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Preventable causes of death

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Preventable causes of death are causes of death related to risk factors which could have been avoided.[1] The World Health Organization has traditionally classified death according to the primary type of disease or injury. However, causes of death may also be classified in terms of preventable risk factors—such as smoking, unhealthy diet, sexual behavior, and reckless driving—which contribute to a number of different diseases. Such risk factors are usually not recorded directly on death certificates, although they are acknowledged in medical reports.

Figure 1: In 2011, deaths from potentially avoidable causes accounted for approximately 24% of all deaths registered in England and Wales. The leading cause of avoidable deaths was ischaemic heart disease in males and lung cancer in females.

Worldwide

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It is estimated that of the roughly 150,000 people who die each day across the globe, about two thirds—100,000 per day—die of age-related causes.[2] In industrialized nations the proportion is much higher, reaching 90 percent.[2] Thus, albeit indirectly, biological aging (senescence) is by far the leading cause of death. Whether senescence as a biological process itself can be slowed, halted, or even reversed is a subject of current scientific speculation and research.[3]

2001 figures

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Risk factors associated with the leading causes of preventable death worldwide as of the year 2001, according to researchers working with the Disease Control Priorities Network (DCPN):[4][5]

Cause Number of deaths resulting (millions per year)
Hypertension 7.8
Smoking tobacco 5.4
Alcohol use disorder 3.8
Sexually transmitted infections 3.0
Poor diet 2.8
Overweight and obesity 2.5
Physical inactivity 2.0
Malnutrition 1.9
Indoor air pollution from solid fuels 1.8
Unsafe water and poor sanitation 1.6

By contrast, the World Health Organization (WHO)'s 2008 statistics list only causes of death, and not the underlying risk factors.

In 2001, on average 29,000 children died of preventable causes each day (that is, about 20 deaths per minute). The authors provide the context:

About 56 million people died in 2001. Of these, 10.6 million were children, 99% of whom lived in low-and-middle-income countries. More than half of child deaths in 2001 were attributable to acute respiratory infections, measles, diarrhea, malaria, and HIV/AIDS.[5]

Western societies

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In 2017, The Lancet published a large study by Swiss epidemiologist Silvia Stringhini and her collaborators, analysing the impact of the most important causes of preventable death in Western societies.[6] They estimated the number of years of life lost for each risk factor at the individual level and its contribution to preventable death at the societal level (PAF = Population Attributable Fraction).

The multicohort study and meta-analysis used individual-level data from 48 independent prospective cohort studies with information on socioeconomic status, high alcohol consumption, physical inactivity, current smoking, hypertension, diabetes and obesity, and mortality, for a total population of 1,751,479 from seven high-income WHO member countries.

A limitation of many studies of health risk factors is confounding bias: many risk factors are interrelated and cluster together in high-risk populations. For example: Low physical activity and obesity go hand in hand. People who are physically inactive tend to gain weight, and people who are severely obese have difficulty exercising. The unique advantage of the huge amount of individual data in the Stringhini study is that it allows (estimation of) the relative contribution of each separate risk factor.

As shown in summary Table 2, at an individual level, smoking is the single greatest risk of avoidable death, followed by diabetes and high alcohol consumption. At the population level, diabetes and high alcohol consumption have a low prevalence. Physical inactivity, smoking and low socioeconomic status (SES) are then the top three preventable causes of early death. Smoking, physical inactivity and low SES account for almost two thirds of all avoidable deaths.

Table 2: Risk factors for avoidable death: Pooled hazard ratios, life years lost and population attributable fraction (PAF) for six WHO-defined health risks and socioeconomic status (SES) (Meta-analysis data of prospective cohort studies, from Stringhini et al., Lancet 2017).[6]
Risk factor Hazard ratio Live-years lost
between ages
40 and 85 Years 		Prevalence Percentage of
deaths who
died prematurely
(PAF)
Physical inactivity 1,59 2,30 43,7% 24,5%
Current smoking (reference is never smoking) 2,08 4,60 23,3% 24,0%
Low Socio-Economic Status (reference high SES) 1,38 2,06 35,4% 17,2%
Diabetes 1,79 3,99 9,0% 6,5%
High alcohol (reference moderate alcohol intake) 1,62 0,48 6,8% 3,7%
Hypertension 1,29 1,54 34,0% 8,8%
Obesity (reference is normal BMI) 1,11 0,68 20,9% Small

A puzzling finding is the small contribution of obesity as a cause of avoidable premature death. There are two reasons why obesity is not an important independent risk factor, as is often assumed.

First, being overweight is a risk for early death without correcting for confounding risk factors. Overweight is usually measured by the body mass index (BMI = kg/m2), which is much easier to measure than physical activity. Most studies only measured BMI, not physical activity, and did not correct for confounding.

Second, a major pitfall in many studies of weight and health is that 'normal' and 'healthy' are often confused. The WHO definition of 'normal' adult BMI (between 18.5 and 24.9 kg/m2) is based on a normal weight and height distribution of US citizens in the 1960s, not on the associated risk of death in 2023.[7][8] A meta-analysis of the association between BMI and mortality in 230 cohort studies with 3.74 million deaths among 30.3 million participants found that the risk of death in adults is not increased between 23 and 30 kg/m2 (see Figure 2).[9] An adult BMI of 18.5 kg/m2, considered 'normal' by WHO criteria, is associated with a 30% increase in all-cause mortality.

 
Figure 2: The association between body mass index (BMI) and relative risk of all-cause mortality (data from Aune et al., BMJ 2016; curve fitting by L. Stalpers, Amsterdam UMC, 2023).

United States

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The three risk factors most commonly leading to preventable death in the population of the United States are smoking, high blood pressure, and being overweight.[10] Pollution from fossil fuel burning kills roughly 200,000 per year.[1]

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    Figure 3: Leading preventable causes of death in the United States in the year 2000.[11] Note: This data is outdated and has been significantly revised, especially for obesity-related deaths.[10]

Accidental death

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  •  
    Figure 4: Leading causes of accidental death in the United States by age group as of 2002.[12]
  •  
    Figure 5: Leading causes of accidental death in the United States as of 2002, as a percentage of deaths in each group.[12]

Annual number of deaths and causes

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Table 3: Avoidable causes and numbers of death per year.

Cause of death Number Percent of total Notes
Adverse events in hospitals in low- and middle-income countries 2.6 million deaths[13] "one of the 10 leading causes of death and disability in the world"
Smoking tobacco 435,000[11] 18.1%
Obesity 111,900[14] 4.6% There was considerable debate about the differences in the numbers of obesity-related diseases.[15] The value here reflects the death rate for obesity that has been found to be the most accurate of the debated values.[16] Note, however, that being overweight but not obese was associated with fewer deaths (not more deaths) relative to being normal weight.[14]
Alcohol 85,000[11] 3.5%
Infectious diseases 75,000[11] 3.1%
Toxic agents including toxins, particulates and radon 55,000[11] 2.3%
Traffic collisions 43,000[11] 1.8%
Preventable colorectal cancers 41,400 1.7% Colorectal cancer (bowel cancer, colon cancer) caused 51,783 deaths in the US in 2011.[17] About 80 percent[18] of colorectal cancers begin as benign growths, commonly called polyps, which can be easily detected and removed during a colonoscopy. Accordingly, the tabulated figure assumes that 80 percent of the fatal cancers could have been prevented.
Firearms deaths 31,940[19] 1.3% Suicide: 19,766; homicide: 11,101; accidents: 852; unknown: 822.
Sexually transmitted infections 20,000[11] 0.8%
Substance use disorder 17,000[11][needs update] 0.7%

Among children worldwide

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Various injuries are the leading cause of death in children 9–17 years of age. In 2008, the top five worldwide unintentional injuries in children are as follows:[20]

Table 4: Avoidable numbers of death among children

Cause Number of deaths resulting
Traffic collision

260,000 per year

Drowning

175,000 per year

Viruses

96,000 per year

Falls

47,000 per year

Toxins

45,000 per year

See also

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References

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  1. ^ Danaei, Goodarz; Ding, Eric L.; Mozaffarian, Dariush; Taylor, Ben; Rehm, Jürgen; Murray, Christopher J. L.; Ezzati, Majid (2009-04-28). "The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors". PLOS Medicine. 6 (4): e1000058. doi:10.1371/journal.pmed.1000058. ISSN 1549-1277. PMC 2667673. PMID 19399161.
  2. ^ a b Aubrey D.N.J, de Grey (2007). "Life Span Extension Research and Public Debate: Societal Considerations" (PDF). Studies in Ethics, Law, and Technology. 1 (1, Article 5). CiteSeerX 10.1.1.395.745. doi:10.2202/1941-6008.1011. S2CID 201101995. Archived from the original (PDF) on February 12, 2019. Retrieved August 7, 2011.
  3. ^ "SENS Foundation". Archived from the original on 2019-05-27. Retrieved 2012-10-10.
  4. ^ "DCP3". washington.edu. Archived from the original on 2013-01-28.
  5. ^ a b Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (May 2006). "Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data". Lancet. 367 (9524): 1747–57. doi:10.1016/S0140-6736(06)68770-9. PMID 16731270. S2CID 22609505.
  6. ^ a b Stringhini, Silvia; Carmeli, C; Jokela, M; Avendaño, M; Muennig, P; Guida, F; ...LIFEPATH consortium (2017). "Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women". The Lancet. 389 (10075): 1229–1237. doi:10.1016/S0140-6736(16)32380-7. PMC 5368415. PMID 28159391.
  7. ^ Keys, A; Fidanza, F; Karvonen, MJ; Kimuru, N; Taylor, HL (1972). "Indices of relative weight and obesity". Journal of Chronic Diseases. 25 (6): 329–343. doi:10.1016/0021-9681(72)90027-6. PMID 4650929 – via (Reprinted in Int J Epidemiol 2014: 43(3): 655-665).
  8. ^ WHO – World Health Organization (6 May 2010). "A healthy lifestyle - WHO recommendations". WHO-World Health Organization. Retrieved 18 June 2023.
  9. ^ Aune, Dagfinn; Sen, A; Prasad M, M; Norat T, T; Janszky, I; Tonstad, S; Romundstad, P; Vatten, LJ (4 May 2016). "BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants". British Medical Journal. 353: i2156. doi:10.1136/bmj.i2156. PMC 4856854. PMID 27146380.
  10. ^ a b Danaei; Ding; Mozaffarian; Taylor; Rehm; Murray; Ezzati (2009). "The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors". PLOS Medicine. 6 (4): e1000058. doi:10.1371/journal.pmed.1000058. PMC 2667673. PMID 19399161.
  11. ^ a b c d e f g h Mokdad AH, Marks JS, Stroup DF, Gerberding JL (March 2004). "Actual causes of death in the United States, 2000" (PDF). JAMA. 291 (10): 1238–45. doi:10.1001/jama.291.10.1238. PMID 15010446. Archived (PDF) from the original on 2019-06-20. Retrieved 2008-08-28.
  12. ^ a b National Vital Statistics Report, Vol. 50, No. 15, September 16, 2002 Archived May 5, 2019, at the Wayback Machine as compiled at "Death Statistics Tables". Archived from the original on 2009-02-21. Retrieved 2009-06-21.
  13. ^ "Patient Safety". WHO. 13 September 2019. Retrieved 16 June 2022.
  14. ^ a b Flegal, K.M., B.I. Graubard, D.F. Williamson, and M.H. Gail. (2005). "Obesity". Journal of the American Medical Association. 293 (15): 1861–67. doi:10.1001/jama.293.15.1861. PMID 15840860.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Flegal, Katherine M. (2021). "The obesity wars and the education of a researcher: A personal account". Progress in Cardiovascular Diseases. 67: 75–79. doi:10.1016/j.pcad.2021.06.009. PMID 34139265. S2CID 235470848.
  16. ^ "Controversies in Obesity Mortality: A Tale of Two Studies" (PDF). RTI International. Archived (PDF) from the original on 2016-03-03. Retrieved 2014-02-21.
  17. ^ Centers for Disease Control and Prevention. "Colorectal Cancer Statistics". Archived from the original on May 27, 2019. Retrieved January 12, 2015.
  18. ^ Carol A. Burke; Laura K. Bianchi. "Colorectal Neoplasia". Cleveland Clinic. Archived from the original on October 4, 2018. Retrieved January 12, 2015.
  19. ^ "Deaths: Preliminary Data for 2011" (PDF). CDC. Archived (PDF) from the original on 2014-02-02. Retrieved 2014-02-21.
  20. ^ "BBC News | Special Reports | UN raises child accidents alarm". BBC News. December 10, 2008. Archived from the original on July 5, 2018. Retrieved May 8, 2010.
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