projecting future mortality using information on health behaviors david m. cutler, edward l....

Projecting Future Projecting Future Mortality Using Mortality Using Information on Health Information on Health BehaviorsBehaviors

David M. Cutler, Edward L. David M. Cutler, Edward L. Glaeser, and Allison B. RosenGlaeser, and Allison B. Rosen

QuestionsQuestions

Is the US population healthier Is the US population healthier than in the past?than in the past?– Yes: Smoking has declined greatlyYes: Smoking has declined greatly– No: We are more obeseNo: We are more obese– Yes: We treat disease betterYes: We treat disease better

Will these trends continue?Will these trends continue?

RestrictionsRestrictions

We focus on health behaviors. We focus on health behaviors. – SmokingSmoking– DrinkingDrinking– WeightWeight– Taking medicationsTaking medications

Actual Causes of Death Actual Causes of Death in the United States, in the United States, 20042004 TobaccoTobacco 18%18% ObesityObesity 15%15%

AlcoholAlcohol 4% 4% Microbial agents Microbial agents 3% 3% Toxic agentsToxic agents 2% 2% MVAsMVAs 2% 2% GunsGuns 1% 1% Sexual behaviorsSexual behaviors 1% 1% Illicit use of drugsIllicit use of drugs 1% 1%

Source: Mokdad et al., 2004.

MethodologyMethodology

1.1. Relate risk factors to subsequent Relate risk factors to subsequent mortalitymortality– NHANES I data (1971-75) linked to NHANES I data (1971-75) linked to

subsequent mortalitysubsequent mortality

2.2. Evaluate change in risk factors, 1971-Evaluate change in risk factors, 1971-75 vs. 1999-200275 vs. 1999-2002

3.3. Consider forecasts about risk factors Consider forecasts about risk factors in the future.in the future.

DataData

NHANES I (1971-75) and NHANES NHANES I (1971-75) and NHANES 1999-20021999-2002

Population 25-74 and 55-74Population 25-74 and 55-74

DemographicsDemographics Self reported smoking, alcoholSelf reported smoking, alcohol Physical measures of BP, Physical measures of BP,

cholesterol, BMIcholesterol, BMI

Rough relationshipsRough relationships

Demographics

Behaviors

Risk: BP, Cholesterol

Mortalityweight

smoking

Mortality Equation: 10 Mortality Equation: 10 year mortality as a year mortality as a function of…function of… Age/sex (10 year age x sex)Age/sex (10 year age x sex) Race (white/black/other)Race (white/black/other) Education (<HS, HS, Some College, College+)Education (<HS, HS, Some College, College+)

Smoker (current/former/never)Smoker (current/former/never) BMI (low, normal, overweight, obese)BMI (low, normal, overweight, obese) Alcohol (heavy, light, never)Alcohol (heavy, light, never)

Blood pressure (normal, pre-HTN, Stage 1, Stage Blood pressure (normal, pre-HTN, Stage 1, Stage 2)2)

Cholesterol (low, borderline, high)Cholesterol (low, borderline, high)

Summary Statistics:Summary Statistics:EducationEducation

<HS34%

HS38%

College28%

<HS20%

HS25%

College55%

NHANES I NHANES 1999-2002

Summary Statistics:Summary Statistics:SmokingSmoking

Former21%

Never39%

Current40%

Former26%

Never49%

Current25%

NHANES I NHANES 1999-2002

Summary Statistics:Summary Statistics:DrinkingDrinking

Light72%

Non21%

Heavy7%

Light66%

Non30%

Heavy4%

NHANES I NHANES 1999-2002

Summary Statistics:Summary Statistics:BMIBMI

Obese15%

Over weight

35%

Optimal47%

Under weight

3%

Obese33%

Over weight

35%

Optimal30%

Under weight

2%

NHANES I NHANES 1999-2002

Summary Statistics:Summary Statistics:HypertensionHypertension

Stage 216%

Stage 124%

Pre-HTN38%

Normal22%

Stage 25%

Normal43%

Pre-HTN39%

Stage 113%

NHANES I NHANES 1999-2002

Summary Statistics:Summary Statistics:High CholesterolHigh Cholesterol

High30%

Border line35%

Normal35%

Normal48%

Border line34%

High18%

NHANES I NHANES 1999-2002

Effect of Risk Factors Effect of Risk Factors on 10 Year Mortalityon 10 Year MortalityVariableVariable Odds Odds

RatioRatioVariableVariable Odds Odds

RatioRatio

Race: BlackRace: Black 1.40*1.40* BMI: BMI: UnderweightUnderweight

2.41*2.41*

OtherOther .25.25 OverweightOverweight 0.76*0.76*

Educ: <HSEduc: <HS 1.27*1.27* ObeseObese 1.281.28

CollegeCollege 1.061.06 BP: Pre-HTNBP: Pre-HTN 0.900.90

Smoke: CurrentSmoke: Current 2.13*2.13* Stage 1Stage 1 1.131.13

FormerFormer 1.231.23 Stage 2Stage 2 1.54*1.54*

Drink: HeavyDrink: Heavy 1.021.02 Chol: BorderlineChol: Borderline 1.031.03

LightLight 0.77*0.77* HighHigh 1.151.15

Predicted 10 Year Predicted 10 Year Mortality RiskMortality Risk

Risk in:Risk in: Ages 25-74Ages 25-74 Ages 55-74Ages 55-74

1971-751971-75 9.8%9.8% 25.7%25.7%

1999-021999-02 8.48.4 21.721.7

ChangeChange -1.4-1.4

[-14%][-14%]-3.9-3.9

[-15%][-15%]

Percentage Point Percentage Point Change in Risk Due Change in Risk Due to…to…

-0.4%

0.0%

0.4%

0.8%

1.2%

Smok

ing

BP Contro

l

Educa

tion

Chl C

ontro

l

Drinki

ng BMI

Population 25-74

Percentage Point Percentage Point Change in Risk Due Change in Risk Due to…to…

-0.8%

0.0%

0.8%

1.6%

2.4%

BP Contro

l

Smok

ing

Educa

tion

Chl C

ontro

l

Drinki

ng BMI

Population 55-74

ForecastsForecasts

Simulate 20 years from nowSimulate 20 years from now

Not totally clear what explains Not totally clear what explains these behaviors. these behaviors. – Smoking: Taxes (a bit); Beliefs; Peer Smoking: Taxes (a bit); Beliefs; Peer

effectseffects– Obesity: Lower (time) price of foodObesity: Lower (time) price of food– Assume these are still playing outAssume these are still playing out

ForecastsForecasts

SmokingSmoking– Know ever smoking for many Know ever smoking for many

cohorts (guess for others)cohorts (guess for others)– Assume trend reduction in current Assume trend reduction in current

smoking continuessmoking continues– Smoking rate falls from 25% to 15%Smoking rate falls from 25% to 15%

Per Capita Cigarette Consumption, US1900-2000

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Forecast AssumptionsForecast Assumptions

DrinkingDrinking– Continued reduction in heavy and Continued reduction in heavy and

light drinkinglight drinking

BMIBMI– Same change in BMI over past 20 Same change in BMI over past 20

years as previous 20 yearsyears as previous 20 years– Increase of about 10 lbs.Increase of about 10 lbs.

Implications of higher Implications of higher BMI: BP and BMI: BP and CholesterolCholesterol Use 1959-62 NHANES to relate BP and Use 1959-62 NHANES to relate BP and

cholesterol to obesitycholesterol to obesity– Essentially no treatmentEssentially no treatment

Predict BP and cholesterol 20 years Predict BP and cholesterol 20 years hencehence– Includes random error termIncludes random error term

Assume same share of people treated Assume same share of people treated and same impact of treatmentand same impact of treatment– Draw BP and cholesterol from distribution Draw BP and cholesterol from distribution

among treated.among treated.

Control of Adverse Control of Adverse Risk Factors, 1999-Risk Factors, 1999-20002000

0%

20%

40%

60%

80%

100%

Hypertension High Cholesterol

Aware Treated Controlled

Impact of Changes on Impact of Changes on Population Mortality Population Mortality RateRate

%age %age pointspoints

PercentPercent

Smoking forecastSmoking forecast -0.7%-0.7% -8%-8%

Drinking forecastDrinking forecast 0.1%0.1% 1%1%

BMI forecastBMI forecast 1.4%1.4% 17%17%

- If everyone takes - If everyone takes medsmeds

1.0%1.0% 12%12%

- More effective - More effective meds / meds /

greater adherencegreater adherence

0.2%0.2% 2%2%

Impact of 10% reduction in mortality on Impact of 10% reduction in mortality on expected age at death for people alive at expected age at death for people alive at ageage

75

80

85

90

95

25 30 35 40 45 50 55 60 65 70 75 80 85

Baseline Alternate

1.2 years

1.1 years

0.9 years

0.5 years

ResultsResults

Impact of continued increase in Impact of continued increase in obesity could be enormous.obesity could be enormous.

Key is risk factor controlKey is risk factor control– Get more people treatedGet more people treated– Improve effectiveness of therapy – Improve effectiveness of therapy –

better drugs, and taken more better drugs, and taken more regularlyregularly

QualificationsQualifications

Impact on mortality is not Impact on mortality is not necessarily the same as impact necessarily the same as impact on disabilityon disability– Important for DI and Important for DI and

Medicare/Medicaid forecastsMedicare/Medicaid forecasts