Association between GDP and old-age mortality in seven European countries, 1950-1999. A life-course perspective F.Janssen, A.E.Kunst, J.P.Mackenbach Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands The 1st Human Mortality Database Symposium, Rostock, June 18-19, 2004

Part of PhD project: Determinants of trends in old-age mortality in seven European countries Supervisor: Anton Kunst Promotor: Johan Mackenbach Department of Public Health, Erasmus MC, Rotterdam, The Netherlands

Determinants of trends in old-age mortality in seven European countries (1) Objectives: To describe all-cause and cause-specific old-age mortality trends in Denmark, England and Wales, Finland, France, The Netherlands, Norway and Sweden, from 1950-1999. To analyze the role of smoking, mortality selection, socio-economic developments, and medical care as determinants of the trends. To study the implications of increased life expectancy Data: Aggregate data on total- and cause-specific mortality (use of KTDB and HMD) & additional data on the determinants Methods: Poisson regression analyses (APC analyses)

Determinants of trends in old-age mortality in seven European countries (2) Results: Stagnation of mortality decline in Denmark, The Netherlands and among Norwegian men Not only period effects are important, but also cohort effects Cross-national differences in the period trends for cardiovascular diseases Recent mortality increases in diseases specifically related to old age Smoking can not explain cohort mortality patterns fully. Probably also a role of early life circumstances.

Determinants of trends in old-age mortality in seven European countries (3) Publications: - Janssen F, Nusselder WJ, Looman CWN, Mackenbach JP, Kunst AE. Stagnation in mortality decline among elders in The Netherlands, Gerontologist 2003; 43:722-734 - Janssen F, Mackenbach JP, Kunst AE. Trends in old-age mortality in seven European countries, 1950-1999. Journal of Clinical Epidemiology 57(2), 203-216 - Janssen F, Kunst AE. Coding changes and discontinuities in cause-specific mortality trends in six European countries, 1950-1999. Accepted by Bulletin of WHO. Cohort effects in mortality trends among the elderly in seven European countries, 1950-1999. Submitted.

Association between GDP and old-age mortality in seven European countries, 1950-1999. A life-course perspective

INTRODUCTION The ageing of European populations depends on future old-age mortality trends Economic growth may be a key factor in influencing mortality Relationship between current levels of GDP and mortality has often been studied, with varying results Life course perspective: look at the role of GDP at time of death and GDP during the life course of the cohort

OBJECTIVE To assess whether old-age mortality is associated not only with current GDP but also with GDP levels prevailing at birth or at earlier ages of the cohorts involved.

RESEARCH QUESTIONS Is old-age mortality among different cohorts correlated with GDP levels measured at time of death? Is there an additional effect of GDP prevailing at time of birth? What are the effects of GDP measured at different ages of the cohorts?

DATA Countries: Denmark, England&Wales, Finland, France, The Netherlands, Norway, Sweden Ages: 65-99 Period: 1950-1999 Total mortality by sex and Lexis triangles (HMD) Cause-specific mortality by sex, five year age groups and single year of death (national statistical offices and related institutes) Cause of death: infectious diseases, cancer of lung, cancer of stomach, cancer of prostate, cancer of breast, ischaemic heart disease, stroke and COPD GDP per capita at 1995 US Dollars for 1865-1999 (historical overviews; OECD) => Five-year cohort groups from 1865-1869 to 1920-1924

METHODS Poisson regression: sex- and country-specific Comparison of the reduction in scaled deviances of the different models Baseline: model including only age The reduction in scaled deviance is expressed as % of the total reduction in scaled deviances of the full APC model and the model including only age

Cohort trends all-cause mortality Rate ratios with cohort 1890-94 as baseline

Trends of GDP per capita, 1865-1999

The effects of current GDP vs cohort GDP All-cause mortality Comparison of the reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

The effects of current GDP vs cohort GDP All-cause mortality Comparison of the reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

The effects of current GDP vs cohort GDP All-cause mortality Comparison of the reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

The effects of current GDP vs cohort GDP All-cause mortality Comparison of the reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

The effects of current GDP on cohort cause-specific mortality – Men Reduction in scaled deviances (% of the total reduction from age to APC) Model: age and current GDP * No significant reduction in scaled deviance for this model as compared to the previous model Bold - Reduction in scaled deviances >= 80%

The effects of current GDP on cohort cause-specific mortality – Women Reduction in scaled deviances (% of the total reduction from age to APC) Model: age and current GDP * No significant reduction in scaled deviance for this model as compared to the previous model Bold - Reduction in scaled deviances >= 80%

The effects of current GDP vs cohort GDP Cause-specific mortality (1) Reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

The effects of current GDP vs cohort GDP Cause-specific mortality (2) Reduction in scaled deviances (% of the total reduction from age to APC) * No significant reduction in scaled deviance for this model as compared to the previous model

SUMMARY All-cause mortality Women: strong correlation current GDP x cohort mortality Men: moderate correlation current GDP x cohort mortality (S) weak correlation current GDP x cohort mortality (DK, NL, NO) Additional effects from cohort GDP among men: Relatively weak for GDP at birth Stronger for GDP at subsequent ages of the cohort Cause-specific mortality Strong correlation current GDP x cohort mortality: stomach cancer, stroke, lung cancer and COPD (men) Additional effects for cohort GDP (especially at higher ages): lung cancer, IHD, COPD (stroke and breast cancer)

CONCLUSION Levels of current GDP are strongly correlated with cohort old-age mortality GDP levels at earlier ages of the cohort had an important additional effect on total mortality among men, and on some causes of death (although not so much for GDP at birth)

THUS…. Economic conditions as experienced during childhood and adulthood might influence mortality up to high ages