June 2004

Grant Results

SUMMARY

Between 1997 and 1999, researchers with the Association of Academic Health Centers updated a 1993 analysis of external (nongenetic) factors that contribute to the leading causes of death in the United States.

Key Findings
In a March 10, 2004 editorial in the Journal of the American Medical Association (JAMA), the researchers commented:

  • In 2000, dietary patterns and sedentary lifestyles represent the most common source of unnecessary death and disease among Americans.

In a July 1999 report to RWJF, the researchers noted:

  • At least 40 percent, and possibly 47 percent, of deaths reported in 1996 were attributable to behavior patterns, including diet and activity, tobacco, alcohol, firearms, illicit use of drugs and sexual behavior.
  • Between 1980 and 1992, the number of deaths in the United States caused by infectious diseases increased by more than 75 percent.
  • The firearm death rate for children under age 15 was nearly 16 times higher than the combined rate for 25 other industrialized countries.
  • While the number of Americans who report using illicit drugs has decreased significantly since 1979, the number of new users between the ages of 12 and 26 increased between 1994 and 1996.
  • Drug use, and behavior associated with it, is the single largest factor in the spread of HIV/AIDS in the United States.

Funding
The Robert Wood Johnson Foundation (RWJF) supported the research with a grant of $168,285 from November 1997 to July 1999.

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THE PROBLEM

Health statistics on causes of death tend to report the conditions present near the time of death. The use of traditional diagnostic categories, however, may obscure the importance of causal factors leading to certain health conditions — e.g., 90 percent of lung cancers result from exposure to tobacco use. It is important to know the actual "causes" of death, according to McGinnis, so that public health attention and funds can be focused appropriately.

A 1993 study by McGinnis and William Foege, M.D., published in the Journal of the American Medical Association (JAMA), estimated that the most prominent contributors to mortality in the U.S. were, in order, tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles and illicit drug use. The work presented in the 1993 article addressed these issues for Americans in all age groups, and was confined to mortality. Although the researchers noted the importance of socioeconomic factors such as poverty, access to medical care, and educational level, they restricted their analyses to those items for which there was a clear biological mechanism.

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THE PROJECT

This project sought to update and expand the 1993 analysis by examining the specific experiences of children and adolescents and older Americans, and by addressing the underlying causes of morbidity (illness and injury), as well as death. The investigators updated mortality statistics for the general population using vital statistics records for the last decade and data from two surveys conducted by the federal Centers for Disease Control and Prevention (CDC) — the National Health Interview Survey and the National Health and Examination Survey. They reviewed articles published in the scientific literature that assess factors identified as health determinants, including social determinants. For data on the general population, they reviewed articles from 1990 to 1998, and for children and older adults, literature from 1975 to 1998. Investigators selected only those articles for which they could establish adequate methodological rigor.

The investigators discovered that epidemiological studies of the entire population could not be easily used to form conclusions about specific age groups, as hoped. The social determinants of morbidity and mortality (such as income levels, education levels, etc.) were also difficult to quantify based on epidemiological statistics. In both cases, the investigators made some qualitative observations based on research studies, and postponed definitive conclusions, pending further research.

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FINDINGS

From the March 10, 2004 issue of JAMA, editorial, "The Immediate vs. the Important," by McGinnis and Foege commenting on an article by Ali H. Mokdad, Ph.D. et al., "Actual Causes of Death in the United States," 2000:

  • In combination, in 2000 dietary patterns and sedentary lifestyles represent the most common source of unnecessary death and disease among Americans, with a range from 340,000 to 642,000 deaths annually. "The estimates would suggest that diet/physical activity patterns are now in fact likely greater contributors to mortality than tobacco is (and, in retrospect probably were in 1990) and are most likely increasing in their impact."

From a July 1999 report to RWJF:

  • At least 40 percent, and possibly 47 percent, of deaths reported in 1996 were attributable to behavior patterns. Of 2.3 million deaths, approximately 1.08 million were attributable to diet and activity patterns, tobacco, alcohol, firearms, illicit use of drugs and sexual behavior. (Of the remaining deaths, 90,000 were due to microbial agents, 70,000 to toxic agents, and 25,000 to motor vehicles.) About 92 percent of the 90.6 million illnesses and injuries requiring medical treatment in 1996 were attributable to behavior patterns. Preliminary assessment indicates that some 30 million were attributable to diet and activity patterns, 25 million to tobacco, 13.5 million to sexual behavior, 10 million to alcohol, 3 million to illicit drug use, and 90,000 to firearms. Of the remaining illnesses and injuries, 3 million were attributable to motor vehicle injuries, 3 million to microbial agents, and 1.5 million to toxic agents. Of all premature deaths (before age 75) in 1996, approximately 40 percent were attributable to behavioral factors. Of the remaining, 30 percent were attributable to genetic predisposition, 15 percent to social circumstances, 10 percent to inadequacies in medical care, and 5 percent to environmental exposures. Tobacco, in 1996, accounted for nearly 400,000 deaths and more than 25,000,000 illnesses requiring medical care annually. This toll on Americans comes despite impressive gains made against the use of tobacco. Misuse of alcohol is responsible for approximately 90,000 deaths each year. Approximately 13 million illnesses and injuries that required treatment in 1995 could be traced to the use of alcohol.
  • Between 1980 and 1992, the number of deaths in the United States caused by infectious diseases increased by more than 75 percent, to more than 165,000. The firearm death rate for children under age 15 was nearly 16 times higher than the combined rate for 25 other industrialized countries.
  • While the number of Americans who report using illicit drugs had decreased significantly since 1979, the number of new users between the ages of 12 and 26 increased between 1994 and 1996. Estimates of the number of deaths from illicit drug usage among all age groups range from 9,000 to 35,000 per year.
  • Drug use, and behavior associated with it, is the single largest factor in the spread of HIV/AIDS in the United States. Fully half of all new HIV infections occur among injecting drug users. Injecting drug use was estimated to be the source for 25 percent of the 633,000 adult AIDS cases reported in the United States by the end of 1997. Another 10 percent of cases are traceable to sex with injection drug users.
  • While motor vehicle fatality rates among 16 to 20 year olds have been reduced by 27 percent, the fatality rate for young people remains twice that for the general population. Among all age groups, injuries to passengers and pedestrians caused about 43,500 deaths and nearly 3.5 million injuries in 1996.
  • The most consistent predictor of the likelihood of death in the United States is level of education. Americans aged 45 to 64 with the highest level of education have death rates 2.5 times lower than those in the lowest level.
  • Poverty has been estimated to account for 6 percent of U.S. deaths. The observation has been made that each 1 percent rise in income inequality (the income difference between rich and poor) is associated with about a 4 percent increase in deaths among those on the low end of the income scale.
  • If current patterns prevail, at least 20 million of the 45 million children born in the United States in the next 15 years will die prematurely — before age 75 — most due to preventable problems. The problems will stem largely from behaviors established, education and coping skills acquired, and exposure to hazardous conditions experienced in childhood.
  • Of the leading causes of death for people over age 65, most are clearly related to controllable factors. Lifelong dietary habits, physical activity patterns, and tobacco use have vital impacts on heart disease, cancers, stroke and diabetes.

Communications

Researchers compiled preliminary findings, plus Bibliography and supporting tables, in a July 1999 report to RWJF. The findings related specifically to the impact of addictive substances on morbidity and mortality were published in Proceedings of the Association of American Physicians in early 1999 (see the Bibliography for details). The principal investigator also presented preliminary findings at four professional meetings during 1998 and 1999.

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AFTER THE GRANT

Using the methodology developed for this project, researchers with the federal Centers for Disease Control and Prevention are updating the analysis to include mortality and morbidity data from 2000. JAMA published the findings in March 2004 with an accompanying editorial by McGinnis and Foege.

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GRANT DETAILS & CONTACT INFORMATION

Project

Analysis of Causes of Morbidity and Mortality in the United States

Grantee

Association of Academic Health Centers (Washington,  DC)

  • Amount: $ 168,285
    Dates: November 1997 to July 1999
    ID#:  032016

Contact

J. Michael McGinnis, M.D., M.P.P.
(202) 293-4296
mcginnis@rwjf.org

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

McGinnis JM. Causes of Morbidity and Mortality in the United States: Report to the Robert Wood Johnson Foundation, July 1999.

Articles

McGinnis JM and Foege WH. "The Immediate vs. the Important." Journal of the American Medical Association, 291(10): 1263–1264, 2004.

McGinnis JM and Foege WH. "Actual Causes of Death in the United States." Journal of the American Medical Association, 270(18): 2207–2212, 1993. Abstract available online.

McGinnis JM and Foege WH. "Mortality and Morbidity Attributable to Use of Addictive Substances in the United States." Proceedings of the Association of American Physicians, 111(2): 109–118, 1999. Abstract available online.

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Report prepared by: Kelsey Menehan
Reviewed by: James Wood
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans

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