Transcript Life Settlement Underwriting Conservatism versus No Quote

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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Future life expectancy can be
calculated for any starting age
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
US Vital Statistics 2004
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Life expectancy at birth 1900 to 2000
85
80
79
75
74
70
Age
65
women
60
55
50
45
40
1900
1920
1940
1960
1980
2000
Source: U.S. Vital Statistics, 2004
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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
1 to 1.5
65% in those over
age 45
Reduction in CV events and
decline in preemie deaths
? Greatest at oldest
ages
↑ LE: Health Care
Genetics
↓ LE: Allocation of Resources
Obesity Epidemic
1960 to present
2000 forward
??
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
Cutler and Meara, Sept 2001, Changes in the Age Distribution of Mortality Over the 20 th Century
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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.
Cutler and Meara, Sept 2001, Changes in the Age Distribution of Mortality Over the 20 th Century
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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 riskfactors 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 forward
Continuing 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 forward
Recent 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,
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by Age Group, US, 1971-2002
16
16
Prevalence (%)
15
11
11
10
10
7
5
7
6
5
5
4
5
0
2 to 5 years
NHANES I (1971-74)
6 to 11 years
NHANES II (1976-80)
12 to 19 years
NHANES III (1988-94)
NHANES 1999-2002
*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.
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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
22
20
19
18
women
15
16
14
12
10
1900
1920
1940
1960
1980
2000
Source: U.S. Vital Statistics, 2004
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Years of Life Remaining at Age 85
8
7
6.5
6
5.8
5
4
women
3
men
2
1
0
1880
1900
1920
1940
1960
1980
2000
2020
Source: U.S. Vital Statistics, 2004
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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 Expectancy
Correlations:
• 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
Source: Centers for Disease Control and Prevention, National Center for Health Statistics (US)
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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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Source: Centers for Disease Control and Prevention, National Center for Health Statistics (US)
US Population Decennial Life Table 1989-1991
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Fasano Associates 6th Annual Life Settlement Conference
26 October 2009
Washington, DC
Michael Fasano
Fasano Associates
1201 15th Street, NW – Suite 250
Washington, DC 20005
202-457-8188
202-457-8198 (fax)
[email protected]
www.fasanoassociates.com
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