The WHO's framework views health as being influenced by a complex web of interconnected social, environmental, and individual circumstances, all of which are captured through specific indicators.
Risk factors are generally categorized to reflect the diverse threats to well-being. These categories often overlap, and factors frequently interact to increase the overall risk of developing conditions like Noncommunicable Diseases (NCDs), which account for a majority of global mortality.
These factors relate to the immediate and broader surroundings where people live and work.
By measuring and acting on this comprehensive set of risk factors, the WHO supports a global movement to transition from a reactive model of treating illness to a proactive model of health promotion and prevention.
The WHO Behavioural Risk Factors for Non-Communicable Diseases
Non-communicable diseases (NCDs), such such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, are the leading cause of death globally. These long-term illnesses are not directly transmissible but result from a complex interaction of genetic, physiological, environmental, and, significantly, behavioural factors.
The World Health Organization (WHO) has identified a core set of modifiable behavioural risk factors that are the major determinants of NCDs. By monitoring and addressing these factors, countries can make substantial progress in preventing premature deaths and improving public health. The WHO's framework for Non-Communicable Diseases emphasizes surveillance, with the STEPwise approach to NCD risk factor surveillance (STEPS) being a key standardized tool for data collection.
Key Behavioural Risk Factors
The four primary behavioural risk factors for NCDs, as identified by the WHO, are: tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol. Modifying these behaviours can dramatically reduce an individual's risk of developing and dying prematurely from an NCD.
These factors often lead to subsequent metabolic/biological risk factors, including:
Raised blood pressure (hypertension)
Overweight and obesity
Raised blood glucose (diabetes)
Abnormal blood lipids (high cholesterol)
Addressing the behavioural factors is crucial, as they are the most accessible to modify through public health policies, health promotion, and individual choice.
The WHO Behavioural Risk Factors Indicator Table
The table below outlines the four primary WHO-defined behavioural risk factors for NCDs, their associated health consequences, and corresponding global targets set by the WHO's Global Monitoring Framework for NCDs (which often aim for a reduction by 2025 or 2030, with a 2010 baseline).
| Behavioural Risk Factor | Associated Health Consequences | Core Indicator (Monitoring) | Global Voluntary Target |
| Tobacco Use | Cancer, chronic respiratory diseases, cardiovascular diseases. | Age-standardized prevalence of current tobacco use among persons aged 18+ years. | 30% relative reduction in prevalence of current tobacco use. |
| Physical Inactivity | Cardiovascular diseases, diabetes, colon and breast cancers. | Age-standardized prevalence of insufficiently physically active persons aged 18+ years (less than 150 minutes of moderate-intensity activity per week, or equivalent). | 15% relative reduction in prevalence of insufficient physical activity (Target updated for 2030). |
| Unhealthy Diet | High blood pressure, obesity, diabetes, cardiovascular diseases, cancer. | Age-standardized mean population intake of salt/sodium per day in grams in persons aged 18+ years. | 30% relative reduction in mean population intake of salt/sodium. |
| Harmful Use of Alcohol | Liver disease, cancer, cardiovascular diseases, mental health issues, injuries. | Total (recorded and unrecorded) alcohol per capita (aged 15+ years old) consumption within a calendar year in litres of pure alcohol. | At least 10% relative reduction in the harmful use of alcohol. |
Global Action and Monitoring
The monitoring of these behavioural risk factors is critical for countries to track their progress toward global health goals, such as the Sustainable Development Goal (SDG) Target 3.4, which calls for a one-third reduction in premature mortality from NCDs by 2030.
Effective national strategies often involve:
Policy Interventions: Implementing policies like tobacco taxes, alcohol regulations, and restrictions on the marketing of unhealthy foods to children.
Health Promotion: Launching national campaigns to promote healthier diets (e.g., reducing salt intake), regular physical activity, and to discourage smoking and harmful drinking.
Surveillance: Regularly conducting surveys, like WHO STEPS, to collect standardized data on the prevalence of these risk factors and evaluate the effectiveness of interventions.
By prioritizing action on these major behavioural risk factors, public health efforts can significantly lessen the global burden of NCDs and enhance the overall well-being of populations.
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WHO Physiological and Metabolic Risk Factors for NCDs
While behavioural factors often set the stage, physiological and metabolic risk factors are the direct biological consequences that significantly increase an individual's likelihood of developing non-communicable diseases (NCDs). These factors represent measurable changes within the body's systems that are often influenced by genetics, lifestyle, and environmental exposures.
The World Health Organization (WHO) emphasizes the importance of monitoring these "intermediate" risk factors, as they are strong predictors of future NCDs such as heart disease, stroke, diabetes, and certain cancers. Often, these factors can exist without overt symptoms, making regular screening and early detection crucial for timely intervention.
Key Physiological and Metabolic Risk Factors
The primary physiological and metabolic risk factors for NCDs, as highlighted by the WHO, are: raised blood pressure, overweight and obesity, raised blood glucose, and abnormal blood lipids. These factors are frequently intertwined; for instance, obesity often contributes to raised blood pressure, elevated blood glucose, and dyslipidemia.
Addressing these factors often involves a combination of lifestyle modifications (targeting the behavioural risk factors discussed previously) and, when necessary, medical interventions.
The WHO Physiological and Metabolic Risk Factors Indicator Table
The table below outlines the key physiological and metabolic risk factors, their associated health consequences, and the core indicators used for global monitoring as part of the WHO's Global Monitoring Framework for NCDs. These indicators often have global voluntary targets aimed at preventing a rise or achieving a reduction by 2025 or 2030, with a 2010 baseline.
| Physiological/Metabolic Risk Factor | Associated Health Consequences | Core Indicator (Monitoring) | Global Voluntary Target |
| Raised Blood Pressure (Hypertension) | Heart attack, stroke, kidney disease, heart failure. | Age-standardized prevalence of raised blood pressure (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg) among persons aged 18+ years. | 25% relative reduction in the prevalence of raised blood pressure. |
| Overweight and Obesity | Diabetes, cardiovascular diseases, certain cancers, musculoskeletal disorders. | Age-standardized prevalence of obesity (BMI ≥30 kg/m²) among persons aged 18+ years. | No increase in the prevalence of obesity and diabetes. |
| Raised Blood Glucose (Diabetes) | Heart disease, stroke, kidney failure, blindness, nerve damage, amputations. | Age-standardized prevalence of raised blood glucose/diabetes (fasting plasma glucose ≥7.0 mmol/L or on medication for diabetes) among persons aged 18+ years. | No increase in the prevalence of obesity and diabetes. |
| Abnormal Blood Lipids (Dyslipidemia) | Heart attack, stroke. | Age-standardized mean total cholesterol among persons aged 18+ years. | No global target for abnormal blood lipids, but often addressed as part of overall cardiovascular risk management. |
The Interplay and Global Response
It's crucial to understand that behavioural, physiological, and metabolic risk factors are not isolated but form a complex web. An unhealthy diet (behavioural) can lead to overweight/obesity (physiological), which in turn can lead to raised blood pressure and blood glucose (metabolic).
Global efforts to combat NCDs therefore require a comprehensive approach that includes:
Early Detection and Screening: Regular check-ups to measure blood pressure, blood glucose, and lipid levels, especially for individuals with behavioural risk factors or a family history of NCDs.
Integrated Care: Developing health systems capable of managing these risk factors, including access to medication, lifestyle counselling, and ongoing support.
Public Health Campaigns: Continuing to promote healthy behaviours that can prevent the onset or progression of these physiological and metabolic changes.
By systematically monitoring and addressing these critical physiological and metabolic indicators, countries can enhance early diagnosis, facilitate effective management, and ultimately reduce the devastating impact of NCDs on individuals and healthcare systems worldwide.
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WHO Environmental Risk Factors for NCDs
Environmental factors are increasingly recognized by the World Health Organization (WHO) as critical determinants of non-communicable diseases (NCDs), such as cardiovascular diseases, chronic respiratory diseases, and cancer. While behavioural and metabolic factors are often direct causes, the environmental risk factors create the fundamental context and exposure that drive a significant portion of the global NCD burden.
These factors encompass the external physical, chemical, and biological elements that affect human health, with air pollution being the most prominent and globally monitored indicator. The inclusion of environmental risks reflects a necessary broadening of public health strategy, moving beyond individual lifestyle changes to address the systemic causes of disease embedded in our surroundings and infrastructure.
The Core Environmental Risk: Air Pollution
The WHO's Global Monitoring Framework for NCDs specifically highlights air pollution as a core environmental risk factor. Air pollution—both ambient (outdoor) and household (indoor)—is a major contributor to premature death and illness worldwide. The fine particulate matter (PM$_{2.5}$) and other pollutants penetrate deep into the lungs and bloodstream, leading to inflammation, oxidative stress, and damage that contribute to respiratory failure, heart attacks, strokes, and lung cancer.
Other environmental factors, such as climate change, exposure to chemicals and radiation, and urban design (affecting noise and physical activity opportunities), are also essential to NCD prevention, even if they aren't all assigned specific, standalone global targets within the core NCD monitoring framework.
WHO Environmental Risk Factor Indicator Table
The table below outlines the primary environmental factor directly integrated into the WHO's Global Monitoring Framework for NCDs, alongside its indicator and target.
| Environmental Risk Factor | Associated Health Consequences | Core Indicator (Monitoring) | Global Voluntary Target (NCD-related) |
| Air Pollution | Chronic Respiratory Disease (COPD, asthma), Lung Cancer, Stroke, Ischemic Heart Disease. | Age-standardized death rate attributed to the combined effects of household and ambient (outdoor) air pollution. | No specific global target for air pollution within the NCD Global Monitoring Framework, but it is included as a key indicator due to its immense impact on NCD mortality. |
Expanding the Environmental Health Perspective
While the NCD Monitoring Framework focuses heavily on air pollution due to its sheer scale of impact, the broader WHO perspective on environmental determinants of health for NCDs includes:
Climate Change: Increased heat waves and extreme weather events exacerbate cardiovascular and respiratory conditions, especially for those with existing NCDs.
Chemical and Heavy Metal Exposure: Contamination from lead, arsenic, and endocrine-disrupting chemicals (EDCs) in air, water, and food is linked to increased risks of cancer, diabetes, and neurological disorders.
Noise Pollution: Chronic exposure, especially from transportation, can induce stress and inflammation, increasing the risk of hypertension and cardiovascular disease.
Land Use and Urban Design: Poor urban planning that lacks green spaces and safe walking/cycling infrastructure discourages physical activity, a key behavioural risk factor for NCDs.
Addressing environmental risk factors requires multisectoral action, going beyond the health ministry to involve energy, transport, agriculture, and urban planning sectors. Reducing these exposures is a powerful, cost-effective intervention that can simultaneously prevent multiple NCDs across entire populations.
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WHO Social Determinants and Structural Factors in NCDs
The World Health Organization (WHO) recognizes that health is not merely a matter of individual behavior but is profoundly shaped by the Social Determinants of Health (SDH). These are the "causes of the causes"—the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life.
For non-communicable diseases (NCDs), social and structural factors determine the distribution of risk. For instance, low socioeconomic status often leads to greater exposure to cheap, unhealthy food and aggressive marketing of tobacco and alcohol, while limiting access to health education, safe environments for physical activity, and quality healthcare. This results in a social gradient where the poorest and most vulnerable populations bear the heaviest burden of NCDs.
The WHO's approach to the SDH is generally divided into two main categories:
Structural Determinants: These are the root causes, including the socioeconomic and political context (governance, public policies, values) that lead to social stratification (income, education, gender, race/ethnicity).
Intermediary Determinants: These are the living and working conditions directly related to daily life, such as housing, employment, food security, and psychosocial factors.
WHO Indicators Related to Social and Structural Factors
While the main WHO Global Monitoring Framework for NCDs focuses on immediate outcomes (mortality), behavioral risk factors (tobacco, alcohol, diet, physical inactivity), and health system response, structural factors are primarily monitored through indicators of national capacity and multisectoral action rather than standalone prevalence rates.
In other words, the WHO monitors whether a country has the policies and systems in place to tackle the root causes, as these are the levers that address the social and structural drivers of the NCD epidemic. The table below outlines these key indicators.
| Factor Category | Indicator (Monitoring) | Relevance to Social/Structural Factors |
| National Policy & Governance | Existence of a functioning multisectoral national NCD policy, strategy, or action plan. | Assesses the structural capacity of a government to engage all relevant sectors (e.g., finance, agriculture, education) to implement "Health in All Policies" and address SDH. |
| Universal Health Coverage (UHC) | Availability of essential NCD medicines and basic technologies. | Measures the intermediary determinant of access. Lack of affordability and availability disproportionately affects lower socioeconomic groups, widening health inequities. |
| National Targets | Setting of time-bound national targets based on the WHO Global Monitoring Framework. | Indicates the level of political commitment and governance structure in place to track and be accountable for reducing NCDs and their determinants. |
| Specific Policy Implementation | Implementation of 'Best Buys' policy interventions (e.g., tobacco tax, salt reduction, alcohol marketing bans). | These fiscal and legislative measures are structural interventions designed to make the healthy choice the easy choice, countering the negative influence of commercial and socioeconomic determinants. |
| Outcomes (Equity Focus) | Premature mortality from NCDs (aged 30-70) disaggregated by socioeconomic status. | Although a mortality indicator, disaggregating data by income, education, or geographic location is the primary way to measure health inequity, which is the direct result of structural determinants. |
The Importance of Structural Action
The WHO emphasizes that public health cannot succeed by only focusing on individual risk factors (e.g., "stop smoking," "eat healthier") without addressing the structural factors that create barriers to health for the majority of the population.
Poverty and Income: Low income restricts access to nutritious food, quality education, and safe housing—all precursors to NCDs.
Education: Lower educational attainment correlates with lower health literacy and greater adoption of risky behaviors.
Commercial Determinants: Aggressive marketing of unhealthy commodities (tobacco, ultra-processed food, alcohol) targets vulnerable populations, directly undermining personal choice and structural policy efforts.
Therefore, the WHO's indicators reflect a shift toward monitoring multisectoral action and policy interventions that correct the fundamental socioeconomic and political structures responsible for the unequal burden of NCDs.
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Countries with the Lowest WHO NCD Risk Factors
Identifying a single country with the "lowest" overall non-communicable disease (NCD) risk factor burden according to World Health Organization (WHO) indicators is complex because the major risk factors—like tobacco use, physical inactivity, unhealthy diet, and harmful alcohol use—vary dramatically in prevalence across different populations, regions, and income levels.
A country may have very low smoking rates but very high physical inactivity rates, making a simple ranking impossible.
However, analysis of WHO Global Health Observatory data and related studies reveals that countries with highly effective public health policies often achieve the lowest rates for specific risk factors, and High-Income Countries (HICs) generally report lower age-standardized NCD mortality rates, which is the ultimate outcome indicator.
The table below highlights some of the countries that have historically recorded or are estimated to have the lowest prevalence in specific WHO core NCD risk factor categories.
Countries with Lowest Prevalence in Key WHO NCD Risk Factors
The data shown are based on available global estimates (usually age-standardized prevalence among adults), where the lowest figures are often found in either high-income countries due to decades of prevention efforts or in countries where cultural/religious factors suppress certain risk behaviors.
| WHO Risk Factor Indicator | Country with Low Prevalence (Example) | Estimated Lowest Prevalence (Approx.) | Context and Contributing Factors |
| Current Tobacco Use (Adults) | Eritrea, Ethiopia, Ghana (African Region) | $<5\%$ (varies) | Strict tobacco control policies, cultural norms, and low purchasing power often keep prevalence rates lower in some African countries compared to global averages. |
| Harmful Use of Alcohol (Per Capita Consumption) | Kuwait, Saudi Arabia, Egypt (Eastern Mediterranean Region) | $<0.1$ Litres of pure alcohol per capita | Religious and legal restrictions on alcohol consumption are the primary factor driving very low rates in predominantly Muslim countries. |
| Raised Blood Pressure (Hypertension) | Canada, United States (High-Income North America) | $\approx 18-20\%$ | Strong primary care systems, high rates of diagnosis, and effective treatment coverage lead to better control and lower prevalence of raised blood pressure compared to global averages. |
| Overweight and Obesity | Vietnam, Cambodia, Bangladesh (Low/Middle-Income Asia) | $\approx 20-30\%$ (Overweight) | Traditionally lower-fat diets and higher levels of occupational physical activity have historically kept BMI rates lower, although this trend is rapidly changing due to globalization. |
| Insufficient Physical Activity | Uganda, Mozambique (African Region) | $\approx 5-10\%$ | Many low-income settings involve high levels of necessity-based physical activity (walking for transport, manual labor) which contrasts with high rates of sedentary behavior in high-income countries. |
The Best Indicator: Lowest Premature NCD Mortality
While risk factor prevalence is fragmented, the best overall measure of a country's success in controlling NCDs is the WHO's main outcome target: the probability of dying between age 30 and 70 from the four major NCDs (cardiovascular disease, cancer, diabetes, and chronic respiratory disease). This indicator reflects the combined impact of all risk factors, prevention policies, and health system effectiveness.
The countries with the lowest rates of premature NCD mortality are typically wealthy nations with robust public health and advanced healthcare systems.
| WHO Indicator | Country with Lowest Rate (Example) | Age-Standardized Probability of Premature Death (Approx.) | Note on Success |
| Premature NCD Mortality (30-70 years) | Iceland, Norway, Switzerland, Japan, Canada | <10% | These countries have excellent universal healthcare access, comprehensive tobacco control, successful hypertension/cholesterol screening programs, and generally high standards of living. |
Key Takeaway: The "lowest" rate for a behavioral risk factor (like alcohol use) is often a result of cultural or legal contexts, whereas the "lowest" rate for a physiological risk factor (like raised blood pressure) and mortality is primarily achieved through strong, well-funded health systems and effective government policies.
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Countries with the Highest WHO NCD Risk Factors
Identifying a single country with the "highest" overall risk is challenging because NCD risk factors (tobacco, alcohol, unhealthy diet, physical inactivity, obesity, hypertension) vary geographically. For example, some low-income countries have high rates of smoking but low rates of obesity, while some high-income countries have the opposite.
However, certain countries and regions consistently rank at the top for major metabolic and behavioral risk factors, often leading to the highest rates of premature non-communicable disease (NCD) mortality.
The regions with the most severe combined burden of metabolic risk factors (obesity, high blood pressure, high cholesterol) are often Oceania (Pacific Island Nations) and parts of the Middle East and The Americas.
Highest Prevalence in Key WHO NCD Risk Factor Indicators
The table highlights countries or regions that show the highest recorded or estimated prevalence for specific core NCD risk factors among adults, based on WHO Global Health Observatory data and related global studies.
| WHO Risk Factor Indicator | Country/Region with High Prevalence | Estimated Highest Prevalence (Approx.) | Context and Contributing Factors |
| Overweight and Obesity (BMI $\ge 30$) | Pacific Island Nations (e.g., Nauru, American Samoa, Palau, Cook Islands) | $\mathbf{>60\%}$ (for obesity alone) | Characterized by a rapid transition from traditional diets to highly processed, imported foods and reduced physical activity, creating an extreme burden of metabolic disease. |
| Current Tobacco Use (Adults) | Kiribati, Nauru, Southeast Europe (e.g., Serbia, Bosnia and Herzegovina) | $\mathbf{35\% - 50\%}$ (Varies by sex/region) | Often linked to weak tobacco control policies, cultural acceptance, or low cost, though rates are generally declining globally. |
| Harmful Use of Alcohol (Total Per Capita Consumption) | Eastern Europe / Caucasus Region (e.g., Moldova, Lithuania, Czechia) | $\mathbf{>12}$ Litres of pure alcohol per capita | High consumption is often driven by cultural norms, weak regulatory environments, and high consumption of unrecorded/homemade alcohol. |
| Insufficient Physical Activity | Kuwait, Saudi Arabia, American Samoa | $\mathbf{>50\%}$ | High prevalence is often a result of rapid urbanization, high vehicle ownership, and climates (extreme heat) that discourage outdoor physical activity. |
| Raised Blood Pressure (Hypertension) | Sub-Saharan Africa, South Asia, Eastern Europe | $\mathbf{>30\%}$ (up to $40\%$ in some African nations) | Factors include high salt intake, low diagnosis and treatment coverage, and high socioeconomic stress. |
The Critical Outcome: Highest Premature NCD Mortality
The most significant indicator of a country's overall NCD burden is the probability of dying between age 30 and 70 from the four major NCDs (cardiovascular disease, cancer, diabetes, and chronic respiratory disease). These countries have the lowest success in preventing these deaths.
| WHO Indicator | Country with Highest Rate (Example) | Age-Standardized Probability of Premature Death (Approx.) | Note on Challenge |
| Premature NCD Mortality (30-70 years) | Mongolia, Fiji, Guyana, Russian Federation | $\mathbf{>25\% - 30\%}$ | High mortality reflects a combination of high-risk factor prevalence (especially tobacco and alcohol in Eastern Europe, and obesity/hypertension in Pacific nations) and weak health systems for screening and treatment. |
Key Takeaway: The countries facing the highest NCD risks are generally those in rapid health transition (Pacific Islands/Middle East) where metabolic risks have surged due to lifestyle change, and certain Low and Middle-Income Countries (Eastern Europe, parts of the Americas) where high consumption of tobacco/alcohol and ineffective public health measures combine to cause the highest rates of premature death.
Conclusion: The Global Tapestry of WHO NCD Risk Factors
The global landscape of Non-Communicable Disease (NCD) risk factors, as tracked by the World Health Organization (WHO), reveals a complex and often contradictory picture where the highest and lowest burdens are rarely found in the same place.
The Contrast in Global Risk
| Focus of Risk | Lowest Prevalence (Success) | Highest Prevalence (Challenge) | Key Driver |
| Behavioral (Alcohol & Smoking) | Predominantly Muslim nations (due to religious/legal restrictions). | Parts of Eastern Europe and the Western Pacific (e.g., Kiribati). | Cultural acceptance, weak regulation, and enforcement. |
| Metabolic (Obesity, Hypertension) | Low-Income Asian/African nations (though rapidly changing). | Pacific Island Nations and parts of the Middle East. | Rapid transition to high-calorie diets and sedentary urban lifestyles. |
| Ultimate Outcome (Premature Mortality) | High-Income Countries (e.g., Iceland, Japan, Switzerland). | Regions with combined high risk and poor healthcare (e.g., Mongolia, Guyana). | Strength and accessibility of health systems for diagnosis and treatment. |
Summary of Findings
Risk is Fragmented: No single country uniformly holds the "highest" or "lowest" risk. The lowest rates for alcohol use are driven by culture and law, while the highest rates for obesity are driven by economic and dietary transitions.
The Double Burden: Many low- and middle-income countries now face a "double burden" of disease, dealing with the traditional challenges of infectious diseases while simultaneously experiencing a surge in NCD risks like hypertension and diabetes, driven by urbanization and dietary change.
Policy is Paramount: The nations consistently achieving the lowest rates of premature NCD death (the best measure of success) are high-income countries. This success is not due to low behavioral risk but rather to effective public health policy, robust primary healthcare, high rates of screening, and the widespread availability of essential medicines to manage conditions like hypertension and high cholesterol.
The Biggest Challenge: The most severe global NCD challenge lies in the Pacific Island nations (highest obesity rates) and certain low-to-middle-income countries where high-risk behaviors intersect with a lack of access to quality NCD care, resulting in the world's highest rates of premature mortality.
Ultimately, the WHO risk factors serve as a vital guide, emphasizing that a nation's health is determined not just by individual behavior, but fundamentally by its socioeconomic context and the effectiveness of its public health and healthcare infrastructure.
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