(February 2011) Life expectancy has improved steadily and substantially in
most high-income countries over the last century. In recent
decades, however, the United States, Denmark, and the
Netherlands have seen gains in life expectancy stagnate
(NRC 2010: Glei, Meslé, and Vallin). U.S. life expectancy
has been rising at a slower pace than other high-income
countries over the last 25 years, particularly for women.
Denmark experienced virtually no growth in life expectancy
from 1980 to 1995. The Netherlands experienced stagnation
in the rate of growth in life expectancy starting in
the early 1980s and continuing until 2002. While increases
in life expectancy in Denmark and the Netherlands have
resumed, the growth rate of U.S. life expectancy remains
Troubled by the widening gap between life expectancy in
the United States and many other industrialized countries,
the Division on Behavioral and Social Sciences and
Education at the National Institute on Aging supported a
National Research Council (NRC) expert panel to investigate
the causes of stagnation in U.S. life expectancy at age
50 and above. The goal is to understand the factors contributing
to stagnating life expectancy gains and identify ways to
improve health in order to narrow the gap between the
United States and countries with improving life expectancy.
This newsletter discusses life expectancy trends in the United
States, Denmark, and the Netherlands, highlighting some of
the key findings from the resulting publications (NRC 2010
and NRC 2011).
Examining Recent Trends in Life
Expectancy in High-Income Countries
The panel focused on life expectancy after age 50 because
most of the variation in life expectancy among high-income
countries is determined by survival beyond age 50. They
noted that “among countries that have recorded reductions
in adult mortality at advanced ages, the United States, the
Netherlands, and Denmark are frequently cited as three
[countries] that have recently underachieved” (NRC 2011). While all countries experienced substantial growth in
female life expectancy at age 50 over the six decades, there
was considerable variation in the level of growth in more
recent decades. Between 1950 and 1980, Japanese women, the world’s leader in life expectancy today, gained 7 years of
life at age 50. The corresponding gains were 5 years for
French women and 4 years for women in all other countries:
United States, Denmark, the Netherlands, and Italy. Gains
since the 1980s were 6 years in Japan and 5 years in France
and Italy, as opposed to 3 years in the Netherlands and 2
years in the United States and Denmark.
These different rates of increase also changed the ranking
of countries with respect to life expectancy. Life expectancies
at age 50 for women in the United States, Denmark, and the
Netherlands were on par with other countries (and led Japan
by several years) in 1950, yet these three countries were at
the bottom by 2007.
There is less variation in life expectancy for men at age 50
among high-income countries, although U.S. men have consistently
ranked among the lowest. While
increases in life expectancy slowed dramatically for women in
the United States, Denmark, and the Netherlands around
1980, they stalled entirely for Danish and Dutch men and
slowed somewhat for U.S. men in the period prior to 1980.
Between 1950 and 1980, Japanese men gained 6 years of life
at age 50. The corresponding gains were 3 years for French
men, 2 years for American men and 1 year or less for men in
Denmark, the Netherlands, and Italy. Gains for men since the
1980s were 6 years in Italy, 5 years in the Netherlands and
France, 4 years in Japan and the United States, and 3 years in
Exploring the Causes of
Stagnation in the Rates of Increase
The panel investigated a range of potential explanations for
the stagnation in the rate of increase in U.S. life expectancy,
including smoking, obesity, access to health care, social
inequality, levels of physical activity, social integration and
social interaction, and hormone replacement therapy. Writing
in the final report, the panel concluded that a “history of
heavy smoking combined with current levels of obesity are
playing a substantial role in the relative poor longevity performance
in the United States” (NRC 2011).
Evidence suggests that smoking is the main culprit in the
slower growth of U.S. life expectancy. Five decades ago, more
Americans smoked, and those who smoked did so more intensively,
compared to their counterparts in Europe and Japan
(NRC 2010: Pampel). After a time lag, the mortality related to
smoking is reflected in the lower rate of growth in U.S. life
expectancy during the past 25 years compared to other countries.
One analysis determined that a large portion (78 percent
for women, 41 percent for men) of the gap in life expectancy
between the United States and other high-income countries in
2003 was the result of higher mortality related to smoking
(NRC 2010: Preston, Glei, and Wilmoth).
Obesity is more prevalent in the United States than in
other high-income countries. Given the rapid increase in
rates of obesity in the United States, it likely contributed to
the stagnation as well (NRC 2010: Alley, Lloyd, and
Shardell). The size of the impact is, however, not clear since
the extent to which obesity at older ages affects mortality is
not fully understood.
Obesity is associated with a lack of physical exercise.
Evidence indicates that U.S. adults are somewhat more sedentary
than their European counterparts. Levels of physical
activity among older adults also likely played some role in
U.S. life expectancy trends, but the degree is difficult to
quantify (NRC 2010: Steptoe and Wikman).
While smoking had the largest impact on trends in U.S.
life expectancy, with obesity likely playing a secondary role,
other contributing factors came into play. The panel examined
research comparing social networks and social support
in the United States with England (where no stagnation
occurred) and found little differences between these countries.
Despite the well-documented link between social integration
and interaction and mortality, these factors do not
appear to have played a measurable role in the stagnation
(NRC 2010: Banks et al.).
Differences among health care systems also help explain
differences in life expectancy. “The lack of universal access
to health care in the United States undoubtedly increases
mortality and reduces life expectancy,” wrote the panel
(NRC 2011). While adults age 65 and older in the United
States have health coverage through the federal Medicare
program, health impairments emerge at earlier ages and
carry over. Evidence indicates the U.S. health care system
does equally well or better than other countries at preventing death among those treated for some of the major causes
of death in old age, such as cancer and cardiovascular disease
(NRC 2010: Preston and Ho). This finding suggests
that the United States does as well as other high-income
countries in preventing death after diseases are diagnosed.
But the U.S. health care system may do a poor job preventing
disease compared to European health systems; some
analysts think the U.S. obesity epidemic reflects a failure of
preventive medicine. Available evidence supporting the
notion that a lack of preventive medicine in the United
States is hampering gains in life expectancy is inconclusive
(NRC 2010: Preston and Ho).
Although socioeconomic disparities in mortality in the
United States are wide, they are unlikely to explain more
than a small percentage of the gap between gains in U.S.
life expectancy and those of the highest achieving countries
(NRC 2010: Avedano et al.). While Americans with the
lowest levels of educations have higher mortality rates than
the least educated people in other high-income countries,
this difference is largely offset by higher average education
levels in the United States than elsewhere. Evidence shows
that the life expectancy of residents of “even the most
advantaged areas of the United States (at the state and
county level) have been falling behind in international
comparisons” (NRC 2011). This suggests that despite widening
geographic disparity in life expectancy in recent
decades in the United States, inequality is unlikely to have
contributed very much to the life expectancy stagnation
(NRC 2010: Wilmoth, Boe, and Barbieri).
There is also no solid evidence that postmenopausal hormone
therapy played a role in the stagnation of life expectancy
gains for U.S. women (NRC 2010: Goldman). Use of
hormone therapy was not any more widespread among U.S.
women than among women in certain other countries where
life expectancy continued to rise. When hormone therapy is
begun near the onset of menopause, it does not appear to
increase the risk of heart disease and may decrease that risk
for some women.
Like the United States, Denmark and the Netherlands
have higher mortality rates from lung cancer and respiratory
diseases than other high-income countries, which points
to smoking as a cause of the stagnating life expectancy
gains in those two countries (NRC 2010, Christensen et
al.; and Mackenbach and Garssen). Higher alcohol consumption
and relatively low health care investment also
likely played some role in Denmark’s life expectancy stagnation;
relatively low spending on health care for the elderly
may also have been a factor in the Netherlands. Denmark and the Netherlands have much lower obesity
rates than the United States, however.
Resumption in Rate of Increase
What factors might explain the resumption in the rate of
increase in life expectancy in Denmark and the Netherlands?
Kaare Christensen and colleagues (NRC 2010) explored this
question for Denmark and found that in the mid-1990s
around the time Danish life expectancy started to increase
again, the Danish population also adopted healthier lifestyles
with respect to smoking, alcohol consumption, and physical
activity. They also found that, in the mid-1990s, the Danish
government implemented the “Heart Plan” and increased
funding on treatments of the cardiovascular diseases. They
concluded that increases in Danish life expectancy were likely
explained by declines in mortality from cardiovascular diseases
that resulted from both improvements in the health
related behaviors as well as prevention and treatment of cardiovascular
In an in-depth examination of the renewed gains in life
expectancy seen by the Netherlands, Johan Mackenback and
Joop Garssen (NRC 2010) found that, unlike Denmark, the
Netherlands saw no large changes in smoking, alcohol consumption,
or regular exercise among the elderly in the period
prior to the resumption of the increase in life expectancy.
Rather, they concluded that changes in health care delivery
appear to have played a key role. The rapid growth in the provision
of health care services, especially increases in health care
expenditures and hospital admission rates, occurred roughly
about the same time as the resumption in mortality decline in
older ages. Between 1999 and 2003, the Dutch experienced a
significant growth in annual health care expenditures per
capita—more than 40 percent. The researchers found that
elderly patients also became increasingly more likely to receive
treatments in hospital for diseases that were important causes
of death, including cancer and cardiovascular diseases. They
concluded that older adults benefited from the expansion of
health care services discussed above, which likely explains why
mortality in older ages resumed its decline.
While Denmark and the Netherlands saw the long-term
upward trend in life expectancy resume, the United States has
not. Whereas past smoking rates may explain a large part of
the present mortality disadvantage of the United States, more
recent trends in smoking suggest U.S. mortality may improve
in the future, according to the panel’s report. The cohorts of
American women who had the highest prevalence of smoking—those
born in the 1940s—are now entering advanced ages. Life expectancy for older women in the United States will
continue to be hampered by smoking-related mortality for a
decade or two longer (Wang and Preston 2009), but as these
cohorts die, younger cohorts have increasingly lower rates of
smoking than their European counterparts. The U.S. female
life expectancy at older ages may, thus, resume its rapid upward
trajectory. Among U.S. men, the impact of smoking on mortality
has already started declining.
Some researchers argue, however, that any improvements in
life expectancy from declining smoking rates may be offset by
the health impact of obesity (Olshansky et al. 2005; Stewart,
Cutler, and Rosen 2009). This impact is not certain, however,
as recent data suggests a leveling off of the growth in obesity
rates in the United States and possibly also reduced risk of
death from obesity (Flegal et al. 2010; Mehta and Chang
2010). The NRC panel report emphasizes the importance of
obesity in affecting U.S. life expectancy in the future, writing
that it bears watching as an “important factor in future longevity
trends in the United States” (NRC 2011).
Toshiko Kaneda is a senior research associate at the Population Reference Bureau. Paola Scommegna is a senior writer/editor at PRB.
Please refer to PDF of report.