healthcare organisations. I have used the narrative of Greener Practice's growth and establishment on the larger stage to illustrate my own leadership lessons that inform how we support our network's emerging leaders. This paper summarises my personal experience as I have grown and developed as a leader and approached the challenges of leading a grassroots movement. It has five sections entitled Leadership to: engage and inspire; educate and empower; grow the movement; nurture and develop new leaders; and influence systems. After each section, I have drawn out lessons learned in these areas. I conclude with further reflections on the importance of self-awareness, resonant leadership and active hope. Greener Practice aims to be a beacon of hope and inspiration, both for, and through, its leaders; visionary, nurturing and actively hopeful leadership is crucial to support emerging leaders to address the planetary health crisis.
As health-care systems and organisations worldwide transition to sustainable health care, reliable guidance and standardised approaches are needed to monitor and report progress. A robust measurement framework can inform the development of indicators to track progress, compare performance, guide interventions, and reduce the risk of greenwashing. The Lancet Commission on Sustainable Health Care convened a working group to develop a measurement framework to support data-driven and evidence-based indicators in comprehensively assessing health-care system performance across environmental and health outcomes dimensions. The working group included representatives from several disciplines, such as environmental engineering, industrial and social ecology, health promotion theory, environmental chemistry, sustainability, health-care quality and safety, clinical care, epidemiology, and public policy, and diverse geographical settings. The measurement framework developed by the Lancet Commission on Sustainable Health Care integrates concepts from previous frameworks and approaches and encompasses sustainability concepts across two domains: the physical domain (contributing directly and indirectly to resource use, operational resilience, emissions, and environmental impacts) and the people, policies, and programmes domain (contextual characteristics surrounding operations in nations and organisations). Each domain is divided into five categories: inputs, structures, processes, outputs, and outcomes or effects, including health effects. In this Personal View, we describe the conceptual development of this measurement framework; the indicators for performance measurement by health-care organisations and countries will be presented in companion papers. The framework aims to address all three aspects of performance measurement-namely, research, improvement of health-care system performance, and accountability to external entities. The proposed measurement framework can guide the development and implementation of indicators for health-care system benchmarking and monitoring, aiming to accelerate the global advancement of sustainability-related health-care performance by adopting evidence-based policies and practices.
The 2022 and 2025 floods in Pakistan forced more than 33 million people to flee from their homes, destroyed medical facilities across a large portion of Punjab, Khyber-Pakhtunkhwa, Sindh, and Balochistan, and revealed major deficiencies in government management, healthcare systems, environmental protection, and climate preparedness. Pakistan emits <1% of worldwide greenhouse gases, yet remains among the most climate-sensitive nations, reflecting global inequities in climate impact. Floods destroyed basic health determinants, thus contributing to infectious disease epidemics, malnutrition, and mental health problems. To evaluate the short- and long-term flood impacts, this article applies the Disaster Management Cycle, along with the One Health, Planetary Health, and Doughnut Economy frameworks. The framework demonstrates the impact of floods on the health and healthcare system while simultaneously eroding the ecosystem and making the population more susceptible. The article identifies priorities for climate-adaptive health care infrastructure, environmental recovery, equity-centered disaster preparedness, and integration of One Health principles into medical education.
As one of China's densely populated and economically developed regions, the Beijing-Tianjin-Hebei (BTH) area faces severe ozone (O3) pollution, largely driven by nitrogen oxides (NOx) and volatile organic compounds (VOCs) through complex chemical reactions. A detailed quantification of the specific contributions of various NOx and VOCs sources to O3 levels under meteorological and boundary-layer dynamics is crucial for effective pollution control in the BTH region. In this study, we developed and implemented an explicitly tagging approach and process analysis method in the WRF-Chem model to attribute O3 formation separately to NOx and VOCs from various sources, thereby quantifying the contributions of anthropogenic and natural emissions in O3 budget in the BTH region. The results reveal that NOx emissions primarily contribute to O3 through anthropogenic sources (63.5%), while for VOCs, the contributions from anthropogenic emissions (29.3%), background methane (15.8%), and biogenic sources (11.8%) are comparable. Notably, regional transport significantly contributes to O3 levels in the BTH region through both VOCs (80.4%) and NOx (71.2%), with emissions from Shandong, Henan, northeast China, and the Yangtze River Delta, identified as key anthropogenic sources regions of the interprovincial transport. The northeastern low-pressure system and the western Pacific subtropical high drive interprovincial pollutant transport through the free troposphere, with subsequent downward mixing of O3 formed in the free troposphere, contributing significantly to regional transport's impact on O3 pollution in the BTH. This study provides a comprehensive assessment of ozone source attribution in the BTH area, emphasizing the importance of coordinated regional strategies for O3 mitigation, with particular attention to synoptic influences and planetary boundary layer processes.Regional pollutant transport strongly affects BTH ozone levels, particularly from Shandong, Henan, and the Yangtze River Delta. Large-scale weather systems further enhance long-range ozone transport through vertical mixing. These findings highlight the need for coordinated regional and cross-sector emission control strategies to effectively reduce ozone pollution in northern China.