11 research outputs found
Antifungal effects of echinocandins diminish when exposed to intestinal lumen contents: a finding with potentially significant clinical implications
No full textEchinocandins, a prominent class of antifungals, are known for their broad-spectrum activity and favorable safety profiles. However, their bioavailability and efficacy via oral route are suboptimal. In this study, caspofungin and micafungin, the two most commonly used echinocandins, were evaluated in various in vitro environments simulating intestinal lumen. The results revealed that while both antifungals are effective in standard medium, their efficacy significantly diminishes in the presence of human small bowel aspirates and bovine bile. The study suggests that bowel contents and specifically bile acids may be a suppressive component, hindering the antifungal effects of echinocandins. This novel exploration sheds light on the poor oral bioavailability of echinocandins. The findings imply that echinocandins alone, regardless of administration route, may not be optimal for gastrointestinal (GI) fungal infections or invasive fungal infections originating from intestinal translocation. Further clinical investigations are warranted to validate and expand upon these observations
Determining Cardiometabolic and Antioxidant Effects of Olive Leaf Extract in Patients with Essential Hypertensio
No full textBackground Hypertension is one of the most common clinical disorders affecting millions worldwide.
Some studies have indicated the role of oxidative stress in the pathogenesis of hypertension and the
importance of antioxidant compounds in their control.
Objective The aim of this study was to evaluate the effects of olive leaf extract (OLE), Olea europaea L., on
cardiometabolic parameters and biomarkers of oxidative stress in patients with essential hypertension.
Methods This randomized double-blind placebo-controlled clinical trial conducted in 2017 on 60 patients
with essential hypertension aged 30-60 years referred to the cardiovascular clinic of Bu-Ali Sina Hospital
in Qazvin, Iran. The patients were randomly allocated into two groups of OLE (n=30; receiving OLE 250
mg capsules twice per day for 12 weeks) and placebo (n=30, receiving placebo drug for 12 weeks). Before
and after intervention, cardiometabolic parameters and oxidative stress biomarkers were measured using
appropriate laboratory methods. To compare variables and groups, paired-t test and independent
t-test were used, respectively.
Findings The OLE intake led to a significant decrease in systolic blood pressure, serum total cholesterol,
and malondialdehyde levels in hypertensive patients compared to the placebo group, but significantly
increased superoxide dismutase activity (P<0.05). Moreover, the OLE intake had no significant effect on
diastolic blood pressure, other lipid profiles and biomarkers of oxidative stress (P>0.05).
Conclusion OLE intake for 12 weeks had beneficial effects on some types of cardiometabolic and oxidative
stress biomarkers in hypertensive patients
Flood susceptibility mapping using multi-temporal SAR imagery and novel integration of nature-inspired algorithms into support vector regression
No full textFlood has long been known as one of the most catastrophic natural hazards worldwide. Mapping flood-prone areas is an important part of flood disaster management. In this study, a flood susceptibility mapping framework was developed based on a novel integration of nature-inspired algorithms into support vector regression (SVR). To this end, various remote sensing (RS) and geographic information system (GIS) datasets were applied to the hybridized SVR models to map flood susceptibility in Ahwaz township, Iran. The proposed framework has two main steps: 1) updating the flood inventory (historical flooded locations) using the proposed RS-based flood detection method developed within the google earth engine (GEE) platform. The mosaicked images of multi-temporal Sentinel-1 synthetic aperture radar (SAR) data have been used in this step; 2) producing flood susceptibility map using the standalone SVR and hybridized model of SVR. The hybridized methods were derived from a novel integration of SVR with meta-heuristic algorithms, hence forming the SVR-bat algorithm (SVR-BA), SVR-invasive weed optimization (SVR-IWO), and SVR-firefly algorithm (SVR-FA). A spatial database of flood locations and 11 conditioning factors (altitude, slope angle, aspect, topographic wetness index, stream power index, normalized difference vegetation index (NDVI), distance to stream, curvature, rainfall, soil type, and land use/cover) were built for the susceptibility modelling. The accuracy of the proposed model was evaluated using the statistical and sensitivity indices, such as root mean square error (RMSE), receiver operating characteristic (ROC) and area under the ROC curve (AUROC) index. The results indicated that all hybridized models outperformed the standalone SVR. According to AUROC values, the predictive power of the SVR-FA was the highest with the value of 0.81, followed by SVR-IWO, SVR-BA, and SVR with values of 0.80, 0.79, and 0.77, respectively.Geo-engineerin
Allergies and risk of head and neck cancer: a case–control study
No full textAlthough the relationship between allergies and cancer has been investigated extensively, the role of allergies in head and neck cancer (HNC) appears less consistent. It is unclear whether allergies can independently influence the risk of HNC in the presence of substantial environmental risk factors, including consumption of alcohol, betel quid, and cigarettes. This study aims to find this association. We examined the relationship between allergies and HNC risk in a hospital-based case–control study with 300 cases and 375 matched controls. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals, controlling for age, sex, tobacco smoking and opium usage history, alcohol consumption, and socioeconomic status. Our study showed a significant reduction in the risk of HNC associated with allergy symptoms after adjusting for confounders. The risk of HNC was greatly reduced among those with any type of allergy (OR 0.42, 95% CI 0.28, 0.65). The ORs were considerably reduced by 58–88% for different kinds of allergies. The risk of HNC reduction was higher in allergic women than in allergic men (71% vs. 49%). Allergies play an influential role in the risk of HNC development. Future studies investigating immune biomarkers, including cytokine profiles and genetic polymorphisms, are necessary to further delineate the relationship between allergies and HNC. Understanding the relationship between allergies and HNC may help to devise effective strategies to reduce and treat HNC.Peer reviewe
A Systematic Review on the Effect of the Picture Exchange Communication System (PECS) on the Development of Social and Communication Skills of Children with Autism Spectrum Disorder
No full textAbstract
This systematic review evaluates the efficacy of the Picture Exchange Communication System (PECS) in promoting communication and social skill development among children with autism spectrum disorder (ASD). Employing qualitative research methods, the study analyzed 51 peer-reviewed international studies (2012-2024) selected from an initial pool of 77 articles across Google Scholar, PubMed, and Science Direct databases. The investigation specifically addressed whether PECS contributes to measurable improvements in communicative and social functioning for children with ASD. Results demonstrated consistent positive outcomes, including enhanced communication abilities, improved social interaction skills, and increased quality of life indicators. The findings provide robust empirical support for implementing PECS as an evidence-based intervention in special education curricula, underscoring its value for fostering critical developmental skills in ASD populations.
Keywords: Autism Spectrum Disorder (ASD), Picture Exchange Communication System (PECS, social skills, communication skills, Augmentative and Alternative Communication (AAC), systematic review
Extended Abstract
Introduction
Autism spectrum disorder (ASD) represents a complex neurodevelopmental condition characterized by: (1) persistent deficits in social communication and interaction across multiple contexts, and (2) restricted, repetitive patterns of behavior, interests, or activities (RRBs). The disorder exhibits remarkable phenotypic heterogeneity, manifesting in wide variations across individuals regarding symptom onset trajectories, severity gradients, clinical profiles, and comorbid psychiatric or medical conditions. While social communication impairments constitute a universal core feature, their specific behavioral manifestations and associated functional impacts demonstrate substantial interindividual variability, ranging from subtle pragmatic language difficulties to complete absence of verbal communication.
The Picture Exchange Communication System (PECS) is an empirically supported augmentative and alternative communication (AAC) intervention that has become one of the most extensively implemented support methodologies for individuals with ASD. Grounded in applied behavior analysis (ABA) principles, this structured protocol employs a graduated six-phase instructional approach to systematically develop functional communication competencies. As a visually based system, PECS specifically addresses core communication challenges in ASD by: (1) circumventing verbal language demands through picture-based exchanges, (2) reinforcing spontaneous communication initiations, and (3) progressively building complex communication repertoires.
The Picture Exchange Communication System (PECS) facilitates the development of both expressive and receptive communication skills. Rooted in behavioral theory, PECS incorporates Skinner's verbal operants (1957) within a pyramidal training framework to systematically teach functional communication. This approach mirrors natural language acquisition patterns, progressing from basic picture exchanges to constructing multi-phrase sentences using sentence strips.
Empirical evidence confirms PECS's effectiveness in supporting communication development. Maj's (2018) study demonstrated that PECS implementation not only reduces speech acquisition difficulties but also enhances overall communication growth. Functioning as a dual-purpose intervention, PECS serves as both:
A supplementary aid for developing verbal skills
An alternative communication system for individuals with complex communication needs
Notably, PECS facilitates functional communication—intentional, socially-directed exchanges that enable users to express needs and desires (Maj, 2018). This capacity for purposeful interaction constitutes a critical developmental milestone for nonverbal individuals or those with limited verbal abilities.
Children with autism spectrum disorder (ASD) exhibit significant impairments in both communication and social skills. While these domains are distinct—with social skills involving appropriate behavioral responses in social contexts, and communication skills encompassing verbal and nonverbal expression of needs and intentions—they remain fundamentally interconnected. Improvements in one domain often lead to gains in the other (Gobro et al., 2021).
Recent empirical studies (Pratama & Paramita, 2023; Tamanaha et al., 2023) have demonstrated the effectiveness of the Picture Exchange Communication System (PECS) in addressing these core deficits among children with ASD. Nevertheless, despite accumulating evidence supporting PECS efficacy, the literature has lacked a comprehensive systematic review synthesizing this research. This gap motivated our current systematic examination of PECS interventions targeting communication and social skill development in ASD populations.
Research Question(s)
In this article, we examine the role of the Picture Exchange Communication System (PECS) in developing communication and social skills among children with autism spectrum disorder (ASD), drawing upon both theoretical foundations and empirical evidence. Subsequently, through a systematic review of studies published between 2012 and 2024, we investigate the following research question: Does the Picture Exchange Communication System (PECS) effectively enhance social and communication skills in children with ASD?
Literature Review
Historically, therapeutic interventions for language and communication development in children with autism spectrum disorder (ASD) focused predominantly on speech production through response training. In contrast to nonverbal training approaches, this method demonstrated limited efficacy in developing functional communication abilities. Modern rehabilitation paradigms for nonverbal children with ASD now prioritize cultivating functional spontaneous communication (Lerna et al., 2012).
Autism interventions commonly target both speech and social skills development, with treatment outcomes typically assessed through multiple behavioral indicators including:
Eye contact frequency and duration
Verbal output measures (e.g., number of spoken words)
Appropriateness of motor movements
Frequency and quality of social interactions
Context-appropriate facial expressions
Relevance and pragmatics of speech content
Matheson and colleagues categorized these interventions into five primary approaches:
(a) Modeling and reinforcement techniques
(b) Mediated intervention strategies
(c) Structured reinforcement programs and activities
(d) Social scripts and narrative-based interventions
(e) Miscellaneous intervention programs (including response-centered training and Picture Exchange Communication System implementation) (Mayharvid et al., 2021).
Applied Behavior Analysis (ABA) is an evidence-based intervention designed to support communication skill development in children with autism spectrum disorder (ASD). This structured approach utilizes reinforcement-based learning principles to help children acquire essential language and communication abilities, including language comprehension, verbal fluency, interpretation of facial expressions and body language, and effective social communication. By systematically breaking down complex skills into manageable components and employing positive reinforcement, ABA facilitates meaningful progress in both verbal and nonverbal communication domains, ultimately promoting more successful social interactions for children with ASD.
Empirical research has consistently demonstrated the efficacy of Applied Behavior Analysis (ABA) in promoting language and communication skill acquisition among children with autism spectrum disorder (ASD). ABA-based interventions systematically employ three core components: (1) structured instructional techniques, (2) positive reinforcement strategies, and (3) continuous progress monitoring. This comprehensive approach not only enhances fundamental communication capabilities but also enables children with ASD to develop the necessary skills for establishing meaningful social connections (Prattama & Pradhanaparamita, 2022).
Within his theoretical framework, Skinner proposed that verbal behavior, like other behavioral domains, is acquired through fundamental principles of behavior modification. He argued that such verbal behavior can be methodically shaped and strengthened through structured intervention, wherein appropriate reinforcement contingencies serve to increase the probability of desired verbal responses.
Skinner conceptualized verbal behavior as a broad behavioral category encompassing all forms of communication, including - but not limited to - spoken language, sign systems, pictorial representations, written expression, and alternative verbal response modalities. He introduced this comprehensive framework alongside his foundational theory of verbal operants in his seminal 1957 work Verbal Behavior, which established a systematic approach for analyzing language as learned behavior.
The Pyramid Approach to Education is a comprehensive instructional framework that specifies the essential components for establishing effective learning environments. This three-dimensional model consists of two primary structural elements: (1) a foundational base addressing core pedagogical considerations ("what to teach" and "why students learn"), and (2) supporting pillars implementing instructional delivery. The base incorporates four critical elements: functional skills development, reinforcement systems, functional relationships, and challenging behavior prevention/management. The model's pillars comprise: (a) generalization - involving systematic, incremental modifications to produce measurable behavioral gains, and (b) effective lesson design - requiring deliberate planning of instructional variables for optimal skill acquisition (Maj, 2018).
The Picture Exchange Communication System (PECS) is one of the most widely used augmentative and alternative communication (AAC) interventions for individuals with autism spectrum disorder. As an evidence-based AAC approach, PECS is specifically designed to enhance communication skills and facilitate participation across multiple domains, including academic settings, social relationships, and community interactions. This structured protocol follows a six-phase training sequence grounded in behavioral and developmental principles to teach functional communication skills. The intervention progresses systematically from teaching basic requesting behaviors (Phases I–V) using preferred items and activities. As learners master each phase, the program introduces increasingly sophisticated communication demands, such as: (1) initiating interactions with partners across varying distances, and (2) constructing simple sentence structures (Jassim Omar & Shiromaru, 2022).
The Picture Exchange Communication System (PECS) is an augmentative and alternative communication (AAC) system that utilizes visual symbols to facilitate functional communication of wants and needs (Kasanen, 2020). Designed to promote rapid, independent, and functional communication skills in children with autism spectrum disorder (ASD), PECS begins with basic symbol exchange and systematically progresses to more complex sentence construction (Al-Dawaidah & Al-Amirah, 2013). While comprehensive meta-analyses have not yet conclusively established PECS efficacy across all ASD populations, multiple empirical studies demonstrate consistent positive outcomes in communication and social skill development. Key findings include:
Pratama & Paramita (2023): Significant improvements in communication skills
Kruger (2022): Enhanced social skills and functional independence
Santos et al. (2021): Progress in social and functional skills among nonverbal children
Mehravar et al. (2020): Particularly strong effects from Phases I–III of the six-phase protocol
Mark (2019): Benefits for both communication and social skills in nonverbal individuals
Mirnovati (2018): Effective communication skill acquisition
This converging evidence from multiple research teams, using varied methodologies across different populations, substantiates PECS as an effective intervention for enhancing communication and social skills in children with ASD.
Methodology
This study was conducted with an applied purpose, adopting a qualitative approach and employing a systematic review as the research method. Data collection involved systematically reviewing articles available on Google Scholar, PubMed, and ScienceDirect using the following keywords: image exchange communication system, autism spectrum disorder, social skills, and communication skills. The inclusion criteria stipulated that article titles must contain at least one of the two key phrases: autism spectrum disorder and/or image exchange communication system. Additionally, the full text of the articles had to include references to image exchange communication system, autism spectrum disorder, social skills, and communication skills.
An initial screening compiled a list of article titles and abstracts published between 2012 and 2024. Out of the 77 initially selected articles, 26 were excluded due to irrelevance to the research question or duplication across databases, leaving 51 articles for final analysis. The study's inclusion criteria were as follows:
Exclusion of purely qualitative research,
Requirement for full keywords (image exchange communication system, communication, and social skills) in the article title,
Inclusion of qualitative studies, single-case studies, and case reports
For analysis, key details including author names, publication year, and study results were examined.
Results
Research on the Picture Exchange Communication System (PECS) and autism spectrum disorder (ASD) demonstrates that this image-based intervention can significantly benefit children with ASD by increasing vocabulary, reducing maladaptive behaviors, and enhancing observational learning and skill generalization. PECS effectively promotes communication initiation—including requesting and expressing needs—while expanding expressive language through improved speech production. Educationally, it strengthens attention span, reduces distractions, and increases task completion, while also improving compliance with rules in both school and home settings. The system further encourages help-seeking behavior, reduces restricted or repetitive behaviors, and enhances language comprehension (including words, sentences, and contextual meaning). Additional observed benefits include decreased self-injury and tantrums, better instruction-following, and reduced screaming episodes. Collectively, these findings underscore PECS as a comprehensive intervention for addressing core ASD challenges.
The reviewed studies collectively highlight the importance of the Picture Exchange Communication System (PECS) for children with autism spectrum disorder (ASD). All examined research consistently reported PECS's effectiveness in improving communication and social skills in this population. From an initial screening of 77 articles using predetermined inclusion/exclusion criteria, 51 studies were selected for final analysis of PECS's impact on ASD children's communication and social skills. These studies' key details - including authors, publication years, and main findings - are systematically organized in the table below.
Discussion
This study investigated both theoretical foundations and empirical evidence to answer a key research question: How effective is the Picture Exchange Communication System (PECS) in fostering communication and social skill development in children with autism spectrum disorder (ASD)? ASD is a lifelong neurodevelopmental condition marked by core symptoms including restricted/repetitive behaviors and profound challenges in communication and social interaction. These deficits significantly impair quality of life and independent functioning. Maladaptive behaviors like aggression and emotional outbursts often result in social exclusion, further restricting peer interactions and environmental engagement. Among various interventions designed to enhance communication skills in children with ASD, PECS has demonstrated particular effectiveness as a systematic approach.
This review study demonstrates that the Picture Exchange Communication System (PECS) offers multifaceted benefits for children with autism spectrum disorder (ASD), including: (1) enhanced communication skills through vocabulary expansion, improved communication initiation, advanced expressive language (including speech production), and increased ability to request and express needs; (2) improved social functioning manifested through greater attention-seeking, help-seeking behaviors, and adherence to rules in both school and home environments; (3) reduction in maladaptive behaviors including diminished self-injury, tantrums, screaming episodes, and restricted/repetitive behaviors; and (4) cognitive and educational improvements such as enhanced observational learning, skill generalization, sustained attention, task completion, visual processing, and comprehension of verbal and written language. These robust findings collectively highlight PECS's substantial impact on improving core communication and social skills in children with ASD, as consistently evidenced across all examined studies.
Conclusion
The findings confirm that the Picture Exchange Communication System (PECS) serves as an effective intervention for developing social and communication skills in children with autism spectrum disorder (ASD). Implementation can be adapted to specific needs, ranging from individual stages to the complete six-stage protocol. While studies indicate that even partial implementation enhances communication abilities and social functioning, the most significant outcomes emerge from full protocol adherence. These evidence-based results advocate for wider adoption of PECS in special education contexts, specifically through: (1) broader implementation across specialized educational institutions and therapy centers, and (2) comprehensive training initiatives for both professionals and parents to ensure treatment fidelity.
To advance research in this field, future studies should: (1) employ larger sample sizes with more comprehensive datasets to strengthen generalizability, and (2) examine broader applications across diverse demographic and clinical populations. Institutional support through education and welfare systems—particularly via professional development programs for practitioners—could substantially improve both the accessibility and implementation fidelity of PECS. While this systematic review offers meaningful insights, its scope was inherently constrained by existing literature, underscoring the necessity for more extensive empirical investigations in future research.
Acknowledgments
We express our profound gratitude to the professors and subject matter experts whose invaluable guidance and thoughtful recommendations greatly contributed to both the implementation and refinement of this study. Their specialized knowledge and insightful feedback were pivotal in shaping the research methodology and strengthening our findings
Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021
No full textFunding: Bill & Melinda Gates Foundation.Peer ReviewedArticle signat per 1420 autors/es. Membres del GBD 2021 Forecasting Collaborators:
Stein Emil Vollset*, Hazim S Ababneh, Yohannes Habtegiorgis Abate, Cristiana Abbafati, Rouzbeh Abbasgholizadeh, Mohammadreza Abbasian, Hedayat Abbastabar, Abdallah H A Abd Al Magied, Samar Abd ElHafeez, Atef Abdelkader, Michael Abdelmasseh, Sherief Abd-Elsalam, Parsa Abdi, Mohammad Abdollahi, Meriem Abdoun, Auwal Abdullahi, Mesfin Abebe, Olumide Abiodun, Richard Gyan Aboagye, Hassan Abolhassani, Mohamed Abouzid, Girma Beressa Aboye, Lucas Guimarães Abreu, Abdorrahim Absalan, Hasan Abualruz, Bilyaminu Abubakar, Hana Jihad Jihad Abukhadijah, Giovanni Addolorato, Victor Adekanmbi, Charles Oluwaseun Adetunji, Juliana Bunmi Adetunji, Temitayo Esther Adeyeoluwa, Rishan Adha, Ripon Kumar Adhikary, Qorinah Estiningtyas Sakilah Adnani, Leticia Akua Adzigbli, Fatemeh Afrashteh, Muhammad Sohail Afzal, Saira Afzal, Faith Agbozo, Antonella Agodi, Anurag Agrawal, Williams Agyemang-Duah, Bright Opoku Ahinkorah, Austin J Ahlstrom, Aqeel Ahmad, Firdos Ahmad, Muayyad M Ahmad, Sajjad Ahmad, Shahzaib Ahmad, Anisuddin Ahmed, Ayman Ahmed, Haroon Ahmed, Safoora Ahmed, Syed Anees Ahmed, Karolina Akinosoglou, Mohammed Ahmed Akkaif, Ashley E Akrami, Ema Akter, Salah Al Awaidy, Syed Mahfuz Al Hasan, Amjad S Al Mosa, Omar Al Ta’ani, Omar Ali Mohammed Al Zaabi, Fares Alahdab, Muaaz M Alajlani, Yazan Al-Ajlouni, Samer O Alalalmeh, Ziyad Al-Aly, Khurshid Alam, Noore Alam, Tahiya Alam, Zufishan Alam, Rasmieh Mustafa Al-amer, Fahad Mashhour Alanezi, Turki M Alanzi, Almaza Albakri, Wafa A Aldhaleei, Robert W Aldridge, Seyedeh Yasaman Alemohammad, Yihun Mulugeta Alemu, Adel Ali Saeed Al-Gheethi, Mohammed Khaled Al-Hanawi, Abid Ali, Amjad Ali, Iman Ali, Mohammed Usman Ali, Rafat Ali, Syed Shujait Shujait Ali, Victor Ekoche Ali, Waad Ali, Akram Al-Ibraheem, Gianfranco Alicandro, Sheikh Mohammad Alif, Syed Mohamed Aljunid, François Alla, Joseph Uy Almazan, Hesham M Al-Mekhlafi, Ahmed Yaseen Alqutaibi, Ahmad Alrawashdeh, Sahel Majed Alrousan, Salman Khalifah Al-Sabah, Mohammed A Alsabri, Zaid Altaany, Ala’a B Al-Tammemi, Jaffar A Al-Tawfiq, Khalid A Altirkawi, Deborah Oyine Aluh, Nelson Alvis-Guzman, Mohammad Sami Al-Wardat, Yaser Mohammed Al-Worafi, Hany Aly, Mohammad Sharif Alyahya, Karem H Alzoubi, Walid Al-Zyoud, Reza Amani, Edward Kwabena Ameyaw, Tarek Tawfik Amin, Alireza Amindarolzarbi, Sohrab Amiri, Mohammad Hosein Amirzade-Iranaq, Hubert Amu, Dickson A Amugsi, Robert Ancuceanu, Deanna Anderlini, David B Anderson, Pedro Prata Andrade, Catalina Liliana Andrei, Tudorel Andrei, Erick Adrian Andrews, Abhishek Anil, Sneha Anil, Amir Anoushiravani, Catherine M Antony, Ernoiz Antriyandarti, Boluwatife Stephen Anuoluwa, Saeid Anvari, Anayochukwu Edward Anyasodor, Francis Appiah, Michele Aquilano, Juan Pablo Arab, Jalal Arabloo, Elshaimaa A Arafa, Mosab Arafat, Aleksandr Y Aravkin, Ali Ardekani, Demelash Areda, Brhane Berhe Aregawi, Abdulfatai Aremu, Hany Ariffin, Mesay Arkew, Keivan Armani, Anton A Artamonov, Ashokan Arumugam, Mohammad Asghari-Jafarabadi, Charlie Ashbaugh, Thomas Astell-Burt, Seyyed Shamsadin Athari, Prince Atorkey, Maha Moh’d Wahbi Atout, Avinash Aujayeb, Marcel Ausloos, Hamzeh Awad, Adedapo Wasiu Awotidebe, Haleh Ayatollahi, Jose L Ayuso-Mateos, Sina Azadnajafabad, Fahad Khan Azeez, Rui M S Azevedo, Muhammad Badar, Soroush Baghdadi, Mahboube Bagheri, Nasser Bagheri, Ruhai Bai, Jennifer L Baker, Abdulaziz T Bako, Senthilkumar Balakrishnan, Wondu Feyisa Balcha, Ovidiu Constantin Baltatu, Martina Barchitta, Erfan Bardideh, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Hiba Jawdat Barqawi, Sandra Barteit, Afisu Basiru, João Diogo Basso, Mohammad-Mahdi Bastan, Sanjay Basu, Matteo Bauckneht, Bernhard T Baune, Mohsen Bayati, Nebiyou Simegnew Bayileyegn, Amir Hossein Behnoush, Payam Behzadi, Maryam Beiranvand, Olorunjuwon Omolaja Bello, Luis Belo, Apostolos Beloukas, Maryam Bemanalizadeh, Isabela M Bensenor, Habib Benzian, Azizullah Beran, Zombor Berezvai, Robert S Bernstein, Paulo J G Bettencourt, Kebede A Beyene, Melak Gedamu Beyene, Devidas S Bhagat, Akshaya Srikanth Bhagavathula, Neeraj Bhala, Dinesh Bhandari, Ravi Bharadwaj, Nikha Bhardwaj, Pankaj Bhardwaj, Ashish Bhargava, Sonu Bhaskar, Vivek Bhat, Natalia V Bhattacharjee, Gurjit Kaur Bhatti, Jasvinder Singh Bhatti, Manpreet S Bhatti, Mohiuddin Ahmed Bhuiyan, Catherine Bisignano, Bijit Biswas, Tone Bjørge, Virginia Bodolica, Aadam Olalekan Bodunrin, Milad Bonakdar Hashemi, Berrak Bora Basara, Hamed Borhany, Samuel Adolf Bosoka, Alejandro Botero Carvajal, Souad Bouaoud, Soufiane Boufous, Christopher Boxe, Edward J Boyko, Oliver J Brady, Dejana Braithwaite, Michael Brauer, Javier Brazo-Sayavera, Hermann Brenner, Colin Stewart Brown, Annie J Browne, Traolach Brugha, Dana Bryazka, Norma B Bulamu, Danilo Buonsenso, Katrin Burkart, Richard A Burns, Reinhard Busse, Yasser Bustanji, Zahid A Butt, Florentino Luciano Caetano dos Santos, Mehtap Çakmak Barsbay, Daniela Calina, Luciana Aparecida Campos, Shujin Cao, Angelo Capodici, Rosario Cárdenas, Giulia Carreras, Andrea Carugno, Márcia Carvalho, Joao Mauricio Castaldelli-Maia, Giulio Castelpietra, Maria Sofia Cattaruzza, Arthur Caye, Luca Cegolon, Francieli Cembranel, Edina Cenko, Ester Cerin, Steven J Chadban, Joshua Chadwick, Chiranjib Chakraborty, Sandip Chakraborty, Julian Chalek, Jeffrey Shi Kai Chan, Rama Mohan Chandika, Sara Chandy, Jaykaran Charan, Anis Ahmad Chaudhary, Akhilanand Chaurasia, An-Tian Chen, Haowei Chen, Meng Xuan Chen, Simiao Chen, Nicolas Cherbuin, Gerald Chi, Fatemeh Chichagi, Odgerel Chimed-Ochir, Ritesh Chimoriya, Patrick R Ching, Jesus Lorenzo Chirinos-Caceres, Abdulaal Chitheer, Daniel Youngwhan Cho, William C S Cho, Dong-Woo Choi, Bryan Chong, Chean Lin Chong, Hitesh Chopra, Dinh-Toi Chu, Eric Chung, Muhammad Chutiyami, Justin T Clayton, Rebecca M Cogen, Aaron J Cohen, Alyssa Columbus, Haley Comfort, Joao Conde, Jon T Connolly, Ezra E K Cooper, Samuele Cortese, Natália Cruz-Martins, Alanna Gomes da Silva, Omid Dadras, Xiaochen Dai, Zhaoli Dai, Bronte E Dalton, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Jai K Das, Saswati Das, Subasish Das, Nihar Ranjan Dash, Kairat Davletov, Fernando Pio De la Hoz, Diego De Leo, Shayom Debopadhaya, Ivan Delgado-Enciso, Edgar Denova-Gutiérrez, Nikolaos Dervenis, Hardik Dineshbhai Desai, Vinoth Gnana Chellaiyan Devanbu, Syed Masudur Rahman Dewan, Kuldeep Dhama, Amol S Dhane, Sameer Dhingra, Diana Dias da Silva, Daniel Diaz, Luis Antonio Diaz, Michael J Diaz, Adriana Dima, Delaney D Ding, Thao Huynh Phuong Do, Camila Bruneli do Prado, Masoud Dodangeh, Milad Dodangeh, Phidelia Theresa Doegah, Sushil Dohare, Wanyue Dong, Mario D’Oria, Rajkumar Doshi, Robert Kokou Dowou, Haneil Larson Dsouza, Viola Dsouza, John Dube, Samuel C Dumith, Bruce B Duncan, Andre Rodrigues Duraes, Senbagam Duraisamy, Oyewole Christopher Durojaiye, Anar Dushpanova, Sulagna Dutta, Paulina Agnieszka Dzianach, Arkadiusz Marian Dziedzic, Ejemai Eboreime, Alireza Ebrahimi, Mohammad Ebrahimi Kalan, Hisham Atan Edinur, Ferry Efendi, Terje Andreas Eikemo, Ebrahim Eini, Temitope Cyrus Ekundayo, Rabie Adel El Arab, Iman El Sayed, Osman Elamin, Noha Mousaad Elemam, Ghada Metwally Tawfik ElGohary, Muhammed Elhadi, Omar Abdelsadek Abdou Elmeligy, Adel B Elmoselhi, Mohammed Elshaer, Ibrahim Elsohaby, Mohd. Elmagzoub Eltahir, Theophilus I Emeto, Babak Eshrati, Majid Eslami, Zahra Esmaeili, Natalia Fabin, Adeniyi Francis Fagbamigbe, Omotayo Francis Fagbule, Luca Falzone, Mohammad Fareed, Carla Sofia e Sá Farinha, MoezAlIslam Ezzat Mahmoud Faris, Andre Faro, Kiana Fasihi, Ali Fatehizadeh, Nelsensius Klau Fauk, Timur Fazylov, Valery L Feigin, Ginenus Fekadu, Xiaoqi Feng, Seyed-Mohammad Fereshtehnejad, Pietro Ferrara, Nuno Ferreira, Belete Sewasew Firew, Florian Fischer, Ida Fitriana, Joanne Flavel, Luisa S Flor, Morenike Oluwatoyin Folayan, Kristen Marie Foley, Marco Fonzo, Lisa M Force, Matteo Foschi, Alberto Freitas, Ni Kadek Yuni Fridayani, Kai Glenn Fukutaki, João M Furtado, Blima Fux, Peter Andras Gaal, Muktar A Gadanya, Silvano Gallus, Balasankar Ganesan, Mohammad Arfat Ganiyani, Rupesh K Gautam, Tilaye Gebru Gebi, Miglas W Gebregergis, Mesfin Gebrehiwot, Lemma Getacher, Genanew K A Getahun, Peter W Gething, Delaram J Ghadimi, Fataneh Ghadirian, Sadegh Ghafarian, Khalid Yaser Ghailan, MohammadReza Ghasemi, Ghazal Ghasempour Dabaghi, Ramy Mohamed Ghazy, Sama Ghoba, Ehsan Gholami, Ali Gholamrezanezhad, Nasim Gholizadeh, Mahsa Ghorbani, Pooyan Ghorbani Vajargah, Elena Ghotbi, Artyom Urievich Gil, Tiffany K Gill, Alem Girmay, James C Glasbey, Ekaterina Vladimirovna Glushkova, Elena V Gnedovskaya, Laszlo Göbölös, Mohamad Goldust, Pouya Goleij, Davide Golinelli, Sameer Vali Gopalani, Alessandra C Goulart, Mahdi Gouravani, Anmol Goyal, Michal Grivna, Giuseppe Grosso, Giovanni Guarducci, Mohammed Ibrahim Mohialdeen Gubari, Stefano Guicciardi, Rafael Alves Guimarães, Snigdha Gulati, David Gulisashvili, Damitha Asanga Gunawardane, Cui Guo, Anish Kumar Gupta, Rahul Gupta, Rajeev Gupta, Renu Gupta, Sapna Gupta, Vijai Kumar Gupta, Annie Haakenstad, Najah R Hadi, Nils Haep, Abdul Hafiz, Dariush Haghmorad, Demewoz Haile, Adel Hajj Ali, Ali Hajj Ali, Arvin Haj-Mirzaian, Esam S Halboub, Sebastian Haller, Rabih Halwani, Kanaan Hamagharib Abdullah, Nadia M Hamdy, Rifat Hamoudi, Nasrin Hanifi, Graeme J Hankey, Zaim Anan Haq, Md Rabiul Haque, Harapan Harapan, Arief Hargono, Josep Maria Haro, Ahmed I Hasaballah, S. 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AmirAli Moodi Ghalibaf, Maryam Moradi, Yousef Moradi, Paula Moraga, Lidia Morawska, Rafael Silveira Moreira, Negar Morovatdar, Shane Douglas Morrison, Abbas Mosapour, Jonathan F Mosser, Elias Mossialos, Rohith Motappa, Vincent Mougin, Parsa Mousavi, Matías Mrejen, Sumaira Mubarik, Ulrich Otto Mueller, Francesk Mulita, Kavita Munjal, Efrén Murillo-Zamora, Khaled M Musallam, Ana-Maria Musina, Ghulam Mustafa, Woojae Myung, Ayoub Nafei, Ahamarshan Jayaraman Nagarajan, Pirouz Naghavi, Ganesh R Naik, Gurudatta Naik, Firzan Nainu, Soroush Najdaghi, Noureddin Nakhostin Ansari, Vinay Nangia, Sreenivas Narasimha Swamy, Shumaila Nargus, Delaram Narimani Davani, Bruno Ramos Nascimento, Gustavo G Nascimento, Abdallah Y Naser, Abdulqadir J Nashwan, Zuhair S Natto, Javaid Nauman, Samidi N K Navaratna, Muhammad Naveed, Nawsherwan , Biswa Prakash Nayak, Vinod C Nayak, Hadush Negash, Ionut Negoi, Ruxandra Irina Negoi, Seyed Aria Nejadghaderi, Chakib Nejjari, Soroush Nematollahi, Henok Biresaw Netsere, Marie Ng, Georges Nguefack-Tsague, Josephine W Ngunjiri, Anh Hoang Nguyen, Dang H Nguyen, Duc Hoang Nguyen, Hau Thi Hien Nguyen, Nhan Nguyen, Nhien Ngoc Y Nguyen, Phat Tuan Nguyen, QuynhAnh P Nguyen, Van Thanh Nguyen, Duc Nguyen Tran Minh, Robina Khan Niazi, Yeshambel T Nigatu, Mahdieh Niknam, Ali Nikoobar, Amin Reza Nikpoor, Nasrin Nikravangolsefid, Efaq Ali Noman, Shuhei Nomura, Syed Toukir Ahmed Noor, Nafise Noroozi, Mehran Nouri, Majid Nozari, Chisom Adaobi Nri-Ezedi, George Ntaios, Mengistu H Nunemo, Dieta Nurrika, Jerry John Nutor, Chimezie Igwegbe Nzoputam, Ogochukwu Janet Nzoputam, Bogdan Oancea, Kehinde O Obamiro, Ismail A Odetokun, Michael Safo Oduro, Oluwaseun Adeolu Ogundijo, Adesola Adenike Ogunfowokan, Abiola Ogunkoya, Ayodipupo Sikiru Oguntade, In-Hwan Oh, Tolulope R Ojo-Akosile, Hassan Okati-Aliabad, Akinkunmi Paul Okekunle, Osaretin Christabel Okonji, Andrew T Olagunju, Matthew Idowu Olatubi, Gláucia Maria Moraes Oliveira, Bolajoko Olubukunola Olusanya, Jacob Olusegun 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Changing life expectancy in European countries 1990–2021: a subanalysis of causes and risk factors from the Global Burden of Disease Study 2021
No full textBackground: Decades of steady improvements in life expectancy in Europe slowed down from around 2011, well before the COVID-19 pandemic, for reasons which remain disputed. We aimed to assess how changes in risk factors and cause-specific death rates in different European countries related to changes in life expectancy in those countries before and during the COVID-19 pandemic. Methods: We used data and methods from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to compare changes in life expectancy at birth, causes of death, and population exposure to risk factors in 16 European Economic Area countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, and Sweden) and the four UK nations (England, Northern Ireland, Scotland, and Wales) for three time periods: 1990–2011, 2011–19, and 2019–21. Changes in life expectancy and causes of death were estimated with an established life expectancy cause-specific decomposition method, and compared with summary exposure values of risk factors for the major causes of death influencing life expectancy. Findings: All countries showed mean annual improvements in life expectancy in both 1990–2011 (overall mean 0·23 years [95% uncertainty interval [UI] 0·23 to 0·24]) and 2011–19 (overall mean 0·15 years [0·13 to 0·16]). The rate of improvement was lower in 2011–19 than in 1990–2011 in all countries except for Norway, where the mean annual increase in life expectancy rose from 0·21 years (95% UI 0·20 to 0·22) in 1990–2011 to 0·23 years (0·21 to 0·26) in 2011–19 (difference of 0·03 years). In other countries, the difference in mean annual improvement between these periods ranged from –0·01 years in Iceland (0·19 years [95% UI 0·16 to 0·21] vs 0·18 years [0·09 to 0·26]), to –0·18 years in England (0·25 years [0·24 to 0·25] vs 0·07 years [0·06 to 0·08]). In 2019–21, there was an overall decrease in mean annual life expectancy across all countries (overall mean –0·18 years [95% UI –0·22 to –0·13]), with all countries having an absolute fall in life expectancy except for Ireland, Iceland, Sweden, Norway, and Denmark, which showed marginal improvement in life expectancy, and Belgium, which showed no change in life expectancy. Across countries, the causes of death responsible for the largest improvements in life expectancy from 1990 to 2011 were cardiovascular diseases and neoplasms. Deaths from cardiovascular diseases were the primary driver of reductions in life expectancy improvements during 2011–19, and deaths from respiratory infections and other COVID-19 pandemic-related outcomes were responsible for the decreases in life expectancy during 2019–21. Deaths from cardiovascular diseases and neoplasms in 2019 were attributable to high systolic blood pressure, dietary risks, tobacco smoke, high LDL cholesterol, high BMI, occupational risks, high alcohol use, and other risks including low physical activity. Exposure to these major risk factors differed by country, with trends of increasing exposure to high BMI and decreasing exposure to tobacco smoke observed in all countries during 1990–2021. Interpretation: The countries that best maintained improvements in life expectancy after 2011 (Norway, Iceland, Belgium, Denmark, and Sweden) did so through better maintenance of reductions in mortality from cardiovascular diseases and neoplasms, underpinned by decreased exposures to major risks, possibly mitigated by government policies. The continued improvements in life expectancy in five countries during 2019–21 indicate that these countries were better prepared to withstand the COVID-19 pandemic. By contrast, countries with the greatest slowdown in life expectancy improvements after 2011 went on to have some of the largest decreases in life expectancy in 2019–21. These findings suggest that government policies that improve population health also build resilience to future shocks. Such policies include reducing population exposure to major upstream risks for cardiovascular diseases and neoplasms, such as harmful diets and low physical activity, tackling the commercial determinants of poor health, and ensuring access to affordable health services. Funding: Gates Foundation. © 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens
Changing life expectancy in European countries 1990-2021: a subanalysis of causes and risk factors from the Global Burden of Disease Study 2021.
No full textBACKGROUND: Decades of steady improvements in life expectancy in Europe slowed down from around 2011, well before the COVID-19 pandemic, for reasons which remain disputed. We aimed to assess how changes in risk factors and cause-specific death rates in different European countries related to changes in life expectancy in those countries before and during the COVID-19 pandemic. METHODS: We used data and methods from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to compare changes in life expectancy at birth, causes of death, and population exposure to risk factors in 16 European Economic Area countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, and Sweden) and the four UK nations (England, Northern Ireland, Scotland, and Wales) for three time periods: 1990-2011, 2011-19, and 2019-21. Changes in life expectancy and causes of death were estimated with an established life expectancy cause-specific decomposition method, and compared with summary exposure values of risk factors for the major causes of death influencing life expectancy. FINDINGS: All countries showed mean annual improvements in life expectancy in both 1990-2011 (overall mean 0·23 years [95% uncertainty interval [UI] 0·23 to 0·24]) and 2011-19 (overall mean 0·15 years [0·13 to 0·16]). The rate of improvement was lower in 2011-19 than in 1990-2011 in all countries except for Norway, where the mean annual increase in life expectancy rose from 0·21 years (95% UI 0·20 to 0·22) in 1990-2011 to 0·23 years (0·21 to 0·26) in 2011-19 (difference of 0·03 years). In other countries, the difference in mean annual improvement between these periods ranged from -0·01 years in Iceland (0·19 years [95% UI 0·16 to 0·21] vs 0·18 years [0·09 to 0·26]), to -0·18 years in England (0·25 years [0·24 to 0·25] vs 0·07 years [0·06 to 0·08]). In 2019-21, there was an overall decrease in mean annual life expectancy across all countries (overall mean -0·18 years [95% UI -0·22 to -0·13]), with all countries having an absolute fall in life expectancy except for Ireland, Iceland, Sweden, Norway, and Denmark, which showed marginal improvement in life expectancy, and Belgium, which showed no change in life expectancy. Across countries, the causes of death responsible for the largest improvements in life expectancy from 1990 to 2011 were cardiovascular diseases and neoplasms. Deaths from cardiovascular diseases were the primary driver of reductions in life expectancy improvements during 2011-19, and deaths from respiratory infections and other COVID-19 pandemic-related outcomes were responsible for the decreases in life expectancy during 2019-21. Deaths from cardiovascular diseases and neoplasms in 2019 were attributable to high systolic blood pressure, dietary risks, tobacco smoke, high LDL cholesterol, high BMI, occupational risks, high alcohol use, and other risks including low physical activity. Exposure to these major risk factors differed by country, with trends of increasing exposure to high BMI and decreasing exposure to tobacco smoke observed in all countries during 1990-2021. INTERPRETATION: The countries that best maintained improvements in life expectancy after 2011 (Norway, Iceland, Belgium, Denmark, and Sweden) did so through better maintenance of reductions in mortality from cardiovascular diseases and neoplasms, underpinned by decreased exposures to major risks, possibly mitigated by government policies. The continued improvements in life expectancy in five countries during 2019-21 indicate that these countries were better prepared to withstand the COVID-19 pandemic. By contrast, countries with the greatest slowdown in life expectancy improvements after 2011 went on to have some of the largest decreases in life expectancy in 2019-21. These findings suggest that government policies that improve population health also build resilience to future shocks. Such policies include reducing population exposure to major upstream risks for cardiovascular diseases and neoplasms, such as harmful diets and low physical activity, tackling the commercial determinants of poor health, and ensuring access to affordable health services. FUNDING: Gates Foundation
Changing life expectancy in European countries 1990–2021: a subanalysis of causes and risk factors from the Global Burden of Disease Study 2021
No full textBackground: Decades of steady improvements in life expectancy in Europe slowed down from around 2011, well before the COVID-19 pandemic, for reasons which remain disputed. We aimed to assess how changes in risk factors and cause-specific death rates in different European countries related to changes in life expectancy in those countries before and during the COVID-19 pandemic. Methods: We used data and methods from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to compare changes in life expectancy at birth, causes of death, and population exposure to risk factors in 16 European Economic Area countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, and Sweden) and the four UK nations (England, Northern Ireland, Scotland, and Wales) for three time periods: 1990–2011, 2011–19, and 2019–21. Changes in life expectancy and causes of death were estimated with an established life expectancy cause-specific decomposition method, and compared with summary exposure values of risk factors for the major causes of death influencing life expectancy. Findings: All countries showed mean annual improvements in life expectancy in both 1990–2011 (overall mean 0·23 years [95% uncertainty interval [UI] 0·23 to 0·24]) and 2011–19 (overall mean 0·15 years [0·13 to 0·16]). The rate of improvement was lower in 2011–19 than in 1990–2011 in all countries except for Norway, where the mean annual increase in life expectancy rose from 0·21 years (95% UI 0·20 to 0·22) in 1990–2011 to 0·23 years (0·21 to 0·26) in 2011–19 (difference of 0·03 years). In other countries, the difference in mean annual improvement between these periods ranged from –0·01 years in Iceland (0·19 years [95% UI 0·16 to 0·21] vs 0·18 years [0·09 to 0·26]), to –0·18 years in England (0·25 years [0·24 to 0·25] vs 0·07 years [0·06 to 0·08]). In 2019–21, there was an overall decrease in mean annual life expectancy across all countries (overall mean –0·18 years [95% UI –0·22 to –0·13]), with all countries having an absolute fall in life expectancy except for Ireland, Iceland, Sweden, Norway, and Denmark, which showed marginal improvement in life expectancy, and Belgium, which showed no change in life expectancy. Across countries, the causes of death responsible for the largest improvements in life expectancy from 1990 to 2011 were cardiovascular diseases and neoplasms. Deaths from cardiovascular diseases were the primary driver of reductions in life expectancy improvements during 2011–19, and deaths from respiratory infections and other COVID-19 pandemic-related outcomes were responsible for the decreases in life expectancy during 2019–21. Deaths from cardiovascular diseases and neoplasms in 2019 were attributable to high systolic blood pressure, dietary risks, tobacco smoke, high LDL cholesterol, high BMI, occupational risks, high alcohol use, and other risks including low physical activity. Exposure to these major risk factors differed by country, with trends of increasing exposure to high BMI and decreasing exposure to tobacco smoke observed in all countries during 1990–2021. Interpretation: The countries that best maintained improvements in life expectancy after 2011 (Norway, Iceland, Belgium, Denmark, and Sweden) did so through better maintenance of reductions in mortality from cardiovascular diseases and neoplasms, underpinned by decreased exposures to major risks, possibly mitigated by government policies. The continued improvements in life expectancy in five countries during 2019–21 indicate that these countries were better prepared to withstand the COVID-19 pandemic. By contrast, countries with the greatest slowdown in life expectancy improvements after 2011 went on to have some of the largest decreases in life expectancy in 2019–21. These findings suggest that government policies that improve population health also build resilience to future shocks. Such policies include reducing population exposure to major upstream risks for cardiovascular diseases and neoplasms, such as harmful diets and low physical activity, tackling the commercial determinants of poor health, and ensuring access to affordable health services. Funding: Gates Foundation.</p
