Letter to the editor

The role of smoking in changes in the survival curve: an empirical study in 10 European countries

Divergent mortality trends by ethnicity in Fiji.

The management of alcohol-associated cirrhosis has improved in the last decades, but whether the prognosis has changed over time is uncertain. We aimed to assess time trends in mortality and life expectancy in patients hospitalized with alcohol-associated cirrhosis. In this population-based cohort study, we used the Swedish national population and health registers to identify all patients with a first episode of in-hospital alcohol-associated cirrhosis from 1969 to 2019 (n = 22,658). Time trends in 1-year mortality were assessed with multivariable Cox regression. A flexible parametric model was fitted to evaluate loss in life expectancy. Crude mortality was similar in the 2010s and 1980s (unadjusted HR = 1.00, 95% CI = 0.93-1.08, ptrend = 0.767). However, when adjusting for baseline characteristics, mortality was lower in the 2010s than in the 1980s (adjusted HR = 0.74, 95% CI = 0.68-0.80), including both liver- and nonliver-related mortalities. These results were consistent in men but not in women, where only nonliver mortality had decreased. The average loss in life expectancy for patients with alcohol-associated cirrhosis compared with the general population was similar throughout the study period (in the 2010s: 14.3y shorter (95% CI = 13.7-14.9) in men and 15.8 years shorter (95% CI = 14.9-16.7) in women). Mortality in patients hospitalized with alcohol-associated cirrhosis has improved somewhat when accounting for baseline characteristics, but the loss in life expectancy remains substantial. This underscores the need for new therapeutic options and health policy interventions to further improve the dismal prognosis and life expectancy of patients with alcohol-associated cirrhosis.

Vitamin E plays a crucial role in cellular protection, supporting the immune system. This study aims to explore the impact of dietary vitamin E intake on all-cause mortality, cause-specific mortality, and life expectancy. This study included 12 977 participants from the US National Health and Nutrition Examination Survey (NHANES) cohort and 70 369 participants from the UK Biobank cohort. Participants were divided into three groups (lower, higher, and highest tertiles) based on their vitamin E intake levels. The primary outcomes were all-cause, cardiovascular disease (CVD), and cancer mortality across the three groups in both cohorts. The secondary outcome was life expectancy in participants with diabetes, CVD, and hypertension across the three groups. After multivariable adjustment, participants in the highest tertile in the US NHANES cohort had a 32% lower risk of mortality [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.55-0.84] compared with those in the lowest tertile. In the UK Biobank cohort, participants in the highest tertile had a 7% lower risk of mortality compared with those in the lowest tertile (HR: 0.93, 95% CI: 0.86-0.99). A significant association between vitamin E intake and CVD mortality was observed in the US NHANES, but this association was not found in the UK Biobank. In the US NHANES, participants in the highest tertile of vitamin E intake with diabetes, CVD, or hypertension had a 33-35% lower risk of all-cause mortality. In the UK Biobank, the highest tertile was associated with a 13% (95% CI: 0.78-0.97) and 9% (95% CI: 0.83-1.00) lower risk of all-cause mortality for CVD and hypertension, respectively. Nonlinear threshold effects of dietary vitamin E intake on all-cause mortality were observed, with changepoints at 6.68-13.70 mg/day in the UK Biobank and 4.78-36.95 mg/day in the US NHANES. Population attributable fraction analysis indicated that approximately 3.65-10.29% of all-cause mortality could be attributed to low dietary vitamin E intake. Compared with the general participant population, those with underlying conditions such as diabetes, CVD, and hypertension showed a significant increase in life expectancy. Higher dietary vitamin E intake was associated with lower all-cause mortality, with stronger associations observed in the US NHANES cohort and weaker effects in the UK Biobank. Dose-response analyses indicated a nonlinear relationship, with protective effects concentrated within an optimal intake range rather than increasing indefinitely.

ObjectiveThis study assesses the impact of obesity on life expectancy for 26 European national populations and the USA over the 1975–2012 period.DesignSecondary analysis of population-level obesity and mortality data.SettingEuropean countries,...

The purpose of this study is to analyze contributions of mortality change by age group and selected causes of death to the increase in life expectancy at birth from 1950 to 2000 in Japan, which has the longest longevity in the world. Using mortality data from Japanese vital statistics from 1950 to 2000, we analyzed contributions of mortality change by age group and selected causes of death to the increase in life expectancy at birth by the method of decomposition of changes and calculated age-adjusted death rates for selected causes of death. Gastroenteritis, tuberculosis and pneumonia largely contributed to an increase in life expectancy in childhood and in the young in the 1950s and 1960s. The largest contributing disease changed from tuberculosis and pneumonia in earlier decades to cerebrovascular diseases in the 1970s. The largest contributing age group also shifted to older age groups. Age-adjusted death rate for cerebrovascular diseases in 2000 was one fifth of the 1965 level. Cerebrovascular diseases contributed to an increase in life expectancy at birth of 2.9 years in males and 3.1 years in females from 1970 to 2000. In the 1990s, the largest contributing age group, both among males and among females, was the 75-84 age group. Of the selected causes of death, heart diseases other than ischemic heart disease became the largest contributor to the increase in life expectancy at birth. Unlike cerebrovascular diseases, cancer and ischemic heart disease contributed little to change in life expectancy at birth over the past 50 years. In conclusion, although mortality from ischemic heart disease has not increased since 1970 and remained low compared with levels in western countries, mortality from cerebrovascular diseases has dramatically decreased since the mid-1960s in Japan. This gave Japan the longest life expectancy at birth in the world. It is necessary to study future trends in life expectancy at birth in Japan.

Background During the last 20 years, a threefold increase in obesity prevalence has occurred in Europe, which is likely to affect trends in life expectancy. Previous studies on the impact of obesity on populations’ life expectancy focused on the United States or only provided estimates for a single year. We assessed the impact of obesity on life expectancy for 30 European national populations over the period 1975 to 2012. Methods We calculated obesity-attributable mortality fractions by applying the weighted sum method to obesity prevalence data (NCD Risk Factor Collaboration, 2016) and age and sex specific European RRs (DYNAMO). We estimated potential gains in life expectancy (PGLE) by eliminating obesity attributable mortality using associated single decrement life tables. All-cause mortality and exposure data came from the Human Mortality Database. Results In the 30 European countries studied, the PGLE due to obesity in 2012 ranged from 0.86 to 1.73 years among men, and from 0.66 to 1.54 years among women. In all studied European countries, the PGLE increased over time, from average levels of 0.48 (men) and 0.65 (women) years in 1975, to average levels of 1.23 (men) and 1.00 (women) years in 2012. Time trends in PGLE ranged from an annual increase of 2.63 to 8.76 percent among men, and from 0.09 to 5.99 percent among women. In some countries (Denmark, Switzerland, women in Eastern European countries) the increase is leveling off. Conclusions The impact of obesity on life expectancy is increasing over time in Europe, especially among men. The leveling off as observed in some western European countries could potentially point to successful anti-obesity public health initiatives. Key messages: Important differences in the impact of obesity on life expectancy between European countries exist. Although the effect of obesity on life expectancy is generally increasing over time in Europe, some European countries witnessed a leveling off.

Cohort studies about the sleep duration on the risk of death among Chinese older adults are still lacking. The aim of this study was to examine whether extremely long or short sleep duration was associated with mortality in Chinese adults aged 65 years or older. We included participants aged 65 years or older in 2011 at baseline in 23 provinces from the Chinese Longitudinal Healthy Longevity Survey who were followed up in 2014/2018 in China. Sleep duration was categorized as short sleep duration (< 7 hours) and long sleep duration (> 8 hours). We used the Cox proportional hazards model and restricted cubic spline analysis to explore the association between sleep duration and mortality. Among 9578 participants, short sleep duration was associated with an 11% higher risk of death (adjusted hazard ratio [aHR]: 1.11; 95% confidence interval [CI]: 1.02-1.20) and long sleep duration was associated with a 24% higher risk of death (aHR: 1.24; 95% CI: 1.15-1.34), after adjustment for all covariates. There was a U-shaped association between sleep duration and all-cause mortality (nonlinear, P < .0001). Stratified analyses showed that the risk was higher among older people who smoked and with a higher level of education both for short and long sleepers than for those who never smoked and were illiterate (P value for interaction < .05). There was a U-shaped association between sleep duration and all-cause mortality in Chinese older adults, especially in more educated individuals and smokers. Du M, Liu M, Liu J. The association between sleep duration and the risk of mortality in the Chinese older adults: a national cohort study. J Clin Sleep Med. 2021;17(9):1821-1829.

Tempo effects may distort the interpretation of trends in life expectancy

Objective: To understand the geographical variations and temporal trends of all-cause mortality rate and life expectancy in China at national and subnational levels during 2005-2018. Methods: Using data from National Cause-of-death Reporting System, China National Maternal and Child Health Surveillance System, Under-reporting Surveys, and related social determinants covariates, we estimated all-cause mortality rate and life expectancy at national and subnational levels in China during 2005-2018. We depicted the geographical variations and temporal trends between provinces on mortality rate and life expectancy. We then decomposed changes in national and subnational deaths into three explanatory components: change due to age-specific mortality rate, change due to the population structure by age, and change due to growth of the total population. Results: In 2018, it was estimated that there were 10 482 297 total deaths (95%CI: 9 723 233-11 466 875 deaths) in China, with 6 113 926 men (95%CI: 5 773 158-6 572 407 men) and 4 368 241 women (95%CI: 3 950 075-4 894 468 women). The all-cause mortality rate was 755.54 per 100 000 (95%CI: 701.49 per 100 000-825.78 per 100 000), with 861.78 per 100 000 (95%CI: 813.75 per 100 000-926.40 per 100 000) in men and 642.73 per 100 000 (95%CI: 581.20 per 100 000-720.15 per 100 000) in women, while age-standardized all-cause mortality rate was 652.27 per 100 000 (95%CI: 599.22 per 100 000-721.71 per 100 000), with 806.38 per 100 000 (95%CI: 755.10 per 100 000-874.31 per 100 000) in men and 503.37 per 100 000 (95%CI: 450.50 per 100 000-572.01 per 100 000) in women. In 2018, it was estimated that the life expectancy in the whole country was 77.15 years old (95%CI: 75.92-78.11 years old), with 74.81 (95%CI: 73.57-75.76) in men and 79.87 (95%CI: 78.61-80.91) in women. Developed areas as Shanghai, Beijing, Jiangsu, and Zhejiang owned comparatively higher life expectancy, while undeveloped areas like Tibet, Guizhou, Xinjiang, and Qinghai showed lower levels. During 2005-2018, there was a 29.87% increase in total deaths at the national level, with 27.74% in men and 31.29% in women. Changes due to age-specific mortality rate, the population structure by age, and the growth of the total population constituted -35.74%, 7.34%, and 58.28% of the total increase, respectively. Conclusions: From 2005 to 2018, the all-cause mortality rate increased while the age-standardized mortality rate decreased substantially among Chinese residents. Change due to population structure by age was the dominant driver. An upward trend of life expectancy was observed in all provinces, with marked differences between the provinces.

Purpose People with a severe mental illness (SMI) have a marked reduction in life expectancy which is largely attributable to somatic morbidity. Life expectancy has increased in Global North populations, yet it remains unclear whether people with SMI have benefitted equally from this increase. Our objective was to explore time trends of all-cause and selected cause-specific mortality among all people in Denmark with registered diagnosis codes of SMI: depression, bipolar disorder, or schizophrenia at psychiatric out- and in-patient settings. Materials and methods In consecutive yearly cohorts from 2000 to 2018, we examined all-cause and cause-specific mortality in all adults (aged ≥18) with and without diagnosis codes of SMI. Results We found that all-cause mortality, and mortality from cardiovascular, cancer, respiratory, infections, trauma, and suicide were consistently elevated in those registered with SMI. While the crude all-cause mortality decreased substantially for all, also in people registered with SMI, after adjustment for sex and age, the mortality relative to people without SMI, remained unchanged or slightly increased for people registered with SMI, particularly among people registered with schizophrenia. Conclusion Despite a decrease in crude all-cause mortality, the consistently elevated mortality for people registered with SMI relative to the general population suggests that concerted efforts to reduce health inequity remain important.

This study aims to assess the associations of serum and red blood cell (RBC) folate with cardiovascular and all-cause mortality in hypertensive adults. Data on serum and RBC folate from the 1999-2014 National Health and Nutrition Examination Survey were included. Through December 31, 2015, cardiovascular and all-cause mortality were identified from the National Death Index. Multiple Cox regression and restricted cubic spline analyses were used to determine the relationship between folate concentrations and outcomes. A total of 13,986 hypertensive adults were included in the analysis (mean age, 58.5 ± 16.1 years; 6898 [49.3%] men). At a median of 7.0 years of follow-up, 548 cardiovascular deaths and 2726 all-cause deaths were identified. After multivariable adjustment, the fourth quartile of serum folate was associated with cardiovascular (HR = 1.32 [1.02-1.70]) and all-cause (HR = 1.20 [1.07-1.35]) mortality compared to the second quartile, whereas the first quartile was only linked with increased all-cause (HR = 1.29 [1.15-1.46]) mortality. The inflection points for the non-linear associations of serum folate with cardiovascular and all-cause mortality were 12.3 ng/mL and 20.5 ng/mL, respectively. In addition, the highest quartile of RBC folate was associated with cardiovascular (HR = 1.68 [1.30-2.16]) and all-cause (HR = 1.30 [1.16-1.46]) mortality compared to the second quartile, but the lowest quartile was not associated with either outcome. The inflection points for the non-linear associations of RBC folate with cardiovascular and all-cause mortality were 819.7 and 760.1 ng/mL, respectively. The findings suggest non-linear associations between serum and RBC folate levels and the risk of cardiovascular and all-cause mortality in hypertensive adults.

Recent research has documented increasing education inequality in life expectancy among U.S. adults; however, much is unknown about other health status changes. The objective of study is to assess how healthy and unhealthy life expectancies, as classified by common chronic diseases, has changed for older adults across education groups. Data come from the Health and Retirement Study and National Vital Statistics. We created prevalence-based life tables using the Sullivan method to assess sex-specific life expectancies for stroke, heart disease, cancer, and arthritis by education group. In general, unhealthy life expectancy increased with each condition across education groups. However, the increases in unhealthy life expectancy varied greatly. While stroke increased by half a year across education groups, life expectancy with diabetes increased by 3 to 4 years. In contrast, the evidence for healthy life expectancy provides mixed results. Across chronic diseases, healthy life expectancy decreased by 1 to 3 years for respondents without a 4-year degree. Conversely, healthy life expectancy increased for the college educated by .5 to 3 years. While previous research shows increases in life expectancy for the most educated, trends in life expectancy with chronic conditions is less positive: not all additional years are in lived in good health. In addition to documenting life expectancy changes across education groups, research assessing health of older adults should consider the changing inequality across a variety of health conditions, which will have broad implications for population aging and policy intervention.

The objective of this study is to assess the correlation between composite dietary antioxidant index (CDAI) with all-cause mortality and cause-specific mortality in adults with hypertension. The cohort study comprised adult participants with hypertension from the NHANES database, spanning 9 cycles from 2001 to 2018. Follow-up was conducted until December 31, 2019. Multi-variable Cox regression analysis was utilized to ascertain hazard ratios (HR) and their corresponding 95% confidence intervals, evaluating the relationship between CDAI and the risks of all-cause and cause-specific mortality. To further investigate the association between CDAI and mortality rates in adults with hypertension, Kaplan-Meier survival curves, restricted cubic splines (RCS), subgroup analyses and sensitivity analyses were employed. The analysis included 16,713 adults with hypertension (mean age 56.93 ± 0.23 years, 8,327 [49.61%] male). During the mean follow-up time 102.11 ± 1.22 months, with 3,908 (18.08%) all-cause mortality occurred, 1,082 (4.84%) cardiovascular mortality and 833 (3.80%) cancer mortality. Compared to the lowest quartile of CDAI, the weighted multivariate hazard ratios of participants in the highest quartile was 0.77 (95% CI, 0.68-0.87) for all-cause mortality, 0.83 (95% CI, 0.67-1.04) for cardiovascular mortality, and 0.64 (95% CI, 0.50-0.82) for cancer mortality. RCS analysis demonstrated a nonlinear association of CDAI with all-cause and cancer mortality, and a linear association between CDAI and cardiovascular mortality. The results were robust in subgroup analyses and sensitivity analyses. Higher CDAI is associated with reduced all-cause mortality, cardiovascular mortality, and cancer mortality in hypertensive adults. Our findings highlight the importance of an antioxidant diet in improving outcomes in adults with hypertension.

Background Homocysteine (Hcy) was implicated in oxidative stress and diabetes biologically. However, the clinical evidence on the link between Hcy level and diabetes is limited and controversial. This study is aimed at investigating the association of serum Hcy with all-cause and cardiovascular mortality in diabetic patients. Methods Serum Hcy was measured among 2,286 adults with type 2 diabetes in NHANES 1999-2006. Cox proportional hazard regression was used to estimate hazard ratios (HR) and 95% CIs for the association of Hcy with all-cause and cause-specific mortality. Results Over a median follow-up of 11.0 (interquartile range, 8.9-13.4) years, 952 of the 2286 patients with diabetes died, covering 269 (28.3%) cardiovascular deaths and 144 (15.2%) cancer deaths. Restricted cubic spline showed the linear relationship between Hcy and all-cause mortality risk. After multivariate adjustment, higher serum Hcy levels were independently associated with increased risk of all-cause and cardiovascular mortality. Compared with participants in the bottom tertile of Hcy, the multivariate-adjusted HRs and 95% CI for participants in the top quartile were 2.33 (1.64-3.30) for all-cause mortality (ptrend < 0.001), 2.24 (1.22-4.10) for CVD mortality (ptrend = 0.017), and 2.05 (0.90-4.69) for cancer mortality (ptrend = 0.096). The association with total mortality was especially stronger among patients with albuminuria. Serum Hcy significantly improved reclassification for 10-year mortality in diabetic patients (net reclassification index = 0.253 and integrated discrimination improvement = 0.011). Conclusions Serum Hcy was associated with risks of all-cause and cardiovascular mortality in diabetic adults. Our results suggested that Hcy was a promising biomarker in risk stratification among diabetic patients.