Projecting Future Mortality
Using Information on Health
Behaviors
David M. Cutler, Edward L. Glaeser, and
Allison B. Rosen
Questions

Is the US population healthier than in
the past?
– Yes: Smoking has declined greatly
– No: We are more obese
– Yes: We treat disease better

Will these trends continue?
Restrictions

We focus on health behaviors.
– Smoking
– Drinking
– Weight
– Taking medications
Actual Causes of Death in
the United States, 2004

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Tobacco
Obesity
Alcohol
Microbial agents
Toxic agents
MVAs
Guns
Sexual behaviors
Illicit use of drugs
Source: Mokdad et al., 2004.
18%
15%
4%
3%
2%
2%
1%
1%
1%
Methodology
1.
Relate risk factors to subsequent mortality
– NHANES I data (1971-75) linked to subsequent
mortality
2.
Evaluate change in risk factors, 1971-75
vs. 1999-2002
3.
Consider forecasts about risk factors in the
future.
Data
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NHANES I (1971-75) and NHANES
1999-2002
Population 25-74 and 55-74
Demographics
Self reported smoking, alcohol
Physical measures of BP, cholesterol,
BMI
Rough relationships
Demographics
weight
Behaviors
Risk: BP,
Cholesterol
smoking
Mortality
Mortality Equation: 10 year
mortality as a function of…

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Age/sex (10 year age x sex)
Race (white/black/other)
Education (<HS, HS, Some College, College+)
Smoker (current/former/never)
BMI (low, normal, overweight, obese)
Alcohol (heavy, light, never)
Blood pressure (normal, pre-HTN, Stage 1, Stage 2)
Cholesterol (low, borderline, high)
Summary Statistics:
Education
NHANES I
NHANES 1999-2002
<HS
20%
College
28%
<HS
34%
College
55%
HS
38%
HS
25%
Summary Statistics:
Smoking
NHANES I
NHANES 1999-2002
Current
25%
Current
Never
39%
40%
Former
21%
Never
49%
Former
26%
Summary Statistics:
Drinking
NHANES I
Non
21%
NHANES 1999-2002
Heavy
7%
Heavy
4%
Non
30%
Light
72%
Light
66%
Summary Statistics:
BMI
NHANES I
Obese
15%
NHANES 1999-2002
Under
weight
3%
Under
weight
2%
Obese
33%
Optimal
30%
Optimal
Over
weight
35%
47%
Over
weight
35%
Summary Statistics:
Hypertension
NHANES I
Stage 2
16%
Normal
22%
NHANES 1999-2002
Stage 2
5%
Stage 1
13%
Stage 1
24%
Pre-HTN
38%
Pre-HTN
39%
Normal
43%
Summary Statistics:
High Cholesterol
NHANES I
High
30%
NHANES 1999-2002
Normal
35%
High
18%
Normal
48%
Border
line
35%
Border
line
34%
Effect of Risk Factors on
10 Year Mortality
Variable
Odds
Ratio
Variable
Odds
Ratio
Race: Black
1.40*
BMI: Underweight
2.41*
Other
.25
Educ: <HS
1.27*
College
1.06
BP: Pre-HTN
0.90
2.13*
Stage 1
1.13
1.23
Stage 2
1.54*
Smoke: Current
Former
Drink: Heavy
Light
1.02
0.77*
Overweight
0.76*
Obese
1.28
Chol: Borderline
High
1.03
1.15
Predicted 10 Year
Mortality Risk
Risk in:
Ages 25-74
Ages 55-74
1971-75
9.8%
25.7%
1999-02
8.4
21.7
Change
-1.4
[-14%]
-3.9
[-15%]
Percentage Point Change
in Risk Due to…
Population 25-74
1.2%
0.8%
0.4%
0.0%
I
M
B
in
g
rin
k
D
on
tr
ol
C
hl
C
at
io
n
Ed
uc
Co
n
P
B
Sm
ok
in
g
tro
l
-0.4%
Percentage Point Change
in Risk Due to…
Population 55-74
2.4%
1.6%
0.8%
0.0%
I
M
B
in
g
rin
k
D
on
tr
ol
C
hl
C
at
io
n
ok
in
g
Sm
Ed
uc
B
P
Co
n
tro
l
-0.8%
Forecasts

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Simulate 20 years from now
Not totally clear what explains these
behaviors.
– Smoking: Taxes (a bit); Beliefs; Peer
effects
– Obesity: Lower (time) price of food
– Assume these are still playing out
Forecasts

Smoking
– Know ever smoking for many cohorts
(guess for others)
– Assume trend reduction in current
smoking continues
– Smoking rate falls from 25% to 15%
Per Capita Cigarette Consumption, US
1900-2000
5,000
4,000
3,000
2,000
1,000
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
Forecast Assumptions

Drinking
– Continued reduction in heavy and light
drinking

BMI
– Same change in BMI over past 20 years
as previous 20 years
– Increase of about 10 lbs.
Implications of higher
BMI: BP and Cholesterol

Use 1959-62 NHANES to relate BP and
cholesterol to obesity
– Essentially no treatment

Predict BP and cholesterol 20 years hence
– Includes random error term

Assume same share of people treated and
same impact of treatment
– Draw BP and cholesterol from distribution among
treated.
Control of Adverse Risk
Factors, 1999-2000
100%
80%
60%
40%
20%
0%
Hypertension
Aware
Treated
High Cholesterol
Controlled
Impact of Changes on
Population Mortality Rate
Smoking forecast
%age
points
-0.7%
Percent
-8%
Drinking forecast
0.1%
1%
BMI forecast
1.4%
17%
- If everyone takes meds
1.0%
12%
- More effective meds /
greater adherence
0.2%
2%
Impact of 10% reduction in mortality on
expected age at death for people alive at age
95
0.5 years
0.9 years
90
1.2 years
1.1 years
85
80
75
25
30
35
40
45
50
55
Baseline
60
65
Alternate
70
75
80
85
Results


Impact of continued increase in
obesity could be enormous.
Key is risk factor control
– Get more people treated
– Improve effectiveness of therapy – better
drugs, and taken more regularly
Qualifications

Impact on mortality is not necessarily
the same as impact on disability
– Important for DI and Medicare/Medicaid
forecasts