PHA-Exch> Life Expectancy Drops for Some U.S. Women

Tue Apr 22 10:13:01 PDT 2008

Life Expectancy Drops for Some U.S. Women

Washington Post, April 22, 2008

For the first time since the Spanish influenza of 1918, life
expectancy is falling for a significant number of American women.

In nearly 1,000 counties that together are home to about 12 percent
of the nation's women, life expectancy is now shorter than it was in
the early 1980s, according to a study published today.

The downward trend is evident in places in the Deep South,
Appalachia, the lower Midwest and in one county in Maine. It is not
limited to one race or ethnicity but it is more common in rural and
low-income areas. The most dramatic change occurred in two areas in
southwestern Virginia (Radford City and Pulaski County), where
women's life expectancy has decreased by more than five years since 1983.

The trend appears to be driven by increases in death from diabetes,
lung cancer, emphysema and kidney failure. It reflects the long-term
consequences of smoking, a habit that women took up in large numbers
decades after men did, and the slowing of the historic decline in
heart disease deaths.

It may also represent the leading edge of the obesity epidemic. If
so, women's life expectancy could decline broadly across the United
States in coming years, ending a nearly unbroken rise that dates to
the mid-1800s.

"I think this is a harbinger. This is not going to be isolated to
this set of counties, is my guess," said Christopher J.L. Murray, a
physician and epidemiologist at the University of Washington who led
the study. It is being published in PLoS Medicine, an open-access
journal of the Public Library of Science.

Said Elizabeth G. Nabel, director of the National Heart, Lung and
Blood Institute of the National Institutes of Health: "The data
demonstrate a very alarming and deeply concerning increase in health
disparities in the United States."

The study found a smaller decline, in far fewer places, in the life
expectancy of men in this country. In all, longevity is declining for
about 4 percent of males.

The phenomenon appears to be not only new but distinctly American.

"If you look in Western Europe, Australia, Japan, New Zealand, we
don't see this," Murray said.

About half of all deaths in the United States are attributable to a
small number of "modifiable" behaviors and exposures, such as
smoking, poor diet and lack of exercise. Although it is impossible to
know exactly what is going on in the 1,000 counties, Murray thinks it
"would be a reasonably obvious strategy" to target them for
aggressive public health campaigns.

Life expectancy is not a direct measure of how long people live.
Instead, it is a prediction of how long the average person would live
if the death rates at the time of his or her birth lasted a lifetime.

For that reason, life expectancy can dip or rise abruptly. The death
rate from the Spanish flu was so high, especially among the young,
that life expectancy fell by about seven years in 1918. But it
rebounded quickly when the epidemic was over.

In general, though, it takes huge forces to drive down life
expectancy over longer periods. The AIDS epidemic has done so in some
African countries. In the early 1990s, the social disruption
following the collapse of the Soviet Union decreased life expectancy
of Russian men by six years and of women by three years -- an
unprecedented decline in a modern industrialized nation.

In the study, Murray and collaborators at the Harvard School of
Public Health examined mortality and cause-of-death data for the
United States from 1961 through 1999. They divided the country into
2,068 units, including cities, counties or combinations of counties.

Across that four-decade period, average life expectancy nationwide
increased from 66.9 years to 74.1 years for men, and from 73.5 years
to 79.6 years for women.

>From 1961 to 1983, life expectancy went up everywhere for both
sexes. This was largely because the death rate from heart attacks,
which had been rising for half a century, began to fall in the late
1960s. There were two reasons.

Huge numbers of people lowered their chances of having a heart attack
by modifying "risk factors," such as smoking, hypertension and high
cholesterol. Improvements in medicine -- coronary care units, use of
aspirin and beta-blocker drugs, and various surgical procedures --
greatly increased survival in patients with heart disease. About
two-thirds of the longevity gained over the past four decades has
come from the decrease in cardiovascular deaths.

These changes were so dramatic that even the poorest and least
healthy groups benefited. In fact, counties with low life expectancy
in 1961 had steeper rises over the next dozen years than counties
that started out with high life expectancy. Overall, the drop in
heart attack deaths more than offset rising mortality from cancer,
emphysema and diabetes during this period.

By the early 1980s, however, the rapid gains were coming to an end.
The low-hanging fruit on the tree of heart-attack prevention and
treatment had been picked. Further strides tended to happen mostly in
places where people were already healthy and long-lived.

As a consequence, the rise in longevity began to stagnate in places
with the least-healthy people. In those counties, life expectancy
increased by only one year (from 74.5 to 75.5) between 1983 and 1999,
while in the healthiest places the life expectancy of women had reached 83.

It was during this interval that women's life expectancy fell in
nearly 1,000 counties. If one adds counties where it rose only
insignificantly, then 19 percent of American women -- nearly 1 in 5
-- are now experiencing stagnating or falling life expectancy.

The trend was far less pronounced for men. That is because they
entered the 1980s with higher death rates from heart attacks than
women, and thus gained more from better prevention and better
treatment. In the 1990s, however, AIDS and homicide began to take
large tolls, depressing male life expectancy in some places.

Murray's team, which also included Ari B. Friedman of Harvard and
Sandeep C. Kulkarni of the University of California at San Francisco,
used Internal Revenue Service data to check whether high levels of
migration, or migration of people with particularly high or low
incomes, might explain the discrepancy between the 1,000 counties and
their neighbors. They found no evidence for it.

Unlike some European countries, the United States does not collect
health information other than birth and death statistics at the local
level. Instead, there are national, state and regional surveys of
people's health, behavior and access to medical care. Trends those
studies have picked up shed light on what is happening in the 1,000
counties.

Obesity has risen markedly in the past two decades, with women more
affected than men. About 33 percent of women are now obese, compared
with 31 percent of men. Extreme obesity is twice as common in women
(7 percent) as in men (3 percent).

Being overweight greatly increases the risk of developing Type 2, or
"adult-onset," diabetes. A national survey in 2002 found that 85
percent of diabetics were overweight or obese.

In recent years, the prevalence of high blood pressure has been
increasing in women, as well -- partly the result of weight gain. In
1990, 42 percent of women older than 60 had hypertension; by 2000 it
was 51 percent. (In men, the trend is still dropping, as it has been
for several decades.)

"This is a story about smoking, blood pressure and obesity," said
Majid Ezzati, of the Harvard Initiative for Global Health, a
co-author of the paper.

===

Majid Ezzati, Ari B. Friedman, Sandeep C. Kulkarni, Christopher J. L.
Murray. The Reversal of Fortunes: Trends in County Mortality and
Cross-County Mortality Disparities in the United States. PLOS
Medicine. 4(4):e66.

Background

Counties are the smallest unit for which mortality data are routinely
available, allowing consistent and comparable long-term analysis of
trends in health disparities. Average life expectancy has steadily
increased in the United States but there is limited information on
long-term mortality trends in the US counties This study aimed to
investigate trends in county mortality and cross-county mortality
disparities, including the contributions of specific diseases to
county level mortality trends.

Methods and Findings

We used mortality statistics (from the National Center for Health
Statistics [NCHS]) and population (from the US Census) to estimate
sex-specific life expectancy for US counties for every year between
1961 and 1999. Data for analyses in subsequent years were not
provided to us by the NCHS. We calculated different metrics of
cross-county mortality disparity, and also grouped counties on the
basis of whether their mortality changed favorably or unfavorably
relative to the national average. We estimated the probability of
death from specific diseases for counties with above- or
below-average mortality performance. We simulated the effect of
cross-county migration on each county's life expectancy using a
time-based simulation model. Between 1961 and 1999, the standard
deviation (SD) of life expectancy across US counties was at its
lowest in 1983, at 1.9 and 1.4 y for men and women, respectively.
Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999.
Between 1961 and 1983 no counties had a statistically significant
increase in mortality; the major cause of mortality decline for both
sexes was reduction in cardiovascular mortality. From 1983 to 1999,
life expectancy declined significantly in 11 counties for men (by 1.3
y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783
(women) counties had nonsignificant life expectancy decline. Life
expectancy decline in both sexes was caused by increased mortality
from lung cancer, chronic obstructive pulmonary disease (COPD),
diabetes, and a range of other noncommunicable diseases, which were
no longer compensated for by the decline in cardiovascular mortality.
Higher HIV/AIDS and homicide deaths also contributed substantially to
life expectancy decline for men, but not for women. Alternative
specifications of the effects of migration showed that the rise in
cross-county life expectancy SD was unlikely to be caused by migration.

Conclusions

There was a steady increase in mortality inequality across the US
counties between 1983 and 1999, resulting from stagnation or increase
in mortality among the worst-off segment of the population. Female
mortality increased in a large number of counties, primarily because
of chronic diseases related to smoking, overweight and obesity, and
high blood pressure.

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