Using the GBD 2021 data, we analyzed the number of deaths, disability-adjusted life years (DALYs), age-standardized DALY rate (ASDR), age-standardized mortality rate (ASMR), and estimated annual percentage change (EAPC) of CVD-DR worldwide. We further examined the CVD-DR burden across regions, sociodemographic indices, sexes, and ages. Because these data are publicly available, no additional ethical approval was required for this study.

The dataset for this study was obtained from the GBD 2021 data (13). CVD was coded as I51.6 according to the International Classification of Diseases, Tenth Revision (ICD-10). We obtained CVD data from the Global Health Data Exchange¹, including six subtypes of CVD: IHD, stroke, lower extremity peripheral artery disease (LEPAD), aortic aneurysm (AA), atrial fibrillation and flutter (AFF), and hypertensive heart disease (HHD). The ICD-10 code for IHD is I20-I25, representing a condition affecting the coronary arteries, typically due to atherosclerosis, which results in angina, myocardial infarction, or ischemic cardiomyopathy. Stroke is coded as I64 and is defined by the rapid onset of focal disturbance of cerebral function persisting for >24 h or resulting in death. HHD, coded as I11, refers to a range of heart conditions induced by long-term high blood pressure that can lead to heart failure, with either preserved or reduced systolic function of the left ventricle. AFF, coded as I48, is an arrhythmia resulting from electrical conduction problems affecting the heart atria. AA is coded as I71.9 and is characterized by abnormal enlargement and weakening of the abdominal or thoracic aorta due to inflammation, high blood pressure, changes in cellular or extracellular structure, or atherosclerosis, resulting in blood vessel tear or rupture. LEPAD is coded as I73.9 and is characterized by an ankle-brachial index of <0.90.

We collected data on 15 dietary risk factors, stratified by sex and age groups for individuals aged ≥25 years from the GBD, and 13 specific dietary risks associated with CVD from the GHDX (accessed April 5, 2025; the definitions are presented in Supplementary Table 1). This included diets high in trans fatty acids, sugar-sweetened beverages, processed meat, sodium, and red meat, as well as diets low in vegetables, fruits, whole grains, seafood omega-3 fatty acids, nuts and seeds, fiber, legumes, and polyunsaturated fatty acids.

The GBD uses a counterfactual framework that defines a theoretical minimum risk exposure level (TMREL) for each risk factor independently, without assuming changes in co-occurring exposures. To address overlapping effects and mediated pathways among multiple risk factors, the GBD methodology incorporates a mediation matrix. This approach prevents overestimation of the combined burden attributable to multiple risks and ensures internal consistency in calculating population-attributable fractions (PAFs). Therefore, the CVD-DR burden estimated in this study reflects the impact of dietary factors itself, without the confounding influence of other risk factors.

All statistical analyses and visualizations were performed using R software (version 4.4.1). We assessed the global burden and temporal trends of CVD-DR according to the number of deaths, DALYs, ASMRs, ASDRs, and EAPCs. The deaths were defined as the number of individuals who died of CVD-DR in a given year. DALY was calculated as the sum of years of life lost (YLL) due to premature mortality and years lived with disability (YLD) due to disease, which reflected the overall disease burden, as follows: DALY = YLL + YLD. We determined the age-standardized rate (ASR) as the weighted average of age-specific rates, where the weights were the proportions of each age group in a standard population, including the ASMR and ASDR. ASMR refers to the age-standardized rate per 100,000 deaths, and ASDR as the age-standardized DALY rate per 100,000 population. We calculated the ASR using the following formula: A⁢S⁢R⁢∑i⁢1Aai⁢wi/∑i⁢1Awi⁢100,000, where a_i represents the i-th age group and w_i is the number (or proportion) of the population in the same age group in the GBD world standard population. All estimates are presented with 95% uncertainty intervals (UIs) derived from the GBD 2021 study framework. These UIs represent Bayesian credible intervals calculated from 1,000 posterior draws that incorporate uncertainties from incomplete data, model assumptions, and measurement errors. The 2.5th and 97.5th percentiles of the ordered draws are considered the lower and upper bounds, respectively, indicating a 95% probability that the true value lies within this range. The EAPC quantifies the average annual percentage change in ASMR or ASDR over a specified period. We assessed these temporal trends using a linear regression model, based on the equation Y = α+βX+ε, where Y is the natural logarithm of the ASR, X denotes the calendar year, and ε is the error term. We calculated EAPC using the formula EAPC = 100 × (exp (β) - 1), which was presented as numerical values and 95% confidence intervals (CIs). EAPC >0 indicated an increasing trend, whereas EAPC <0 indicated a decreasing trend.

We conducted subgroup analyses to comprehensively evaluate heterogeneity in CVD-DR burden. First, we analyzed 21 GBD regions and 204 countries or territories to capture geographical variations. Second, we stratified all countries or territories into five sociodemographic index (SDI) categories (low, low-middle, middle, high-middle, and high) according to the GBD classification. The SDI is a composite measure based on lag-distributed income per capita, average educational attainment in individuals aged ≥15 years, and total fertility rate in women aged <25 years. We assessed the correlation between SDI and disease burden (ASMR, ASDR, and their EAPCs) using the Spearman correlation coefficient (ρ), with |ρ| values close to 1 indicating a strong monotonic relationship and p < 0.05 considered statistically significant. Third, we conducted sex-specific analyses to compare burdens between males and females. Fourth, we grouped individuals aged ≥25 years into 15 consecutive 5-year intervals to evaluate age-related patterns in the ASMR and ASDR. Finally, we quantified the contributions of the 13 dietary risk factors to the burden of CVD and its major subtypes, using the GBD dietary risk definitions to highlight which dietary components most strongly drive disease burden.

The GBD 2021 data reported 13 dietary risks associated with CVD, including low intake of fruits, vegetables, whole grains, nuts and seeds, seafood omega-3 fatty acids, fiber, legumes, and polyunsaturated fatty acids, vegetables, as well as high intake of sodium, processed meat, trans fatty acids, red meat, and sugar-sweetened beverages. In 2021, the highest percentages of deaths and DALYs were attributable to diets low in whole grains, diets low in fruits, and diets high in sodium, thereby identifying these as the primary dietary risks contributing to the burden of CVD-DR.

This study offers the first comprehensive assessment of the burden of CVD-DR, including global trends and their influencing factors. The key findings are as follows: First, between 1990 and 2021, the absolute numbers of deaths and DALYs attributable to CVD-DR increased worldwide, whereas the ASMR and ASDR showed declines. IHD-DR, stroke-DR, and HHD-DR were the primary contributors to the worldwide CVD-DR burden. Second, both ASMR and ASDR were negatively correlated with SDI. Third, the EAPCs of ASMR and ASDR also demonstrated negative correlations with SDI. Fourth, the ASMR and ASDR increased with age and remained higher in males than in females. Fifth, high sodium intake, low fruit intake, and low whole grains consumption were the leading dietary contributors to the global CVD-DR burden. In the following section, we discuss these findings in the context of existing literature.

Over the past 31 years, although global DALYs and deaths from CVD-DR have increased by 44.8 and 36.5%, respectively, the ASDR and ASMR have declined to 61.4 and 62.9% of their 1990 values, respectively. This apparent discrepancy is primarily attributable to rapid global population growth, which has increased the absolute number of cases despite reductions in age-standardized rates. A previous study based on the GBD 2019 data reported a similar pattern, noting an overall increase in the burden of CVD-DR despite a decline in ASR, which the authors also attributed to population growth (14). The trends in death, DALYs, ASMR, and ASDR for IHD-DR, stroke-DR, HHD-DR, AA-DR, and LEPAD-DR were the same as those for CVD-DR, but increased for AFF-DR. In 2021, IHD-DR, stroke-DR, and HHD-DR were the main sources of CVD-DR burden, accounting for 67.0, 18.2, and 14.4% of the ASMR and 67.7, 20.2, and 12.3% of the ASDR, respectively. However, AFF-DR, AA-DR, and LEPAD-DR together accounted for only 0.4 and 0.5% of ASMR and ASDR, respectively. These findings underscore the persistent significant health burden of CVD-DR, particularly for patients with IHD-DR, stroke-DR, and HHD-DR.

In 2021, Central Asia showed the highest ASMR and ASDR, whereas high-income regions such as Western Europe, Southern Latin America, high-income North America, high-income Asia Pacific, and Australasia had significantly lower CVD-DR burdens, suggesting that socioeconomic level is an important influencing factor of CVD-DR burden. Additionally, at the country level, Afghanistan, Nauru, Turkmenistan, Bulgaria, Yemen, the Solomon Islands, the Marshall Islands, and the Federated States of Micronesia had the highest CVD-DR burdens, highlighting the need for more aggressive prevention and treatment policies. Notably, Southern Sub-Saharan Africa was the only region where ASMR and ASDR increased from 1990 to 2021, suggesting that it may emerge as a major hotspot for CVD-DR. This upward trend is likely driven by dietary shifts associated with rapid urbanization and globalization. Since the mid-1990s, following the Southern African Development Community’s implementation of trade and economic liberalization, local diets have transitioned from traditional, fiber- and nutrient-rich foods to imported, ultra-processed products, and sugar-sweetened beverages high in salt, sugar, and fat (15). Concurrently, population growth and increased life expectancy have increased the number of individuals with elevated cardiovascular risk, whereas limited preventive strategies and inadequate acute care capacity have further contributed to rising mortality (16, 17). Unlike most regions where ASMR and ASDR declined over the same period, this divergence highlights the urgency and complexity of CVD-DR prevention in Southern Sub-Saharan Africa. Conversely, Australasia experienced the steepest decline in ASDR and ASMR between 1990 and 2021. Although we also observed declines in high-income Western countries in Europe and North America, the reduction was most pronounced in Australasia. This difference may reflect sustained policy-driven improvements in dietary patterns in this region. Since the early 21st century, federal and state governments have implemented coordinated public health strategies aimed at reducing unhealthy diets and sugar-sweetened beverage consumption. For example, in 2012, Western Australia introduced the Western Australian Health Promotion Strategic Framework 2017–2021, which emphasized balanced diets and reduced consumption of unhealthy foods and sugary drinks (18). Similarly, in 2015, the Australian government launched the Healthy Food Partnership and in 2018 proposed nutritional reformulation targets to reduce consumption of sugar in beverages by 20% by 2025 (19). These policy initiatives have played a significant role in improving dietary behaviors within the region and may have contributed to the observed reductions in the ASMR and ASDR of CVD-DR.

Overall, the CVD-DR burden in a given region is influenced by a combination of factors, including socioeconomic level, dietary patterns, demographics, and healthcare level. Recognizing these regional differences is essential for designing effective, context-specific prevention and management strategies.

Correlation analysis showed that the ASMR and ASDR of CVD-DR and its major subtypes, IHD-DR, stroke-DR, and HHD-DR, were negatively correlated with SDI, revealing a strong association between socioeconomic status and the burden of CVD-DR. Since 2010, the low and low-middle SDI regions have been the primary areas affected by CVD-DR (Figure 3). The burden on these regions may be shaped by the combined effects of socioeconomic status on dietary patterns, health care levels, and chronic stress. First, socioeconomic level determines the average income level of a population, which in turn influences food consumption. In low-SDI regions, low incomes make it difficult for residents to afford healthy and abundant food, thereby increasing the consumption of cheap and unhealthy processed foods (20). However, unhealthy food consumption significantly increases the risks of diabetes, hypertension, obesity, and other metabolic diseases, all of which are important risk factors for CVD (20, 21). Second, socioeconomic level directly influences healthcare expenditure and the quality of medical services in a given region. In low-SDI regions, a weak socioeconomic foundation leads to limited healthcare spending, which further restricts improvements in healthcare levels and the development of healthcare systems. For example, in Nepal, national health insurance coverage does not exceed 10% of the population, > 50% of health expenditure is out-of-pocket, and funding for CVD-related healthcare is minimal (22). Moreover, inadequate healthcare can lead to delayed diagnosis, poor management, and a lack of preventive care. Third, socioeconomic level affects mental mood through income level (23). Residents of low-SDI regions may experience chronic stress due to low incomes, job instability, and social isolation (23). Chronic stress can activate the hypothalamic-pituitary-adrenal axis and autonomic nervous system, leading to obesity, dyslipidemia, and insulin resistance, thereby increasing CVD risk (24). Moreover, chronic stress can induce or exacerbate CVD via chronic inflammation, oxidative stress, and endothelial dysfunction (25, 26). These findings indicate that socioeconomic status influences disease burden through dietary patterns, healthcare levels, and chronic stress, which helps explain the link between CVD-DR burden and SDI.

Notably, from 2010 to 2021, low and low-middle SDI regions showed a hump-shaped pattern in ASMR and ASDR, with rates first increasing and then declining, whereas the high-SDI regions displayed a steady, linear decrease. In low- and low-middle SDI regions, the short-term increase was likely driven by rapid urbanization and dietary shifts, including greater consumption of ultra-processed foods, high-sodium meals, and sugar-sweetened beverages, which temporarily offset the benefits of incremental healthcare improvements (27–29). As healthcare systems strengthened and comprehensive prevention strategies, such as salt-reduction initiatives, the Framework Convention on Tobacco Control, and dietary optimization, were more widely implemented, the CVD-DR burden began to decline (30–32). In contrast, high-SDI regions had already completed urbanization and established relatively stable dietary patterns. Combined with earlier adoption of effective prevention policies and advanced healthcare services, these factors contributed to the consistent and sustained declines in ASMR and ASDR.

Additionally, the growth rates of ASDR and ASMR for CVD-DR, IHD-DR, and stroke-DR were negatively correlated with SDI. High-SDI regions showed the most rapid decline in ASMR and ASDR, which was attributed to their high socioeconomic levels. In such regions, strong economic foundations positively impacted local healthcare systems and dietary management. First, per capita health expenditure and health investment in high and middle-high SDI regions are significantly higher than in other SDI regions, leading to the development of more comprehensive healthcare systems (33). Thus, patients with CVD in high-SDI regions receive more comprehensive and advanced preventive, diagnostic, and treatment services, thereby minimizing the health burden caused by CVD-DR. Moreover, these individuals benefit from favorable economic and educational environments, which allow them to choose healthy diets (34). With economic development between 1999 and 2016, the percentage of energy intake from low-quality carbohydrates among US adults decreased significantly, whereas the intake percentages of polyunsaturated fats, plant proteins, and energy from high-quality carbohydrates increased significantly (35). A subsequent clinical study in Canada reported that individuals who adhered to the Canadian Food Guide had a 24% lower risk of developing CVD compared with those who did not (RR: 0.76; 95% CI 0.58–0.94) (36). In general, the positive impact of socioeconomic level on healthcare systems and dietary management explains the association between CVD-DR burden trends and SDI.

Interestingly, among all the subtypes, only the growth rates of ASMR and ASDR of HHD-DR were positively correlated with SDI, with the highest levels observed in high-SDI regions. The rapid increase in the HHD-DR burden in these regions may be related to increasing aging populations. Aging is among the most important risk factors for hypertension and a direct cause of HHD (37). However, although the burdens of HHD-DR in low-SDI regions decrease with socioeconomic development, these regions show the highest ASDR and ASMR. Thus, low-SDI regions remain the primary hotspots for HHD-DR, and their healthcare systems and dietary patterns require further improvement. In summary, the burden of CVD-DR and its subtypes is intricately linked to the SDI through the interplay of socioeconomic levels, healthcare levels, dietary patterns, and population aging. Thus, effective reduction of CVD-DR burden requires prevention and management strategies that are adapted to regional differences in SDI.

Sex-stratified analysis revealed that males had higher ASMR and ASDR values for CVD-DR than females, which may be explained by differences in sex hormone levels, lifestyle behaviors, and healthcare utilization. Biologically, males have significantly lower estrogen levels than females, and estrogen exerts protective effects on the cardiovascular system by downregulating plasminogen activator inhibitor-1, inflammatory markers, and matrix metalloproteinases (38). Behaviorally, males are more likely to engage in unhealthy lifestyle habits such as smoking, alcohol consumption, and unhealthy diet, which are important risk factors for CVD. The World Health Organization (WHO) reports significantly higher global rates of alcohol consumption and smoking among males compared with females (52% and 36.7%, respectively, vs. 35% and 7.8%) (39, 40). Dietary assessments similarly indicate that females generally follow healthier dietary patterns, while males consume higher amounts of ultra-processed foods (41, 42). Additionally, males are more likely to work in physically demanding or high-risk occupations such as construction, mining, and manufacturing, which increases exposure to occupational hazards that can adversely affect cardiovascular health (43). Disparities in healthcare utilization further contribute to the sex difference, as men are less likely than women to seek preventive care, attend routine examinations, or adhere to medical advice, leading to delayed detection and management of key risk factors such as hypertension and hyperlipidemia (44). Collectively, these biological, behavioral, occupational, and healthcare-related differences likely explain the greater burden of CVD-DR observed in males.

Age-stratified analysis revealed higher ASDR and ASMR for CVD-DR among older age groups, consistent with the well-established role of aging as a major risk factor for CVD (45). Cardiac aging is characterized by reduced left ventricular contractility, diminished sympathetic nerve responsiveness, and lower ejection fraction, which decrease cardiac output and promote compensatory myocardial hypertrophy, ultimately leading to progressive functional decline (46, 47). Similarly, vascular aging involves arterial wall thickening, increased stiffness, and endothelial dysfunction, further impairing cardiovascular performance (48). In low- and low-middle SDI regions, the burden of CVD-DR was driven not only by driven not only by adults aged ≥60 years but also by individuals aged 25–59 years. In contrast, in high-middle and high SDI regions, the burden was predominantly concentrated among individuals aged ≥60 years. This shift in high-SDI regions is likely due to an aging population and better prevention strategies. These prevention strategies delay CVD onset in older patients. In low-SDI regions, limited healthcare resources, lower coverage of preventive measures, and persistent exposure to dietary and lifestyle risk factors in younger and middle-aged adults have led to a greater proportion of CVD-DR burden occurring before the age of 60 years. These findings highlight the need for age- and region-specific prevention and management strategies.

Globally, dietary risks contributing to CVD burden, ranked from highest to lowest, include diets low in fruits, high in sodium, low in whole grains, low in polyunsaturated fatty acids, low in vegetables, low in nuts and seeds, low in seafood omega-3 fatty acids, low in fiber, high in processed meat, low in legumes, high in trans fatty acids, high in red meat, and high in sugar-sweetened beverages. Among these, diets high in sodium and low in fruits and whole grains represented the primary dietary risks for CVD.

A high-sodium diet is the leading contributor to CVD-DR burden and its subtypes, including stroke-DR and AFF-DR. Sodium, primarily obtained from processed foods, ready-to-eat meals, and added salt during cooking, is essential in trace amounts but harmful in excess. However, Elevated sodium intake increases extracellular fluid volume, cardiac output, and vascular resistance, thereby raising the risk of hypertension, a major driver of CVD and a key determinant of stroke and AFF risk (49–51). Therefore, the WHO recommends a daily sodium intake of no more than 2.0 g (52), whereas the US Department of Health and Human Services recommends that specific populations, such as patients with hypertension and older adults, limit their intake to ≤1.5 g (53). Our analysis identified Central Europe and East Asia as hotspots for sodium-related CVD burden. Central Europe showed the highest percentage of deaths and the second-highest DALYs percentage, while East Asia had the highest DALYs percentage and the second-highest death percentage. These patterns are further reinforced by local dietary habits. Influenced by traditional diets rich in soy sauce and smoked foods, the average daily sodium intake in East Asia has significantly exceeded the WHO-recommended level (54). Although Japan has achieved notable salt reduction through decreases in sodium from pickled vegetables and miso paste, this progress has been offset by rising consumption of soy sauce, leaving sodium intake persistently high (55, 56). Similarly, in Central Europe, 73.4% of individuals from Poland consume excessive salt (57). Therefore, regions such as Central Europe and East Asia should implement more comprehensive and targeted salt reduction strategies, including nationwide public health campaigns to raise awareness about the harmful effects of high sodium intake, reformulation of processed and packaged foods to reduce sodium content, mandatory front-of-pack sodium labeling, promotion of low-sodium salt alternatives, and community-based dietary education programs. Such multilevel interventions are more likely to achieve sustained reductions in sodium intake and, consequently, mitigate the burden of CVD-DR.

A low-fruit diet was the second leading contributor to CVD-DR burden and the primary contributor to HHD-DR and AA-DR burden. Fruits are rich in potassium and various antioxidants, including polyphenols, flavonoids, and vitamin C, which reduce the risks of HHD and AA by exerting anti-inflammatory and antioxidant effects, improving vascular elasticity, and promoting renal sodium excretion (58). Consequently, the WHO recommends a daily intake of >400 g (59). South Asia was identified as the primary hotspot for fruit-deficient CVD burden, largely due to socioeconomic factors and regional dietary patterns. South Asia is one of the most densely populated regions globally, with nearly 400 people per square kilometer. Except for the Maldives and Sri Lanka, most South Asian countries are classified as low- or lower-middle-income. In such settings, limited household income can restrict fruit consumption, even when fruits are locally available (60). Jayawardena et al. (60) observed that fruit consumption in many South Asian countries remains below the WHO-recommended levels. In India, for example, fruit and vegetable consumption decreased steadily from 1973 to 2004, while meat and salt consumption increased (61). These findings suggest that economic constraints, rather than availability, limit the inclusion of fruit in the daily diet of low-income households. Notably, the widespread use of added salt and soy sauce also contributes to the prevalence of high-sodium diets in South Asia (62). Low fruit intake and high dietary sodium levels have a synergistic effect on elevating blood pressure, as potassium in fruits helps mitigate the hypertensive effects of sodium by promoting sodium excretion and improving vascular function (63). In populations with insufficient fruit consumption, this protective mechanism is weakened, thereby amplifying the blood pressure–raising effect of high-sodium diets (64). These findings underscore the importance of comprehensive dietary interventions in South Asia that simultaneously promote fruit consumption and reduce sodium intake to prevent and manage hypertension and related CVD.

A diet low in whole grains was the third most common contributor to CVD-DR burden and the primary driver of IHD-DR burden. Whole grains are rich in dietary fiber, potassium, and antioxidants, making them an important food source. Whole-grain diets reduce IHD risk by regulating lipid levels, blood glucose levels, and blood pressure (65, 66). The results of a meta-analysis indicated that for every 30 g/day increase in grain intake, the risk of CHD decreases by 6% (RR 0.94, 95% CI 0.92–0.97) (67). Therefore, the US Department of Agriculture and Department of Health and Human Services recommend a daily whole-grain intake of at least 48 g (68). In the present study, Central Asia was the primary hotspot for whole-grain-deficient CVD burden, likely reflecting dietary shifts accompanying economic development. For example, in Kazakhstan, with continuous economic growth, per capita meat consumption increased from 65.9 kg/year to 72.9 kg/year from 2011 to 2017, which may have displaced other foods, including whole grains (69). These findings suggest that public health strategies in Central Asia should emphasize increased whole-grain consumption as part of comprehensive CVD-DR prevention and management programs.

A diet high in processed meat is a major dietary risk factor for LEPAD-DR. Processed meats, which undergo salting, curing, smoking, fermentation, or chemical preservation, are rich in sodium chloride, nitrates, nitrites, phosphates, and saturated fats. The intake of processed meat is associated with a higher risk of peripheral artery disease (70), likely because its components exacerbate atherosclerosis and vascular damage (71, 72). In the present study, high-income North America was the primary hotspot for processed meat-related CVD burden, reflecting both economic levels and dietary patterns. With a robust economic foundation and an extensive industrial system, this region is a major producer and consumer of processed meats. Trade policies, such as the North American Free Trade Agreement, have further encouraged the production, trade, and consumption of agricultural products, including processed meats (73). Data indicate that processed meat intake in high-income North America significantly exceeds the global average, while a 30% reduction in intake could prevent an estimated 92,500 CVD cases nationwide (74, 75). These findings suggest that public health strategies in high-income North America should prioritize reducing processed meat consumption as part of comprehensive CVD-DR prevention and management programs.

Notably, dietary risks arising from insufficient intake of healthy foods include low consumption of fruits, whole grains, polyunsaturated fatty acids, vegetables, nuts and seeds, seafood omega-3 fatty acids, dietary fiber, and legumes. Addressing these deficiencies requires a multipronged approach. Public health authorities should strengthen nutritional education to raise awareness of the benefits of these foods, incorporate healthy eating guidance into school curricula, and promote dietary guidelines through mass media campaigns. Simultaneously, targeted subsidies and price incentives for healthy foods, particularly in low-income communities, can improve affordability and accessibility (76). Efforts to enhance food supply chains, establish farmers’ markets, and encourage local production can help ensure a stable supply of fresh, nutrient-rich foods year-round (76). Conversely, dietary risks from the excessive intake of unhealthy foods include high consumption of processed meat, trans fatty acids, red meat, and sugar-sweetened beverages. Effective prevention strategies should combine public education with fiscal measures, such as taxes on ultra-processed foods and sugar-sweetened beverages, legal limits on industrial trans fats, and clear front-of-package labeling to guide healthier choices (77). Supporting reformulation initiatives by the food industry to reduce sodium, added sugars, and saturated fats can further reduce population-level exposure to dietary risks.

This study has several limitations. First, although the data cover 204 countries and territories globally, the completeness and accuracy of the information may vary across regions owing to differences in socioeconomic status, healthcare access, and reporting systems, particularly in low- and middle-income countries. Second, disease classifications and definitions in the GBD database may differ from international standards, potentially reducing the precision of burden estimates. Third, some data, including dietary and lifestyle information, were self-reported, which may have introduced misclassification bias. Fourth, the reliance on a single data source may lead to potential bias and may not capture all relevant influencing factors. Fifth, as an observational study, our analysis identified associations but could not establish causality. Furthermore, owing to limitations of the GBD database, we were unable to perform subgroup analyses for potential confounders such as physical activity, genetics, or other individual-level factors, which may influence the observed associations. Despite these limitations, this study provides a comprehensive overview of the global and regional burdens of CVD-DR. Future research integrating multiple data sources, incorporating standardized dietary and lifestyle information, and applying methods capable of inferring causality will help clarify the underlying mechanisms and inform prevention and management strategies.