Differential Impact of Fertility on Health-Adjusted Life Expectancy of Older Adults Across Countries of Various Levels of Socio-Demographic Index —Worldwide, 1995–2019

Shuai Guo^1*; Chen Chen^2*; Yunhe Wang^3*,Yi Cao¹; Zhiwei Leng^4#; Xiaoying Zheng^1,5#

Affiliations

1 Department of Population Health and Aging Science, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China

2 School of Population Medicine and Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China

3 Nuffield Department of Population Health, University of Oxford, Oxford, UK

4 Center for Health Policy and Health Economics, National Infrastructures for Translational Medicine, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China

5 Institute for Global Health and Development, Peking University, Beijing, China

* Joint first authors.

# Correspondence authors：Xiaoying Zheng, zhengxiaoying@sph.pumc.edu.cn; Zhiwei Leng, lengzhiwei@pumch.cn.

Health-adjusted life expectancy (HALE) is a crucial indicator of global health. Despite increasing globally, the relationship between fertility rate and HALE, particularly among older adults in countries at varying development levels, remains underexplored. A country-level panel dataset from 1995 to 2019 was constructed using data from the Global Burden of Disease study and Our World in Data, including HALE at age 65, total fertility rate (TFR), and other key social development indicators. Based on generalized estimating equations (GEE) with Gaussian distributions, the crude and net effects of TFR on HALE were explored through univariate and multivariate analyses, respectively, with time effects controlled for in the model. Additionally, sample countries were divided into different socio-demographic index (SDI) groups for stratified analysis. With increasing TFR, global HALE for older adults gradually declined before stabilizing. Stratified analyses by SDI group revealed distinct patterns. In low-SDI countries, HALE increased with rising TFR up to a threshold of 4, after which further TFR increases were associated with HALE decreases. Conversely, in middle- and high-SDI countries, increasing TFR did not reduce HALE; instead, high-SDI countries consistently showed an upward HALE trend. The correlation between TFR and HALE of older adults exhibits markedly different patterns across countries with varying levels of socioeconomic development. This suggests that in countries with low fertility rates and developing socioeconomic conditions, implementing advance measures is necessary to address the potential future phenomenon of older adults experiencing extended lifespans but poor health.

生育率对不同社会人口指数水平国家老年人健康调整预期寿命的差异影响 — 全球，1995-2019

霍郭帅^1*；陈晨^2*；王云鹤^3*；曹祎¹；冷志伟^4#；郑晓瑛^1,5#

1 中国医学科学院北京协和医学院群医学及公共卫生学院人口健康与老龄科学学系，北京，中国；

2 中国医学科学院北京协和医学院群医学及公共卫生学院，北京，中国；

3 英国牛津大学纳菲尔德人口健康系，牛津，英国；

4 中国医学科学院北京协和医院临床医学研究所，国家转化医学基础设施卫生政策与卫生经济研究中心，北京，中国；

5 北京大学全球健康发展研究院，北京，中国。

* 共同第一作者

# 通信作者：郑晓瑛，zhengxiaoying@sph.pumc.edu.cn；冷志伟，lengzhiwei@pumch.cn。

健康调整预期寿命（Health-adjusted life expectancy，HALE）是反映健康状况的关键指标。尽管全球范围内老年人HALE呈现增长趋势，但生育率与HALE之间的关系，特别是在不同发展水平国家中的关系，仍未得到充分探究。本研究利用1995–2019年间的全球疾病负担研究和Our World in Data数据，构建了一个国家级面板数据，变量包括65岁的HALE，总和生育率（TFR）以及其他关键的社会发展指标。基于高斯分布的广义估计方程，分别使用单变量和多变量模型分析探讨了TFR对HALE的粗效应和净效应，并在模型中控制了时间效应；此外，将样本国家按社会人口指数（Socio-Demographic Index, SDI）分组进行了亚组分析。从全球来看，随着TFR上升，老年人HALE逐渐下降后趋于稳定。基于SDI分组的亚组分析发现：在低SDI国家中，HALE随着TFR的上升而增加，但当TFR超过4后HALE开始下降。然而，在中SDI及高SDI国家中，TFR的上升并未导致HALE的降低；相反，在高SDI国家中，HALE呈现持续上升的趋势。TFR与老年人口HALE之间的相关性在不同社会经济发展水平的国家中呈现出明显不同的模式。这提示我们，对于社会经济水平仍处在发展阶段的低生育率国家，有必要提前采取针对性措施，以应对未来可能出现的老年人寿命延长但健康状况不佳的现象。

For more information: https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2024.207

Trends and Distribution of Life Expectancy and Health-Adjusted Life Expectancy — Asia-Pacific Region, 1990–2021

Yanan Luo^1,2*; Panliang Zhong^3*; Yujie Huang¹; Yihao Zhao³; Chenlu Hong¹; Xiaoying Zheng^2,3#

1 Department of Global Health, School of Public Health, Peking University, Beijing, China;

2 Institute for Global Health and Development, Peking University, Beijing, China;

3 School of Population Medicine and Public Health, Chinese: Academy of Medical Sciences/ Peking Union: Medical College, Beijing, China.

* Joint first authors.

# Corresponding author: Xiaoying Zheng: zhengxiaoying@sph.pumc.edu.cn.

The Asia-Pacific region is the most populous and diverse globally, encompassing nations with both the longest and shortest life expectancies (LE). However, less is known about the health-adjusted life expectancy (HALE) situation in this region. Data on LE and HALE across the Asia-Pacific region were collected from the Global Burden of Disease Study (GBD) 2021. LE was calculated using life tables, and HALE was estimated using Sullivan’s method. Trends in LE and HALE from 1990 to 2021 were estimated by the estimated annual percentage change (EAPC), and average annual percentage change (AAPC) employing the joinpoint regression model, and their socio-demographic index (SDI) was examined using Loess regression. This study found diversity in the levels and trends of HALE among countries in the Asia-Pacific region, with HALE in 2021 ranging from 49.87 years in Afghanistan to 74.96 years in Singapore. The largest HALE increase from 1990 to 2021 was observed in the Lao People's Democratic Republic (EAPC=0.93) and the smallest in Fiji (EAPC=0.09). HALE continually increased as SDI increased, but different patterns of HALE across countries varied by SDI level. The diversity among these countries provides a prerequisite and scientific basis for promoting the achievement of health goals in the Asia-Pacific region through multilateral and bilateral cooperation.

预期寿命和健康调整预期寿命的趋势与分布 — 亚太地区，1990–2021年

罗雅楠^1,2*；钟盼亮^3*；黄玉洁¹；赵艺皓³；洪晨璐¹；郑晓瑛^2,3#

1 北京大学公共卫生学院全球卫生系，北京，中国

2 北京大学全球健康发展研究院，北京，中国

3 中国医学科学院/北京协和医学院群医学及公共卫生学院，北京，中国

*共同第一作者。

#通信作者：郑晓瑛，zhengxiaoying@sph.pumc.edu.cn。

全球人口预期寿命（LE）增长迅速，但健康调整预期寿命（HALE）增长相对缓慢。亚太地区是世界上人口最多、最具多样性的地区。本研究使用2021年全球疾病负担研究（GBD 2021）的数据，分析了亚太地区的HALE。结果显示，各国HALE水平存在显著差异，2021年阿富汗的HALE为49.87年，而新加坡的HALE为74.96年。从1990年至2021年，老挝人民民主共和国的HALE增长最大，而斐济的HALE增长最小。总体上，HALE随着社会人口学指数（SDI）的提高而上升，但各国模式有所不同。结果提示，根据区域特色开展卫生合作对实现区域健康目标具有重要意义。

For more information: https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2024.208

A Global Decomposition Analysis of the Effect of Population Aging on Disability-Adjusted Life Years Associated with Cardiovascular Disease — 204 Countries and Territories, 1990–2021

Na Sun¹; Xiaocan Jia¹; Xuezhong Shi¹; Feng Jiang²; Chaojun Yang¹; Yongli Yang^1#

¹ Department of Computer and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou City, Henan Province, China

² Department of disease prevention and control, Zhengzhou University hospital, Zhengzhou City, Henan Province, China

#  Corresponding author: Yongli Yang, ylyang377@zzu.edu.cn

Cardiovascular disease (CVD) is a major cause of premature mortality and a significant factor in escalating healthcare costs. With declining birth rates and increasing life expectancy, the impact of population aging on the burden of CVD has become increasingly severe. This study utilized data from the Global Burden of Disease Study (GBD) 2021 to systematically assess the effect of population aging on disability-adjusted life years (DALYs) related to CVD. The results show that global DALYs due to CVD reached 428.3 million in 2021, marking a 44.0% increase since 1990, with nearly 138.2 million DALYs attributable to population aging since 1990. The impact of population aging on DALYs varies across different countries, regions, and types of CVD. Public health professionals are urged to focus on targeted preventive and treatment strategies to address the challenges posed by population aging, particularly concerning ischemic heart disease and stroke, the two conditions most affected by aging.

人口老龄化对心血管疾病相关的伤残调整生命年影响的全球分解分析—204个国家和地区，1990–2021年

孙娜¹；贾晓灿¹；施学忠¹；姜峰²；杨超君¹；杨永利^1#

1郑州大学公共卫生学院计算机与卫生统计学教研室，郑州市，河南省，中国；

2郑州大学医院疾病预防控制科，郑州市，河南省，中国。

# 通信作者：杨永利，ylyang377@zzu.edu.cn。

心血管疾病（Cardiovascular disease，CVD）是导致过早死亡的主要原因之一，也是医疗成本不断上升的重要因素。随着出生率的下降和预期寿命的延长，人口老龄化及其对CVD负担带来的影响也越来越严峻。本研究使用2021年全球疾病负担研究的数据，系统评估人口老龄化对CVD相关的伤残调整生命年（disability-adjusted life years，DALYs）的影响。结果显示，2021年全球因CVD导致的DALYs达到4.28亿，自1990年以来增加了44.0%，其中因人口老龄化造成的DALYs逐渐增加，自1990年以来已达到近1.38亿。在不同的国家、地区和CVD类型中，人口老龄化对DALYs的影响也不同。公共卫生专业人员应重点关注有针对性的预防和治疗策略，以应对人口老龄化带来的挑战，特别是缺血性心脏病和中风这两种主要受老龄化影响的疾病。

For more information: https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2024.209

Limited Social Support, but Comparable Health Literacy and Service Utilization, Among Elderly People Living Alone — Six PLADs, China, May–September 2020

Hao Lin^1,2; Meijun Chen³; Yuhui Shi^1,2; Ying Ji^1,2; Yuting Lin^1,2; Wangnan Cao^1#; Chun Chang^2#

1 Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, Beijing, China;

2 Peking University Health Science Center for Healthy Aging, Beijing, China;

3 School of Public Health, The University of Hong Kong, Hong Kong Special Administrative Region, China.

# Corresponding authors: Wangnan Cao, wangnancao@bjmu.edu.cn; Chun Chang, changchun@bjmu.edu.cn.

As the global population continues to age, elderly individuals living alone have become a particularly vulnerable subgroup. Living alone is often accompanied by feelings of loneliness, insecurity, and daily life difficulties and has been shown to be a risk factor for a range of adverse health outcomes affecting both physical and mental health. This study, conducted from May to September 2020, used a stratified multi-stage random sampling method to select 2,959 nationally representative elderly individuals in China as study subjects. Each participant, with the assistance of staff, completed a cross-sectional survey questionnaire. The questionnaire included validated scales measuring health literacy, service utilization, and social support. Descriptive statistics and chi-square tests (adjusting for potential confounding factors) were used for analysis. The study found that compared to elderly individuals living with family members, those living alone in China had lower family doctor contract rates and limited social support but comparable levels of health literacy and service utilization. Targeted and effective community care interventions should be developed to improve the quality of life for elderly individuals living alone.

独居老年人社会支持有限但健康素养和服务利用率相当 — 中国六省, 2020 年 5 月-9 月

林浩^1,2；陈美君³；史宇晖^1,2；纪颖^1,2；林郁婷^1,2；曹望楠^1#；常春^2#

1.北京大学公共卫生学院社会医学与健康教育系，北京，中国；

2.北京大学医学部老年健康研究中心，北京，中国；

3.香港大学公共卫生学院，香港，中国。

# 通信作者: 曹望楠, wangnancao@bjmu.edu.cn; 常春, changchun@bjmu.edu.cn。

随着全球人口老龄化加剧，独居老年人已经成为一个特别脆弱的亚群。独居往往伴随着孤独感、不安全感以及日常生活困难，已被证实是影响身体和心理健康等一系列不良健康结果的危险因素。本研究于2020年5月至9月期间，采用分层多阶段随机抽样方法，在中国选取了2959名具有全国代表性的老年人作为研究对象。每位参与者在工作人员的协助下填写了一份横断面调查问卷，该问卷包括经过验证的衡量健康素养、服务利用率和社会支持量表，进行描述性统计和卡方检验（校正潜在混杂因素）。本研究发现，与和家人同住的老年人相比，中国独居老年人的家庭医生签约率较低，社会支持有限，但健康素养和服务利用率相当。应制定有针对性和有效的社区护理干预措施，以提高独居老年人的生活质量。

For more information: https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2024.210