1. Health expectancy in Denmark 3 rd Meeting of the Task Force on Health Expectancies Luxembourg, 12 December 2006 Henrik Brønnum-Hansen Secular trends Social gradient Social differences in the burden of diseases Impact of selected risk factors

2. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen2 Secular trends

3. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen3 Purpose What could be told about the development in Denmark as to the hypothesises Compression of morbidity Expansion of morbidity Dynamic equilibrium ?

4. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen4 Health interview surveys carried out by the National Institute of Public Health. Surveys in 1987, 1991, 1994, 2000 and 2005 Standard life tables from Statistics Denmark for 1986–1987, 1990–1991, 1993–1994, 1999–2000 and 2004–2005 Data sources New data!

5. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen5 Methods Health expectancy by Sullivan’s method Expected lifetime in various health states Self-rated health Functional limitations Long-standing, limiting illness

6. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen6 Interview question: “How do you rate your present state of health in general?” Answer categories:  Very good  Good  Fair  Poor  Very poor Self-rated health } } Dichotomised

7. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen7

8. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen8 Functional limitations walk 400 m without resting, walk up or down a staircase from one floor to another without resting, carry 5 kg, read ordinary newspaper print, hear what is being said in a normal conversation between three or more persons, or speak with minor or major difficulty (assessed by the interviewer) A person was considered to have functional limitations if he/she could do one or more of the following, only with difficulty or not at all:

9. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen9 12.2 13.2 14.7 15.5 5.2 4.4 4.1 4.3 0 5 10 15 20 Lifetime (years) 19942000 60-year-old men 20051987 Trends in life expectancy and expected lifetime without and with functional limitations 13.3 13.1 14.7 15.6 8.4 7.3 7.4 0 5 10 15 20 19942000 60-year-old women 20051987 Expected lifetime without functional limitations with functional limitations

10. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen10 Interview question: “Do you suffer from any long-standing illness, long- standing after-effect of injury, any disability, or other long-standing condition?” If “yes” a question were asked to clarify whether the disease implied restrictions to daily life or at work Long-standing, limiting illness

11. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen11 38.6 40.8 43.5 14.8 14.3 12.8 0 10 20 30 40 50 60 Lifetime (years) 19942000 20-year-old men 2005 Trends in life expectancy and expected lifetime without and with long-standing, limiting illness 38.4 41.1 42.8 20.1 18.4 18.0 0 10 20 30 40 50 60 19942000 20-year-old women 2005 Expected lifetime without long-standing, limiting illness with long-standing, limiting illness

12. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen12 Compression of morbidity is observed in Denmark when health expectancy is measured by Conclusions Self-rated health Functional limitations Long-standing, limiting illness

13. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen13 Social gradient

14. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen14 Purpose To estimate social inequalities as to expected lifetime without and with long-standing, limiting illness Social classification Educational level

15. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen15 The Danish Health Interview Survey 2000 (National Institute of Public Health) Sex-, age- and educational level-specific prevalence of long-standing, limiting illness Mortality, register linkage (Statistics Denmark) Sex- and age-specific numbers of persons at risk and the numbers of deaths during the period 1995-1999 for each of three educational groups Data sources

16. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen16 Information about schooling, vocational training and further education Register information (Statistics Denmark) Questions in the health interview survey (National Institute of Public Health) Educational level Three levels: Low Medium High

17. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen17 Low - persons with a max. of 10 years of schooling and no more than semi-skilled training, basic vocational training or business school (first year) Educational level Medium - persons with either a max. of 10 years of schooling and further vocational or other training or with post-secondary schooling but no higher education High - persons with any type of higher education

18. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen18 0 10 20 30 40 50 Expected life-years HighMediumAllLow Life expectancy 30-year-old men. Denmark 2000 Educational level 0 10 20 30 40 50 Expected life-years HighMediumAllLow Life expectancy 30-year-old women. Denmark 2000 Educational level

19. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen19 Social differences in the burden of diseases

20. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen20 Purpose To quantify the health impact of diseases with high prevalence or mortality, and to evaluate social differences in the burden of long-standing illness

21. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen21

22. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen22 Mortality, register linkage (Statistics Denmark) Sex- and age-specific numbers of persons at risk and the numbers of deaths from selected causes during the period 1995-1999 for each of three educational groups Data sources Long-standing illness, the Danish Health Interview Survey 2000 (National Institute of Public Health) Sex-, age- and educational level-specific prevalence of long-standing, limiting illness

23. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen23 Interview question: “Do you suffer from any long-standing illness, long- standing after-effect of injury, any disability, or other long-standing condition?” If “yes” questions were asked to clarify:  the nature of the disease(s) (up to four diseases)  whether the disease implied restrictions to daily life or at work Long-standing illness

24. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen24 Construction of life tables by sex and educational level Methods Disease elimination Construction of cause-deleted life tables (specific demographic technique) Elimination of specific diseases from prevalence of long-standing, limiting illness Health expectancy, Sullivan’s method Expected lifetime with and without long-standing, limiting illness Observed Hypothetical after disease elimination

25. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen25 Life expectancy and expected lifetime with and without long-standig illness 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0102030405060708090100110 Age Survival probability Years with long- standing illness Years without long-standing illness Life expectancy and expected lifetime with and without long-standing, limiting illness before elimination of a specific disease Partial life expectancy

26. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen26 Life expectancy and expected lifetime with and without long-standig illness 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0102030405060708090100110 Age Survival probability Years with long- standing illness Years without long-standing illness Life expectancy and expected lifetime with and without long-standing, limiting illness after elimination of a specific disease Partial life expectancy

27. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen27 Difference in expected lifetime (between age 30 and 75) with and without long-standing, limiting illness between people with high and low educational level Difference in partial life expectancy: 3.1 years Difference in partial life expectancy: 1.6 years

28. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen28 Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness due to elimination of cancer at age 30

29. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen29 Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness due to elimination of diseases of the circulatory system at age 30

30. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen30 Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness due to elimination of diseases of the musculoskeletal system at age 30 social gradient

31. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen31 Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness due to elimination of mental and behavioural disorders at age 30 social gradient

32. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen32 Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness due to elimination of diseases of the nervous system at age 30 social gradient – opposite direction! ? ?

33. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen33 Persons with a low educational level were more likely to have long- standing, limiting illness than those with a high educational level. Conclusions The gain in partial life expectancy to be expected by eliminating certain diseases decreased with educational level. The gain in partial life expectancy that could be expected to derive from elimination of cancer decreases with educational level, but also added lifetime with long-standing illness decreases with educational level. A similar phenomenon was seen for cardiovascular diseases: if they were eliminated, women with a low educational level would gain lifetime years, but the reduction in lifetime with long-standing illness would be greatest for women with a high educational level. We found a social gradient in the burden of all major diseases with low fatality, except for diseases of the nervous system for women.

34. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen34 Impact of selected risk factors

35. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen35 Risk factors Smoking Never smoker Ex-smoker Moderate smoker1-14 gram of tobacco per day Heavy smoker  15 gram of tobacco per day Alcohol consumption Moderate consumption1-14 units of alcohol per week for women 1-21 units of alcohol per week for men High consumptionmore than 14 units of alcohol per week for women more than 21 units of alcohol per week for men Physical inactivity (during leisure time) ActiveAt least light physical activity 4 hours per week InactiveSedentary (except for disabled individuals) Overweight Normal weight18.5 ≤ BMI < 25.0 Overweight25.0 ≤ BMI < 30.0 Obese30.0 ≤ BMI BMI: Body Mass Index Underweight (BMI < 18.5) excluded

36. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen36 Death rates by sex and age from the Cause of Death Register Data sources As to smoking: Lung cancer death rates and relative risks from the second prospective Cancer Prevention Study (CPS-II) of the American Cancer Society Relative risks for death estimated from the Danish National Cohort Study (DANCOS): the Danish Health Interview Surveys in 1987, 1991, 1994 and 2000 linked to the Danish Civil Registration System and other national registers Prevalence of long-standing, limiting illness by sex, age and risk factor level established from the Danish Health Interview Survey 2000

37. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen37 Construction of life tables by sex and risk factor level P 0 sex and age specific prevalence of unexposed P i prevalence for risk factor exposure level i RR i relative risk (RR 0 = 1) Then sex and age specific death rate, is given by D = ∑ P i ∙RR i ∙D 0 and D 0 death rate of unexposed can be calculated Sex and age specific death rates for unexposed, D 0, are multiplied with the relative risk, RR i to estimate sex and age specific death rates for risk factor level i Finally, risk factor level specific life tables are constructed For smoking an indirect method (Peto and colleagues) was used. Methods

38. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen38 Methods Survey data Prevalence of long-standing, limiting illness by sex and risk factor level Sullivan’s method to estimate expected lifetime without longstanding, limiting illness

39. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen39 Results Risk factors and expected lifetime without longstanding, limiting illness

40. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen40 Summary – Life expectancy Life expectancy lostHealthy life lostRisk factor Prevalence Risk factorYears MenWomen Years MenWomen % MenWomen Smoking Heavy smokers 8.710.410.410.523.216.5 Moderate smokers 5.0 5.3 6.9 5.316.218.1 Ex-smokers 2.4 1.5 5.2 2.525.222.0 Alcohol High consumption 4.7 4.0 5.0 0.814.8 8.7 Physical inactivity Inactive 5.3 5.1 8.310.316.016.9 Body weight Overweight 0.0 0.7 -1.4 3.939.924.8 Obese 2.0 3.2 4.910.0 9.8 9.1

41. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen41 Summary – Health expectancy Life expectancy lostHealthy life lostRisk factor Prevalence Risk factorYears MenWomen Years MenWomen % MenWomen Smoking Heavy smokers 8.710.410.410.523.216.5 Moderate smokers 5.0 5.3 6.9 5.316.218.1 Ex-smokers 2.4 1.5 5.2 2.525.222.0 Alcohol High consumption 4.7 4.0 5.0 0.814.8 8.7 Physical inactivity Inactive 5.3 5.1 8.310.316.016.9 Body weight Overweight 0.0 0.7 -1.4 3.939.924.8 Obese 2.0 3.2 4.910.0 9.8 9.1

42. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen42

43. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen43 Summary – Health expectancy Life expectancy lostHealthy life lostRisk factor Prevalence Risk factorYears MenWomen Years MenWomen % MenWomen Smoking Heavy smokers 8.710.410.410.523.216.5 Moderate smokers 5.0 5.3 6.9 5.316.218.1 Ex-smokers 2.4 1.5 5.2 2.525.222.0 Alcohol High consumption 4.7 4.0 5.0 0.814.8 8.7 Physical inactivity Inactive 5.3 5.1 8.310.316.016.9 Body weight Overweight 0.0 0.7 -1.4 3.939.924.8 Obese 2.0 3.2 4.910.0 9.8 9.1

44. Health expectancy in Denmark 12 December 2006. Henrik Brønnum-Hansen44 Summary – Health expectancy Life expectancy lostHealthy life lostRisk factor Prevalence Risk factorYears MenWomen Years MenWomen % MenWomen Smoking Heavy smokers 8.710.410.410.523.216.5 Moderate smokers 5.0 5.3 6.9 5.316.218.1 Ex-smokers 2.4 1.5 5.2 2.525.222.0 Alcohol High consumption 4.7 4.0 5.0 0.814.8 8.7 Physical inactivity Inactive 5.3 5.1 8.310.316.016.9 Body weight Overweight 0.0 0.7 -1.4 3.939.924.8 Obese 2.0 3.2 4.910.0 9.8 9.1

45. Thank you!