The European Journal of Public Health Advance Access originally published online on April 2, 2007
The European Journal of Public Health 2007 17(6):587-592; doi:10.1093/eurpub/ckm024
Mortality and Life Expectancy |
Increasing life expectancy in Germany: quantitative contributions from changes in age- and disease-specific mortality
Jochen Klenk1,
Kilian Rapp1,
Gisela Büchele1,
Ulrich Keil2 and
Stephan K. Weiland1,
1 Institute of Epidemiology, Ulm University, Germany
2 Institute of Epidemiology and Social Medicine, University of Münster, Germany
Correspondence: Jochen Klenk, Institute of Epidemiology, Ulm University, Helmoltzstrasse 22, D-89075 Ulm, Germany, tel: +49 731 50 31070, fax: +49 731 50 31069, e-mail: jochen.klenk{at}uni-ulm.de
Received July 5, 2006, accepted February 26, 2007
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Abstract |
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Background: Between 1962 and 2002 the average life expectancy in Germany has increased from 67.1 years to 75.6 years in men and from 72.7 years to 81.3 in women. Methods: The cumulative and annual contributions of different age- and disease-groups on life expectancy were calculated using Pollard's actuarial method of decomposing mortality rates. Mortality data were provided by the German Statistical Office. Results: Considering the cumulative contribution over the period of 40 years, the largest contributions came from persons with at least 65 years of age (2.9 years in men and 4.0 years in women). Reductions in cardiovascular disease mortality had the greatest cumulative impact on life expectancy (2.7 years in men and 3.0 years in women). The contribution from reduced cancer mortality on life expectancy was substantially lower (0.6 and 0.9 years, respectively). The annual contributions of several disease-groups varied considerably over time. The positive contribution from cardiovascular diseases started only after 1970, and in men it became solid only after 1980. Regarding malignant neoplasms, the largest cumulative contribution came from stomach cancer (0.4 in both sexes). The annual analyses showed increasing contributions from reduced cancer mortality after 1990. These were strongly influenced by lung, stomach, prostate and colorectal cancer in men, and by breast, colorectal and stomach cancer in women. Conclusions: While life expectancy has increased by about 2.2 years per decade the observed variations in the age- and disease-specific contributions over time have implications for future health care planning and prevention strategies.
Keywords: cancer, cardiovascular diseases, contribution, Germany, life expectancy, mortality
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Introduction |
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From the beginning of the 20th century the trend in life expectancy in most developed countries has been characterized by a steady increase.1,2 In Germany, for example, the life span has increased continuously by 2.2 years per decade and reached 75.6 years in men and 81.3 years in women in 2002. In order to identify further potentials of development, it is important to understand the factors that influence the trends of life expectancy. Education, income, nutrition, medical care, hygiene and personal characteristics like blood pressure or smoking behaviour are known to affect mortality and as a consequence life expectancy at birth.1 Life expectancy is a convenient and important summary measure of mortality and more intuitive than mortality rates. The change over time serves as an interesting indicator for social and economical developments within a population and is therefore a useful instrument for Public Health communication. However, changes of life expectancy are only composite measures of changes of different mortality rates and give no information which age- and disease-groups were responsible for the observed changes. Therefore, we analysed the contribution of age- and disease-specific causes of death on the change of life expectancy. This method is commonly used in the demographic literature to explore differences in life expectancy between groups or within time intervals.3–6 In the United States, for example, the cumulative contribution of different causes of death on life expectancy was evaluated for the time period 1970–2000.7
However, social and environmental factors may influence mortality even within short time periods. In the mid-1990s, for example, life expectancy in Russia declined substantially within few years after the end of the Soviet Union.8 Analysing data only between distant points in time may miss divergent trends in mortality occurring within this time period. In contrast to previous analyses, it was therefore the aim of this study to estimate not only the cumulative but also the annual contributions of age- and disease-specific mortality rates to the change in life expectancy in the German population between 1962 and 2002.
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Methods |
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The mortality data used in this analysis were provided by the German Statistical Office; the time period 1962–2002 was considered.9 In 2001, the estimated completeness of the mortality data was 100% with an uncertainty level of 99.8–100%.10 The data include the number of deaths by cause, sex and 5-year age band for every single calendar year. Disease-specific causes of death were categorized according to the International Classification of Diseases (ICD). Three revisions of the ICD occurred within the analysed time period (1962–68 ICD 7, 1969–78 ICD 8, 1979–97 ICD 9 and 1998–2002 ICD 10). Therefore, a uniform coding scheme was defined to transfer all examined diseases to ICD 10.
The following disease-group-specific causes of mortality, which account for about 80% of all recorded deaths, were analysed: infectious and parasitic diseases (ICD 10: A00-B99), malignant neoplasms (C00-C97), diseases of the circulatory system (I00-I99), diseases of the respiratory system (J00-J99), perinatal diseases (P00-P96) and external causes of mortality (V01-Y98). In addition, several important single diseases were analysed.
Analysis
The contributions of different age groups and disease-specific causes of death to the changes in life expectancy were estimated using an actuarial method of decomposing mortality rates provided by Pollard.11 This technique considers the cause-specific mortality difference in every single age group within a specific time interval. The difference 
in average life expectancy at birth between two points in time, denoted in the following by a superscript 1 or 2, is given by the formula:
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and 
are the life expectancies at age x for specific points in time 1 and 2; n denotes the number of considered causes of death and 
the last included age interval; iQx is the mortality rate of the i-th cause of death at age interval x with the weight wx 
and 
denoting the probability of living from birth to age x. The change in life expectancy was calculated for the complete observation time (1962–2002) and for time intervals of 1 year using data from former West Germany (1962–97), former East Germany (1987–97) and the whole of Germany (1998–2002). To adjust for short-term variability a weighted moving average technique was applied.12 The width of the moving window was 3 years. All calculations were performed using SAS 9.1.13
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Results |
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Between 1962 and 2002 average life expectancy in western Germany increased from 67.1 to 75.6 years in men and from 72.7 to 81.3 years in women with an average gain of about 2.2 years per decade in both sexes. The largest contribution to the increase in life expectancy came from the age group 65 years and older (figure 1). When the annual contribution over time is considered, the strong influence from this age group is demonstrated primarily from 1970 onwards. The youngest age group (0–4 years) contributed substantially to life expectancy during the sixties, but its influence declined strongly during the observation period. The smallest changes of age-specific mortality were observed in children between 5 and 14 years.
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The disease-group specific contribution to changes in life expectancy was most prominent for cardiovascular diseases (CVD) in men (2.7 years) and women (3.0 years) (figure 2). Analysing these findings by CVD subgroups over time showed a consistently positive contribution from cerebrovascular diseases, while the age-specific mortality for ischaemic heart diseases did not decrease until the end of the 1970s (data not shown). The impact of perinatal diseases to the gain in life expectancy decreased corresponding to the decline in the youngest age group during the whole observation period (figure 2). A negative peak was observed around 1968, which was mainly caused by cardiovascular and respiratory diseases in men and women 40 years and older.
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Between 1962 and 2002, reductions in cancer mortality increased life expectancy by 0.6 years for men and 0.9 years for women (figure 3). The annual contribution increased during the last decade. In both sexes the largest positive impact of neoplasms to life expectancy was observed for stomach cancer. This positive effect was found across the entire observation period. In men, lung cancer mortality contributed negatively to life expectancy until 1983 and positively afterwards. This led to a small overall increase of 0.1 years in life expectancy. In women, however, mortality rates of lung cancer increased steadily and therefore the life expectancy decreased by 0.2 years during the whole observation period. There was also a switch in colorectal cancer from a negative to a positive contribution at the end of the 1970s. Prostate and breast cancer had a small impact on life expectancy, which became positive at the end of the observation period in both sexes.
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Another interesting phenomenon which occurred during the last decade in Germany was the convergence of living conditions between East and West Germany. In 1990, the year of the German reunification, the difference in life expectancy was 3.5 years in men and 2.8 years in women. Only 7 years later, when the German Statistical Office ended the separate documentation, these differences had decreased to 2.0 years in men and 1.0 year in women. First, male life expectancy declined substantially in 1989/90 (figures 4 and 5). This was mainly due to an increasing number of deaths by external causes among men between 15 and 64 years. Afterwards, convergence of living conditions between West and East Germany resulted in a very rapid increase of life expectancy in the new federal states, which added up to about 3.2 years in men and women over a period of just 7 years.
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These rapid gains in life expectancy in East Germany were mostly due to mortality reductions among citizens of 65 years and older (figure 4). The disease-specific analysis showed a very strong impact of reductions in CVD mortality (figure 5). The contributions of respiratory diseases and of external causes were also substantial. In contrast, there was no positive effect from malignant neoplasms during this period.
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Discussion |
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In most countries the last century has provided dramatic improvements in health. Life expectancy in the annual record-holding country has continuously increased since 1840.1 In our analyses, the increase in life expectancy in Germany over the period 1962–2002 showed varying contributions from age- and disease-specific reductions in mortality.
Compared with population based morbidity data, mortality data are clear and straightforward. Therefore, life expectancy at birth as a measure of mortality is a valid and important indicator of population's health status. It is easy to interpret and intuitive for both layman and experts. The method of decomposing mortality rates to changes in life expectancy is commonly used in demographical literature to analyse time intervals of several years.3–7 In contrast to previous analyses, our type of presentation illustrates also short time annual effects. This allows to translate the immediate influence of changes in life style and socio-political living conditions on mortality rates into age- and disease-specific contributions to short-term changes in life expectancy.
Before discussing our findings in more detail, some methodological aspects must be considered. A reduced number of deaths in younger age groups has a greater influence on life expectancy than an equal reduction in older age groups due to the fact that more life years are gained. Even great achievements in rare diseases may have only a modest impact on life expectancy at the population level. In turn, achievements in very common diseases may increase life expectancy substantially. The presented analyses reflect changes in mortality over time and not the absolute level of mortality.
The largest contribution to increases in life expectancy in Germany came from CVD, similar to findings from other European countries, Japan and the United States.5–7 The annual analyses show that increasing mortality in CVD had negative impact on life expectancy until the end of the 1960s. Since then reductions in cardiovascular mortality have made substantially larger contributions to the increasing life expectancy than other disease groups. Analysing these changes in further detail, the decline in cerebrovascular diseases tended to precede the decline in coronary heart diseases. This pattern of the so-called epidemiological transition14 was also found in other developed countries like Italy, Spain and the United States.5,7,15 In Japan, however, coronary heart disease rates did not rise as sharply as they did in other industrialized nations after World War II and the contribution of CVDs to life expectancy was mainly due to a reduction of cerebrovascular diseases.16
In European countries, efforts in prevention and achievements in diagnostic as well as in therapeutic measures contributed to the observed reductions in cardiovascular mortality.17,18 There is, however, still a large potential for further improvements in primary and secondary prevention of cardiovascular mortality.7,19 The prevalence of cardiovascular risk factors in Germany is still high.20 For example 65% of all observed myocardial infarctions within the German MONICA study population were attributable to classic risk factors like smoking, hypertension and hypercholesterolaemia.20 Secondary prevention of CVDs in Germany, as in other European countries, is far from being optimal.21 The EUROASPIRE study demonstrated, that in Germany, at least two or more risk factors were still prevalent in >60% of all patients after the diagnosis of coronary heart disease.19
Reductions in cardiovascular mortality were also the major contributor to the very rapid gains in life expectancy in eastern Germany after German reunification. Changes in diet (improved access to fruits and vegetables) and improvements in medical care (e.g. modern pharmaceutical drugs) have been discussed as potential explanations.17,18,22 Similar gains albeit less pronounced were seen in Eastern European countries such as Poland, Hungary, Romania or the Czech Republic after their transition to democracy.23–25
Despite enormous efforts to reduce mortality from cancer in industrialized countries the success to date has been only moderate.5–7 Nevertheless, substantial improvements in therapy and prognosis of several specific types of cancer (i.e. malignant neoplasms during childhood) were made.26,27 Corresponding to worldwide trends in mortality, our data show a strong and continuous contribution of declining mortality from stomach cancer.28 Changes in nutrition resulting in less cured food and more fresh vegetables are discussed as causes for the reduction of the incidence and therefore the mortality of stomach cancer.29 Additionally, the control of Helicobacter pylori infection has improved and may also have contributed to the observed development.30 Although the incidence of stomach cancer has been decreasing for many decades, this cancer site is still among the five most frequent causes of deaths from malignant neoplasms in Germany in men and women.31
The reduction of mortality in colorectal cancer increased life expectancy in both sexes. The contribution, however, was more prominent in women than in men. Screening examinations like faecal occult blood tests as well as a colonoscopy can reduce death rates from colorectal cancer.32,33 The higher participation rates of women in screening examinations (50% women and 19% men) may partly explain the difference between sexes.34
Particularly after 1990, substantial gains in life expectancy were seen in men due to reductions in lung cancer mortality. During the same period potential gains in life expectancy of women were cut substantially due to an increase in lung cancer mortality. The observed changes in lung cancer mortality reflect the changes in smoking behaviour, which has decreased over the past two decades in men and increased in women.35 Although the carcinogenic effects of smoking are unchallenged since many decades the smoking prevalence in Germany remains high in men (33.2% in 2003) as well as in women (22.1%).36 This fact is a disaster for German health policy.
In summary, in men the largest gains in life expectancy from reduced cancer mortality came from malignancies with decreasing incidence rates (i.e. stomach and lung cancer). In women, there were substantial cuts in potential gains in life expectancy due to malignancies with increasing incidence rates (i.e. lung cancer). This demonstrates the large impact and potential benefit of primary prevention on cancer mortality. It also emphasizes that besides continued efforts to improve cancer therapy further efforts in prevention research and implementation (e.g. as required by the Framework Convention on Tobacco Control) are crucial.26,37
Infectious diseases barely influenced the change in life expectancy within the observation period. An exception to this is the influenza virus, which is classified in the category of respiratory diseases. Influenza epidemics can have a great impact on mortality, which affect not only the mortality of respiratory, but also of CVD.38 Therefore, the short term reduction in life expectancy due to respiratory and cardiovascular mortality especially in older people around 1968 is likely to be a consequence of the ‘Hong Kong influenza’ epidemic, which struck Germany at that time.39
Over decades the decrease of infant mortality has had the largest impact on the gain in life expectancy. Since the beginning of the 1990s, there have been hardly any contributions to the change in life expectancy by perinatal diseases. This is in line with data from other developed countries.2 It looks as if a minimum of death rate has been nearly accomplished and further improvements in perinatal mortality are difficult to achieve.2,40
Despite the gains in life expectancy in Germany, nearly 20% of the male and 10% of the female population are still dying before reaching 65 years.41 CVD are still the most frequent causes of death to date. However, until the age group 65–69 years more people die from malignant neoplasms than from CVD (data not shown) reflecting the larger achievements in CVD compared with cancer. It was widely expected that a high life expectancy, such as the one in Germany, will soon approach the biological limit of human longevity.42 However, the worldwide trends in record-holding countries have been fairly stable over recent decades and show no sign that the maximum in life expectancy will be reached soon.1 Nevertheless, within individual countries the development of life expectancy seems to be sensitive to many influences. Events, like the influenza epidemic in 1968, can have substantial impact on life expectancy. Another problem will be the current rise in obesity in many countries, which may diminish health and life expectancy.43,44 Furthermore, changes of political and social systems may strongly influence life expectancy. In Russia, for example, especially male life expectancy decreased significantly after the end of the Soviet Union and still remains low (58.0 years in 2002).8,45 The rapid decrease in male life expectancy in East Germany between 1989 and 1990 occurred during substantial political changes. Amongst others one main reason for the decline in life expectancy was the increasing mortality rate of external causes like car accidents.46 On the other hand the rapid increases in eastern Germany show how fast life expectancy can increase if conditions improve. Especially older people benefited from changes in conditions and behaviours.47,48
In the future, genetic research will play a major role in health sciences. However, overly enthusiastic expectations regarding the benefits of genetic research contain the risk that priorities are changed and research into environmental and social determinants and prevention of diseases are neglected.49 Most common chronic diseases are caused by a complex relationship of lifestyle (e.g. low physical activity, overweight, smoking, etc.), socioeconomic and genetic factors. Epidemiological research has identified major risk factors for CVD and for several types of cancer. Many causes are known and potentially preventable by changes in life-style.49,50 Future efforts to increase life expectancy should aim at further improvements in therapeutic and preventive measures and the social environment.
Conflicts of interest: None declared.
Key points
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Footnotes |
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Coloured versions of all the figures are deposited as online supplement or can be requested from the authors. 
Stephan K. Weiland, head of the Institute of Epidemiology, Ulm University, died completely unexpected on March 19, 2007. He will live in our memories as a warmhearted, friendly and always helpful human being and as a great scientist
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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1 Oeppen J, Vaupel JW. Demography. Broken limits to life expectancy. Science (2002) 296:1029–31.
2 United Nations. World Mortality Report 2005. (2006) New York.
3 Nolte E, Scholz R, Shkolnikov V, et al. The contribution of medical care to changing life expectancy in Germany and Poland. Soc Sci Med (2002) 55:1905–21.[CrossRef][Web of Science][Medline]
4 Gjonca A, Brockmann H, Maier H. Old-Age mortality in Germany prior to and after Reunification. Demogr Res (2000) 3:1.[Medline]
5 Conti S, Farchi G, Masocco M, et al. The impact of the major causes of death on life expectancy in Italy. Int J Epidemiol (1999) 28:905–10.
6 Yoshinaga K, Une H. Contributions of mortality changes by age group and selected causes of death to increase in Japanese life expectancy at birth from 1950 to 2000. Eur J Epidemiol (2005) 20:49–57.[CrossRef][Web of Science][Medline]
7 Lenfant C. Shattuck lecture–clinical research to clinical practice–lost in translation? N Engl J Med (2003) 349:868–74.
8 Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet (2001) 357:917–21.[CrossRef][Web of Science][Medline]
9 Statistisches Bundesamt. Todesursachenstatistik. (2005) Wiesbaden.
10 WHO. Mortality Database. (acessed 30 March 2006). http://www.who.int/whosis/mort/.
11 Pollard JH. The expectation of life and its relationship to mortality. J Inst Actuaries (1982) 109:225–40.
12 Rothman KJ, Greenland S. Modern Epidemiology (1998) 2nd edn. Philadelphia, Lippincott: Williams & Wilkins. 317.
13 SAS for Windows 9.1. Version 9.1. Cary. (2005) NC, USA.
14 Olshansky SJ, Ault AB. The fourth stage of the epidemiologic transition: the age of delayed degenerative diseases. Milbank Q (1986) 64:355–91.[CrossRef][Web of Science][Medline]
15 Gomez-Redondo R, Boe C. Decomposition analysis of Spanish life expectancy at birth: evolution and changes in components by sex and age. Demogr Res (2005) 13:521–46.[Web of Science]
16 Watanabe T, Omori M, Fukuda H, et al. Influence of death from cardiovascular diseases on life expectancy at birth in Japan. J Epidemiol (2002) 12:450–6.[Medline]
17 Kuulasmaa K, Tunstall-Pedoe H, Dobson A, et al. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. Lancet (2000) 355:675–87.[CrossRef][Web of Science][Medline]
18 Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet (2000) 355:688–700.[CrossRef][Web of Science][Medline]
19 Heidrich J, Liese AD, Kalic M, et al. Sekundärprävention der koronaren Herzkrankheit. Dtsch Med Wochenschr (2002) 13:667–72.
20 Keil U, Liese AD, Hense HW, et al. Classical risk factors and their impact on incident non-fatal and fatal myocardial infarction and all-cause mortality in southern Germany. Results from the MONICA Ausburg cohort study 1984–1992. Eur Heart J (1998) 19:1197–207.
21 EUROASPIRE I and II Groups. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. European action on secondary prevention by intervention to reduce events. Lancet (2001) 357:995–1001.[CrossRef][Web of Science][Medline]
22 Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol (1997) 26:1–13.
23 Adeyi O, Chellaraj G, Goldstein E, et al. Health status during transition in Central and Eastern Europe: development in reverse? Health Policy Plann (1997) 12:132–45.
24 Nolte E, Shkolnikov V, McKee M. Changing mortality patterns in East and West Germany and Poland. I: long term trends (1960–1997). J Epidemiol Community Health (2000) 54:890–8.
25 Dolea C, Nolte E, McKee M. Changing life expectancy in Romania after transition. J Epidemiol Community Health (2002) 56:444–9.
26 Bailar JC III, Gornik HL. Cancer undefeated. N Engl J Med (1997) 336:1569–74.
27 Brenner H. Long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. Lancet (2002) 360:1131–5.[CrossRef][Web of Science][Medline]
28 Levi F, Lucchini F, Gonzalez JR, et al. Monitoring falls in gastric cancer mortality in Europe. Ann Oncol (2004) 15:338–45.
29 Adami HO, Hunter D, Trichopoulos D. Cancer epidemiology (2002) Oxford: Oxford Univerity Press.
30 Fischbach W, Chan AO, Wong BC. Helicobacter pylori and Gastric Malignancy. Helicobacter (2005) 10((Suppl 1)):34–9.[CrossRef][Web of Science][Medline]
31 Bertz J, Hentschel S, Stegmaier C, Krebs in Deutschland. Saarbrücken: Arbeitsgemeinschaft Bevölkerungsbezogener Krebsregister in Deutschland. (2004).
32 Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med (1993) 328:1365–71.
33 Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med (2002) 137:132–41.
34 Felix Burda Stiftung. Von der Reaktion zur Prävention – Leitbild für eine moderne Gesellschaft. Studie zum Stand der Prävention in Deutschland. (2005) München.
35 Maziak W, Hense HW, Doring A, et al. Ten-year trends in smoking behaviour among adults in southern Germany. Int J Tuberc Lung Dis (2002) 6:824–30.[Web of Science][Medline]
36 Statistisches Bundesamt. Mikrozensus - Fragen zur Gesundheit. (accessed 31 March 2006). http://www.gbe-bund.de.
37 World Health Organisation. WHO Framework Convention on Tabacco Control. (accessed 31 March 2006). http://www.who.int/gb/fctc/.
38 Smeeth L, Thomas SL, Hall AJ, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med (2004) 351:2611–8.
39 Cockburn WC, Delon PJ, Ferreira W. Origin and progress of the 1968–69 Hong Kong influenza epidemic. Bull World Health Organ (1969) 41:345–48.[Web of Science][Medline]
40 Olshansky SJ, Carnes BA, Desesquelles A. Demography. Prospects for human longevity. Science (2001) 291:1491–92.
41 Lademann J, Kolip P. Schwerpunktbericht der Gesundheitsberichterstattung des Bundes: Gesundheit von Frauen und Männern im mittleren Lebensalter (2005) Berlin: Robert Koch Institut.
42 Olshansky SJ, Carnes BA, Cassel C. In search of Methuselah: estimating the upper limits to human longevity. Science (1990) 250:634–40.
43 James PT, Leach R, Kalamara E, et al. The worldwide obesity epidemic. Obes Res (2001) 9((Suppl 4)):228S–33S.[Medline]
44 Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med (2005) 352:1138–45.
45 WHO. WHO Statistical Information System. (accessed 31 March 2006). http://www.who.int/countries/en/.
46 Winston FK, Rineer C, Menon R, et al. The carnage wrought by major economic change: ecological study of traffic related mortality and the reunification of Germany. BMJ (1999) 318:1647–50.
47 Nolte E, Shkolnikov V, McKee M. Changing mortality patterns in East and West Germany and Poland. II: short term trends during transition and in the 1990s. J Epidemiol Community Health (2000) 54:899–906.
48 Vaupel JW, Carey JR, Christensen K. Aging. It's never too late. Science (2003) 301:1679–81.
49 Willett WC. Balancing life-style and genomics research for disease prevention. Science (2002) 296:695–8.
50 Ezzati M, Lopez AD, Rodgers A, et al. Selected major risk factors and global and regional burden of disease. Lancet (2002) 360:1347–60.[CrossRef][Web of Science][Medline]
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