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Disability, not death, colors Americans' health

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Don't overlook income, social inequality as risk factors

Despite a level of health expenditures that would have seemed unthinkable a generation ago, the health of the U.S. population has improved only gradually and has fallen behind the pace of progress in many other wealthy nations.

The authors’ determination to generate consistent data across a range of national settings and to focus on specific diseases as causes of death is a source of strength and of limitations to the study. The strength is the capacity to compare in a consistent way. The limitation is reliance on data types that are universally available and on analyses that relate to specific disease conditions rather than to overall mortality. The most glaring omission in the assessment of risk factors, as the authors acknowledge, is the role of social factors such as income and inequality as a risk of premature death and disability. This omission should not be allowed to mislead policy makers, because differences in socioeconomic status and other social circumstances are strongly related to differences in mortality, as has been emphasized in a recent, comprehensive assessment by the National Research Council and the Institute of Medicine on U.S. health in comparison with other countries.

Setting the United States on a healthier course will surely require leadership at all levels of government and across the public and private sectors and actively engaging the health professions and the public. Analyses such as the U.S. Burden of Disease can help identify priorities for research and action and monitor the state of progress over time.

Dr. Harvey V. Fineberg is the president of the Institute of Medicine in Washington, D.C. These remarks were taken from his editorial accompanying the JAMA study. He reported no conflicts of interest.


 

AT A PRESS BRIEFING HELD BY JAMA AND THE INSTITUTE OF MEDICINE

Meanwhile, two other studies examined life expectancy and physical activity on a county-by-county basis in America. Both were conducted by researchers at the Institute for Health Metrics and Evaluation, and both were published online in the open-access, peer-reviewed journal Population Health Metrics, which is edited by Dr. Murray.

In the first study, "Prevalence of Physical Activity and Obesity in US Counties, 2001-2011: A Road Map for Action," physical activity did not increase overall in the United States during the study period (2001-2009), but the percentage of the population considered obese did. The authors found that just because an area had higher physical activity levels did not mean that there would be a corresponding drop in obesity. They wrote that from 2001 to 2009, "for every 1 percentage point increase in physical activity, obesity prevalence was 0.11 percentage points lower" (Popul. Health Metr. 2013;11:7 [doi: 10.1186/1478-7954-11-7]).

Some counties – in Florida, Georgia, and Kentucky – saw large gains in physical activity. Among women, for instance, the largest increase in sufficient physical activity (defined as 150 minutes of moderate activity or 75 minutes of vigorous activity weekly) was seen in Morgan County, Ky., where the rate rose from 26% to 44% during 2001-2009.

Generally, physical activity was worse for men and women who lived along the Texas-Mexico border, the Mississippi Valley, parts of the Deep South, and West Virginia, according to the study.

Douglas County, Colo., had the highest rate of activity in the United States (90%) for men in 2011, while Marin County, Calif., had highest rate for women (90%). Wolfe County, Ky., had the lowest rate for men (55%), and McDowell County, W.Va., had the lowest rate for women (51%).

Obesity rates tended to track with activity rates, with higher rates in the South and lower rates in urban areas like San Francisco, New York, and Washington, D.C.

The authors also published a county-by-county analysis of life expectancy, "Left Behind: Widening Disparities for Males and Females in US County Life Expectancy, 1985-2010." They reported that among the top-achieving counties, female life expectancy in 2010 was 85 years (or about 5 years more than the national average) and male life expectancy was 81.7 years (also about 5 years greater than the national average). But, they said, in many counties there has been no increase, or in some cases, declines in life expectancy, especially for women. There was a dramatic increase in inequality in life expectancy at birth among U.S. counties between 1985 and 2010, they concluded (Popul. Health Metr. 2013;11:8 [doi: 10.1186/1478-7954-11-8]).

Dr. Murray’s work is supported in part by the National Institutes of Health and in part by the Bill and Melinda Gates Foundation.

aault@frontlinemedcom.com On Twitter @aliciaault

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