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
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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 500 Fifth Street, NW. Washington, DC 20001 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 National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. 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