Major risk factors and life expectancy disparities in the United States

Majid Ezzati Department of Global Health and Population Department of Environmental Health Harvard School of Public Health

Acknowledgements and collaborators • Core funding: US Centers for Disease Control and Prevention • US comparative risk assessment: Goodarz Danaei, Eric Ding, Dariush Mozaffarian, Ben Taylor, Jürgen Rehm, Christopher JL Murray • US sub-national mortality and risk factors: Goodarz Danaei, Ari B Friedman, Eric Rimm, Shefali Oza, Sandeep C Kulkarni, Christopher JL Murray

Motivation • What are the effects of major preventable risk factors on loss of healthy life in the United States population? • What are the effects of major preventable risk factors on disparities in loss of healthy life in the United States population?

US county life expectancy analysis • 3,141 county and county equivalents merged into 2,068 county units to ensure – 10,000 males and females in 1990 in each county – consistency of county definition between 1959 and 2001

• Census data: 1960, 1970, 1980, 1990, 2000 • Death files: 1959-2001 (currently being updated to 2006) • 5-year pooled death rates • Estimate uncertainty in death rates and life expectancy using a binomial/Poisson simulation

• Forthcoming work uses a geospatial empirical Bayes approach to make real-time annual estimates of units as small as 7,000 M/F population

Life expectancy in US counties, 2006 Female

Kulkarni et al forthcoming

Male

Global rank of life expectancy in US counties, 2006 Female

Kulkarni et al forthcoming

Male

The “Eight Americas” • Identify sub-populations making up the US population with distinct socio-demographic and geographical characteristics that capture the range of mortality experiences across counties and races

2072 counties; 3 races 2072 counties or merged counties; 4 races (Asians, blacks, Native Americans, whites)

Asians in 1,889 counties with Pacific Islanders < 40% of Asians

America 1

Whites in 112 Northland rural counties With white per capita income < $11,770

America 2

All other race-county combinations

America 3

Whites in 467 rural counties in America 4 Appalachia and the Mississippi Valley with white per capita income < $11,770

2072 counties; blacks

Native Americans in 359 counties in Western states

America 5

Blacks in 1,632 other counties

America 6

427 rural counties in the Deep America 7 South with per capita black income 1.0%

Murray et al PLoS Medicine 2006

America 8

Life expectancy at birth in the Eight Americas in 2005

Life expectancy at birth (years)

Male

Female

95

95

90

90

85

85

80

80

75

75

70

70

65

65 America 1

2

3

4

Danaei et al PLoS Medicine 2010

5

6

7

America 8

America 1

2

3

4

5

6

7

America 8

Deaths attributable to individual risk factors in the US, by disease Deaths attributable to individual risks (thousands) in both sexes -50

50

150

250

350

450

Smoking High blood pressure Overweight-obesity (high BMI) Physical inactivity High blood glucose High LDL cholesterol High dietary sodium (salt) Low dietary omega-3 fatty acids (seafood) High dietary trans fatty acids Alcohol use Low intake of fruits and vegetables Low PUFA (in place of SFA)

Danaei et al PLoS Medicine 2009

Cardiovascular Cancer Diabetes Respiratory Other NCD Injury

Major risk factor data sources in the US • National Health and Nutrition Examination Survey (NHANES) – In-person interview and measured tests – Only nationally representative – Traditionally not annual

• Behavioral Risk Factor Surveillance System (BRFSS) – Telephone survey (self report only) – State-representative (+ county-representative in some large counties) – Annual

• Self-reported risk factors are subject to intentional and unintentional bias – Use statistical models to predict measured exposure using self-reported exposure and socio-demographic variables, health system access, and medication use

Risk factors in the Eight Americas: men ≥ 60 years (age-standardized) Current smoking (%)

Former smoking (%)

SBP (mmHg)

BMI (kg/m2)

FPG (mg/dL)

Asians

135 (4.4)

27 (0.81)

106 (1.9)

5 (3.5)

35 (11.7)

Northland rural whites

133 (1.2)

28.6 (0.34)

110 (1.0)

11 (2.3)

59 (3.7)

Middle America

133 (0.3)

27.9 (0.09)

109 (0.3)

11 (0.6)

56 (1.0)

Whites in Appalachia and Mississippi Valley

133 (0.8)

27.9 (0.21)

110 (0.6)

14 (1.4)

56 (2.2)

Western Native Americans

138 (4.0)

29.4 (1.14)

116 (3.6)

21 (9.2)

40 (9.8)

Black middle America

138 (2.0)

28.3 (0.52)

112 (1.4)

19 (4.3)

45 (6.1)

Southern rural blacks

140 (2.0)

28.7 (0.57)

113 (1.8)

17 (3.7)

44 (5.6)

High-risk urban blacks

138 (2.9)

28.0 (0.78)

110 (2.1)

21 (5.9)

39 (7.5)

America

Danaei et al PLoS Medicine 2010

Risk factors in the Eight Americas: women ≥ 60 years (age-standardized) Current smoking (%)

Former smoking (%)

SBP (mmHg)

BMI (kg/m2)

FPG (mg/dL)

Asians

143 (4.8)

27.6 (1.37)

103 (2.4)

3 (2.0)

21 (7.2)

Northland rural whites

139 (1.2)

29.7 (0.39)

104 (0.6)

8 (1.5)

27 (2.7)

Middle America

139 (0.3)

28.9 (0.12)

104 (0.2)

11 (0.5)

34 (0.7)

Whites in Appalachia and Mississippi Valley

139 (0.6)

29.2 (0.25)

105 (0.4)

14 (1.1)

26 (1.4)

Western Native Americans

140 (3.6)

30.1 (1.79)

108 (2.9)

15 (5.7)

36 (10.1)

Black middle America

143 (1.6)

31.9 (0.67)

108 (1.1)

14 (2.7)

27 (3.4)

Southern rural blacks

144 (1.5)

32.7 (0.7)

110 (1.3)

10 (2.4)

20 (3.0)

High-risk urban blacks

144 (2.3)

31.0 (0.87)

106 (1.6)

12 (3.2)

32 (5.5)

America

Danaei et al PLoS Medicine 2010

Simplified causal graph for selected risks Blood glucose Other pathways

Adiposity (BMI)

Blood pressure

Smoking Danaei et al PLoS Medicine 2010

Ischemic heart disease

Life expectancy at birth in the Eight Americas in 2005 without the effects of four leading risks Male

Female

Life expectancy at birth (years)

95

95 Current

90

Optimal

85

85

80

80

75

75

70

70

65

Current

90

Optimal

65 America 1

2

3

4

Danaei et al PLoS Medicine 2010

5

6

7

America 8

America 1

2

3

4

5

6

7

America 8

Probability of dying between 15 and 60 y

Probability of death between 15 and 60 years of age in the Eight Americas (men) Current 0.3

0.2

Optimal 0.3

Other HIV/AIDS

Other

Intentional Injuries

HIV/AIDS

Unintetntional Injuries

Intentional Injuries

Other NCDs

0.2

CVD

Unintetntional Injuries Other NCD CVD

Cancer

Cancer

0.1

0.1

0.0

0.0 America 1

2

3

Danaei et al PLoS Medicine 2010

4

5

6

7

America 8

America 1

2

3

4

5

6

7

America 8

Probability of dying between 15 and 60 y

Probability of death between 15 and 60 years of age in the Eight Americas (women) Current 0.3

Optimal 0.3

Other

Other

HIV/AIDS

HIV/AIDS

Intentional Injuries

Intentional Injuries

Unintetntional Injuries

0.2

Other NCD

0.2

Unintetntional Injuries

CVD

Other NCD

Cancer

CVD Cancer

0.1

0.1

0.0

0.0 America 1

2

3

Danaei et al PLoS Medicine 2010

4

5

6

7

America 8

America 1

2

3

4

5

6

7

America 8

Using disease prevention to reduce health disparities • Strategies to improve population health and reduce health disparities – Address fundamental social and economic inequalities and their institutional determinants – Increase financial, physical, and behavioral access to health care – Reduce inequality in the quality of health care – Reduce risk factors through interventions acting on communities – Reduce risk factors through interventions acting on individuals and groups not in the same community

• How can health reform support disease prevention? • What are the implications for monitoring, evaluation, and accountability?