improvements in life expectancy: past, present and future

© Fasano Associates September 2009 Longevity Conference 2009

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Improvements in Life Expectancy: Past, Present and Future

John R. Iacovino, M.D., F.A.C.P.Medical Director / Senior Consultant

Consistency • Accuracy • Professionalism


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Overview• Mortality Improvements By Period

– 1900 to 1940– 1940 to 1960– 1960 /1980 to 2000– 2000 and forward

• The Aging Process• Effect of Eliminating Cancer and Heart

Disease on Life Expectancy


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Source: Centers for Disease Control and Prevention, National Center for Health Statistics (US)


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Life expectancy for both sexes, US, 1900-2002

Year At birth At age 65 At age 75

1900 47.3 13

1950 68.2 (45%) 13.9 10.9

2000 77.0 (13%) 18.0 (29%) 11.4

Future life expectancy can be calculated for any starting age

US Vital Statistics 2004


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Life expectancy at birth 1900 to 2000

Source: U.S. Vital Statistics, 2004

79

74


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Mortality Improvements.

Time period % annual improvement

% of improvement by age Reason

1900 to 1940 1 80% in those under age 45

Better nutrition and public health measures

1940 to 1960 2 Even across ages Declining infectious diseases, vaccines and antibiotics

1960 to present 1 to 1.5 65% in those over age 45

Reduction in CV events and decline in preemie deaths

2000 forward ?? ? Greatest at oldest ages

↑ LE: Health Care Genetics↓ LE: Allocation of Resources Obesity Epidemic

Cutler and Meara, Sept 2001, Changes in the Age Distribution of Mortality Over the 20 th Century


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Phase 1: 1900 to 1940 Life expectancy increased 16 years

• Decline in infant deaths contributed 4 ½ years • Decline in childhood mortality contributed

4 ½ years

• Decline in young adult mortality contributed 3 ½ years

• Other improvements contributed 3 ½ years Cutler and Meara, Sept 2001, Changes in the Age Distribution of Mortality Over the 20 th Century


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Phase 1: 1900 to 1940 Explanations for declining death rate• In 1900, infections accounted for 32% of all deaths. By

1940, infections were only 8% of deaths.

• Deaths from pneumonia and influenza fell 2.4% annually between 1900 and 1940

• Deaths from TB fell 3 to 6% annually—and fell by 50% after anti-TB drugs were introduced.

• Deaths from vaccine preventable diseases fell 3 to 6% annually.


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Phase 1: 1900 to 1940 Classic public health improvements for whole society• Sanitation and safe drinking water

• Refrigeration and safe food

• Better housing

• Better quality air


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Phase 1: 1900 to 1940 On the downside, heart disease and cancer increased

• Heart disease rose from 22% in 1900 to 44% of all deaths in 1940.

• Cancer deaths rose from 5% in 1900 to 11% of all deaths in 1940.


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Phase 2: 1940 to 1960 Life expectancy increased 6.4 years

• Infections as a cause of death declined faster between 1940 and 1960 than in the first 40 years of the century.

• Much of this decline was due to medical care: new diagnostic tests and medications



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Phase 3: 1960 to 1990• By 1960, infectious disease mortality is already

so low that their further decreases do not materially impact life expectancy.

• Decline in infant mortality adds only 1 ¼ years

• Decline in deaths in those over age 45 added 3 ½ years.



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Phase 3: 1960-1990

• Virtually all of the mortality gain since 1965 is due to decrease in cardiovascular mortality.

• Since 1965, cardiovascular disease

mortality begins to decline at about 2% per year


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Major reasons for CV decline—which has the greatest impact? • Technology (coronary care units, angiography,

coronary interventions, etc.) – 1967 First bypass– 1977 First angioplasty

• Pharmaceutical gains (BP and cholesterol meds, post heart attack protocols)

• Behavioral life style interventions (better diet, more exercise, less smoking)


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Phase 4: 1981 to 2000

• Cardiovascular mortality fell by 54% • Smoking fell by 35%• Population total cholesterol fell 4.2%

– Introduction of statins• Population BP fell 7.7%• Note the gain despite increasing obesity and

inactivity at the same time. An even greater future opportunity.

Unal,B, Am J. Pub Health, 2005 Jan;95(1): 103-108


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Phase 4: 1981 to 2000

• The improvements in cardiovascular risk-factors account for four times more life-years gained than did all of cardiovascular treatments for known disease.– Diet– Exercise– Smoking

Unal,B, Am J. Pub Health, 2005 Jan;95(1): 103-108


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Phase 5: 2000 forward Life expectancy is increasing, but

• Americans lag behind the rest of the world.• America ranks about 30th in life expectancy

– U.S. LE 81 years – Japan / China 84 years - #1– Swaziland 33 years - last

• Immigrants to the US live 3 years longer than their American born relatives.


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Phase 5: 2000 forwardContinuing and future challenges

• Smoking

• Obesity

• Inactivity


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Trends in Cigarette Smoking Prevalence* (%) by Gender, Adults 18 and Older, US, 1965-2002

*Redesign of survey in 1997 may affect trends.

Source: National Health Interview Survey, 1965-2002, National Center for Health Statitics, Centers for Disease Control and Prevention, 2004.


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Phase 5: 2000 forwardRecent health loses - Obesity rises• 15% of Americans were obese in 1976-80, but

up to 31% in 1999-2000

• Between 1988 and 2002, percent of overweight adults climbed from 56 to 65% and percent of obese adults went from 23 to 30%. – Normal – BMI 18.5 – 24.9 – Overweight – BMI 25 – 29.9– Obese – BMI 30 and greater


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Opportunities for improvement: Trends in Overweight* Prevalence (%), Children and Adolescents,

by Age Group, US, 1971-2002

*Overweight is defined as at or above the 95th percentile for body mass index by age and sex based on reference data. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004.

54

65

75

7

11 1110

16 16

0

5

10

15

20

2 to 5 years 6 to 11 years 12 to 19 years

Pre

vale

nce

(%)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94) NHANES 1999-2002


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Phase 5: 2000 forward Diabetes increasing• In 1997, 5.1% of Americans had diabetes,

in 2002, the number was 6.5%.

• 12 million Americans now have type 2 diabetes– Exercise can prevent and/or delay onset of diabetes– On average diabetes decreases life expectancy by

about one third


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Value of Preventive Life Style• A 35-year-old who burns 2,000 calories through exercise each

week gains, on average, more than six years of life expectancy.

• Inverse relationship between cardiovascular fitness and coronary heart disease and all-cause mortality in healthy men and women– Increase in 1 MET higher level of maximal aerobic capacity resulted in a

14% decrease in the history of coronary heart disease and/or all-cause mortality

– Fitness is better correlated with mortality improvement than simple physical activity


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Decline in elderly mortality is accelerating• Between 1900 and 1940, mortality in the

elderly (over age 65) declined to only 0.3% per year.

• Between 1960 and 1990, mortality in the elderly declined 1.1% per year.


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Who lives the longest?

• Best socio-economic class and education

• Best genes

• Best medical care and risk factor reduction


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Years of Life Remaining at Age 65

10

12

14

16

18

20

22

1900 1920 1940 1960 1980 2000

women


19

15


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Years of Life Remaining at Age 85

0

1

2

3

4

5

6

7

8

1880 1900 1920 1940 1960 1980 2000 2020

womenmen


6.5

5.8


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Aging Process Causes• Free radicals

– Antioxidants• Mutations• DNA repair failure• Waste product accumulation• Telomere shortening


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Telomeres• Long chains of DNA at the ends of

chromosomes

• Protect the integrity of the chromosome

• Shorten at the end of each cell division

Exercise Physiology, Brown, Miller and Eason


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http://science.nasa.gov/headlines/y2006/images/telomeres/caps.gif


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The Future: Are telomeres the best life expectancy calculator?• Aging process

– Probably genetically preprogrammed – We lose the ability to repair aging organs– Damage increases as we age

• “Hayflict Limit” on life expectancy• Life style and behaviors profoundly affect the

genetic profile


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Hayflict Limit• Cells divide freely to a predetermined

number of divisions • Then cell division enters a senescence

phase – Each division produces a telomere shortening

• This creates a ticking back of the genetic inner clock for each subsequent cell division-Replicative Senescence

• Stress Induced Premature Senescence


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Telomeres

• The length of the telomere may determine longevity – Progeria

• Very short telomeres– Cancer Cells

• Produce an enzyme that prevents shortening – cell “immortality”

Exercise Physiology, Brown, Miller and Eason


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Effect of Disease Elimination on Life ExpectancyCorrelations: • Positive elimination correlation

– Eliminating cancer or heart disease renders death from other causes in the future more probable

• Independent elimination correlation– Eliminating cancer or heart disease has no effect on

the probability of death from other causes• Negative elimination correlation

– Eliminating cancer or heart disease renders death from other causes in future years less probable



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Source: Centers for Disease Control and Prevention, National Center for Health Statistics (US)US Population Decennial Life Table 1989-1991


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US Population Decennial Life Table 1989-1991


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Michael FasanoFasano Associates1201 15th Street, NW – Suite 250Washington, DC 20005202-457-8188202-457-8198 (fax)[email protected]

Fasano Associates 6th Annual Life Settlement Conference

26 October 2009

Washington, DC

improvements in life expectancy: past, present and future

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