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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