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OCR for page R1
Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
ESTIMATING THE CONTRIBUTIONS OF LIFESTYLE-RELATED FACTORS TO PREVENTABLE DEATH
A Workshop Summary
Board on Population Health and Public Health Practice
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was supported by Contract No. 200-2000-00629, Task Order No. 163 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
Additional copies of this report are available from the
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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin.
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Adviser to the Nation to Improve Health
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
PLANNING COMMITTEE ON ESTIMATING THE CONTRIBUTIONS OF LIFESTYLE-RELATED FACTORS TO PREVENTABLE DEATH
JONATHAN M. SAMET, M.D., M.S., Professor and Chair,
Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
J. MICHAEL MCGINNIS, M.D., M.P.P., Senior Vice President and Director,
Health Group, Robert Wood Johnson Foundation, Washington, DC
MICHAEL A. STOTO, PH.D., Senior Statistical Scientist, and Associate Director for Public Health,
Center for Domestic and International Health Security, RAND, Arlington, VA
STAFF
ROSE MARIE MARTINEZ, Sc.D., Director,
Board on Population Health and Public Health Practice
LINDA G. MARTIN, Ph.D.,
Institute of Medicine Scholar-in-Residence
HOPE HARE, M.F.A., Administrative Assistant
Consultants
MIRIAM DAVIS, LLC, Medical Writer & Consultant
SANDRA HACKMAN, Copy Editor
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
REVIEWERS
This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report:
ALFRED O. BERG, M.D., M.P.H., University of Washington School of Medicine
STEPHEN MARCUS, PH.D., National Cancer Institute, National Institutes of Health
DAVID MATCHAR, M.D., Duke University
CHRISTOPHER MAYLAHN, Chronic Disease Director, New York State Health Department
The review of this report was overseen by MELVIN WORTH, M.D., Scholar-in-Residence at the Institute of Medicine, who was appointed by the Institute of Medicine. He was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the institution.
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
CONTENTS
INTRODUCTION
2
Measuring the Health Impact of Lifestyles: Scientific Challenges
2
Attributing Risks in Preventable Deaths: What Metrics Best Inform Health Policy?
4
SETTING THE STAGE FOR DISCUSSION
6
Causality
6
Attributable Risk in Epidemiology: Interpreting and Calculating Population Attributable Fractions
7
METHODOLOGICAL ISSUES WHEN ESTIMATING LIFESTYLE FACTORS
11
Partial Adjustment
11
Calculating the Number of Deaths Attributable to a Risk Factor Using National Survey Data
12
Caveats in Using Estimates of Deaths Attributable to Lifestyle Factors
13
Estimating Population Attributable Risks: A Simulation Model Based on the NHANES I Followup Study and NHANES III
15
Discussion of Methodological Issues When Estimating Lifestyle Factors
16
ATTRIBUTABLE RISK IN PRACTICE: EXAMPLES FROM THE FIELD
17
Overview of Actual Causes of Death, 1993
17
Rationale for Actual Causes of Death, 2000
18
The Numbers Are the Easy Part: Interpreting and Using Population Attributable Fractions
20
Estimating the Health Impacts Attributable to Alcohol
21
Estimating Deaths Attributable to Alcohol Consumption
22
Estimating Adverse Health Impacts Attributable to Tobacco Use
24
Tobacco Use and Preventable Mortality
26
Obesity, Weight Loss, and Mortality
27
Physical Activity
30
Assessing the Effects of Multiple Public Health Interventions
31
Discussion of Attributable Risk in Practice: Examples from the Field
32
ALTERNATIVE METRICS OF BURDEN
33
Quality-Adjusted Life Years (QALYs)
33
Comparative Risk Assessment (DALYS)
35
HALYs: Measuring Lifestyle-Related Factors that contribute to Premature Death and Disabililty
38
Estimating National and State Medical Costs from Select Risk Factors
39
Using Population Attributable Risk Estimates to Allocate Resources
41
Discussion of Alternative Metrics of Burden
42
PUBLIC POLICY ISSUES
43
General Public Policy Issues
43
State Policy Perspective
44
Discussion of Public Policy and State Policy
45
Ethical Issues
45
Communication Challenges
47
References and Additional Sources for Further Information
48
Rapporteur’s Report
48
DISCUSSION OF LESSONS LEARNED AND NEXT STEPS
50
Reframing the Debate
50
Improving Methodology
51
Developing an Action Plan
51
Guiding Public Policy and Creating Messages for the Public
52
REFERENCES
52
APPENDIX A WORKSHOP AGENDA
55
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Estimating the Contributions of Lifestyle-Related Factors to Preventable Death: A Workshop Summary
APPENDIX B SPEAKER BIOSKETCHES
58
APPENDIX C WORKSHOP PARTICIPANTS
69
APPENDIX D ACRONYM LIST
71
Tables and Figures
TABLE 1
Findings on Actual Causes of Death, 1990
17
TABLE 2
Life-Years per $1 Million (1997 dollars)
42
TABLE 3
Examples of “Attributable” Deaths
49
FIGURE 1
The 10 Leading Causes of Death in the United States, 2002
5
FIGURE 2
Admissions for Acute Myocardial Infarction During 6-Month Periods June–November Before, During, and After the Smoke-Free Ordinance
6
FIGURE 3
Simulation: Prehypertension. Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Prehypertension and Residual Hypertension
16
FIGURE 4
Relative Risk of All-Cause Mortality by Alcohol Consumption, Age, and Cardiovascular Risk, CPS-II Men and Women Combined
24
FIGURE 5
Body Mass Index and Probability of Death
27
FIGURE 6
The Effect of Age on BMI Associated with Lowest Mortality Rate
28
FIGURE 7
The Association between BMI and Mortality, BFMI and Mortality, and FFMI and Mortality, Adjusted for smoking (BFMI and FFMI Mutually Adjusted).
29
FIGURE 8
QALY Calculation
34
FIGURE 9
Attributable Disease Burden of 20 Risk Factors
36
FIGURE 10
Deaths in AMR-A Region. The region includes Canada, US, and Cuba; US population; represents 85% of the region.
37
FIGURE 11
Disease Burden in AMR-A Region. The region includes Canada, US, and Cuba; US population; represents 85% of the region
38
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