Human behavior: an impediment to future mortality improvement a focus on obesity and related matters

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Human behavioran impediment to future mortality
improvementa focus on obesity and related matters

• WorldFuture 2009
• July 19, 2009
• Sam Gutterman, FSA, FCAS, CERA

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Agenda

• Human behavior
• Obesity
• The problem
• The trends
• The effects
• The solutions

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Human behavior

• In contrast to sources of improvement in
  longevity
• We have not always been able to control our
  behavior
• Adverse trends
• Environment
• Macro-level
• Habits
• Smoking limits to improvement
• Nutrition and exercise possibly a two tier
  society
• Human nature
• Accidents

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Effect of smoking
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Obesity the problem

• Two primary contributing factors
• Food intake
• Physical activity
• Possible effects
• Chronic diseases, independent and together with
  others
• Mortality, morbidity, health care needs
• Quality of life

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Obesity and you

• Are you obese? Body Mass Index (BMI, weight(kg) /
  (height(m)2)
• Table in terms of height and weight in pounds

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U.S. obesity trends NHANES

• Age Males Females
• 1988-94 2001-04 1988-94 2001-04
• 20-34 14.1 23.2 18.5 28.6
• 35-44 21.5 33.8 25.5 33.3
• 45-54 23.2 31.8 32.4 38.0
• 55-64 27.2 36.0 33.7 39.0
• 65-74 24.1 32.1 26.9 37.9
• 75 13.2 19.9 19.2 23.2
• Total (age-adjusted) 20.2 29.5 25.5
  33.2
• Ethnic Group
• Non-Hispanic white 20.3 30.2 22.9 30.7
• Non-Hispanic black 20.9 30.8 38.3 51.1
• Mexican 23.8 29.1 35.2 39.4
• Income Males and females
• 1988-94 2001-04
• lt poverty line 28.1 33.7

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U.S. overweight and obesity trendsNHANES

• Age Males Females
• 1988-94 2001-04 1988-94 2001-04
• 20-34 47.5 59.0 37.0 51.6
• 35-44 65.5 72.9 49.6 60.1
• 45-54 66.1 78.5 60.3 67.4
• 55-64 70.5 77.3 66.3 69.9
• 65-74 68.5 76.1 60.3 71.5
• 75 56.5 68.8 52.3 63.7
• Total (age-adjusted) 60.9 70.5 51.4
  61.6
• Ethnic Group
• Non-Hispanic white 61.6 71.0 47.5 57.6
• Non-Hispanic black 57.8 67.0 68.2 79.6
• Mexican 68.9 74.6 68.9 73.0
• Income Males and females
• 1988-94 2001-04
• lt poverty line 59.6 63.4

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Obesity Trends Among U.S. AdultsBRFSS, 1988
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1998
lt10 1014 1519
20
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Obesity Trends Among U.S. AdultsBRFSS, 2008
lt10 1014 1519
2024 2529 30
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Obesity trends
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Obesity trends
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U.S. obesity trendsChildren

• NHANES I NHANES II NHANES III
  NHANES NHANES NHANES
• Age 1971-74 1976-80 1988-94
  1999-2000 2001-02 2003-04
• 2 - 5 5.0 5.0 7.2 10.3
  10.6 13.9
• 6 - 11 4.0 6.5 11.3 15.1
  16.3 18.8
• 12 - 19 6.1 5.0 10.5 14.8
  16.7 17.4

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Obesity relationships
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Causes of increase in obesity

• Food intake
• Snacks
• Increase in number of restaurants, including
  fast-food
• Food prices
• Increase in average portion size
• Hi fructose corn sweetened drinks (incease of 50
  daily calories over past two decades)
• Lack of physical activity
• Less vigorous work, transportation and leisure
• Reduction in school PE and increase in car
  transport
• TV, video games, internet
• Socioeconomic income and education
• Genetic predispositions

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Incentives to obesity

• Decreasing price of calories
• More efficient food technology process
• Less time to prepare
• Have we seen the end of this trend?
• Other economic factors related to food
• Decrease in available time to prepare food
• Increase in convenience of eating out
• Increase in animal fat, energy dense high fat
  foods
• Urbanization/suburbanization
• Increase in cost of exercise

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Relation between childhood and adult obesity

• A great deal of public attention on childhood
  obesity
• Reasons for concern
• Likelihood of leading to adult obesity
• Immediate concerns in childhood
• Early onset diabetes and other health conditions
• Uncertainty associated with long-term effects
• Danish study that indicates long-term concern

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Obesity as a worldwide issue

• Both in developing and developed countries
• May be due primarily to an increase in western
  food
• Also less physical activity in work, transport
  and leisure
• Worldwide obesity levels
• 2005 1995
• Australia 21.7 (1999) 19.8
• Canada 18.0 12.1
• Finland 14.1 10.4
• France 9.5 7.0
• Japan 3.0 2.6
• Mexico 30.2 24.2(2000)
• Netherlands 10.7 6.9
• New Zealand 20.9 17.0
• Spain 13.1 10.3
• Sweden 10.7 7.9
• Switzerland 7.7 6.8
• United Kingdom 23.0 16.0
• United States 32.2 22.9(1991)

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Obesity the effects

• Mortality
• Morbidity and health care costs
• Quality of life

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Obesity and mortality

• Long term effect
• Requires long term follow-up period for proper
  study
• Importance of mitigating factors
• Medical treatment blood pressure, cholesterol
• But not fully effective
• Possible biological and pharmacological
  breakthroughs
• Difficult to separate effects of
• Weight, food intake, physical activity, fitness
• Ultimately their combination counts
• Forgotten in obesity discussions risks of
  underweight
• Confounding causes, especially smoking

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Obesity and cause of death

• Difficult to distinguish between cause and
  association
• Type 2 diabetes
• Increase over last two decades for all ages
• Cardiovascular diseases
• Risk factors blood pressure, cholesterol
• Certain types of cancer
• Others

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Obesity and cancersWorld Cancer Research
Fund/American Institute for Cancer Research (2007)
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Obesity attributable deaths

• Difficult to attribute death to specific causes
• Contributing causes and data issues
• What is the benchmark?
• In 2005, CDC estimates changed from 365,000 to
  112,000 additional U.S. deaths
• Methodological reasons
• Effect of overweight
• Older ages
• Not as significant
• Difficulty in assessment due to confounding
  factors
• Bottom line still a death and health care risk

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Representative study results

• NIH AARP Study (age-adjusted hazard rates for
  U.S.)
• lt18.5 18.5-23.4 23.5-24.9
  25-29.9 30-34.9 35-39.9 gt40
• Men
• All 1.97 1.21 1.00 0.97 1.10 1.35 1.83
• Never smoked 1.67 1.20 1.00 1.10 1.39 1.91 2.59
• White 1.99 1.23 1.00 0.96 1.08 1.32 1.82
• Black 1.90 1.35 1.00 1.02 1.16 1.44 1.68
• Hispanic 2.31 1.31 1.00 1.08 1.17 1.79 2.42
• Women
• All 2.03 1.15 1.00 1.04 1.18 1.49 1.94
• Never smoked 1.70 1.11 1.00 1.20 1.38 1.82 2.52
• White 2.04 1.15 1.00 1.04 1.19 1.54 1.95
• Black 2.16 1.31 1.00 0.88 1.03 1.06 1.70
• Hispanic -- 1.49 1.00 1.98 2.14 1.44 4.12
• Note limited black and Hispanic mortality
  experience

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Special case black females

• High level of obesity and overweight
• Relatively flat additional mortality based on BMI
  gradients
• Inadequate explanation to date
• Causal effects may be different, different
  genetic disposition at work, or factors at
  standard weight levels may be different ?
• Different view on ideal body figure
• May require different benchmark

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Obesity solutions

• Amount and type of nutrition
• Physical activity
• Bariatric surgery
• Education
• Pharmacotherapy
• Incentives, although no
• Taxes
• Reduction in health insurance premiums
• Compensation
• Marshalling other forces
• Schools and communities, the workplace,
  Insurance/health care companies, food industry,
  support groups, health care professionals,
  technology
• Bottom line not easy to turn the clock back