What strategies can be implemented to reduce all-cause mortality in the USA?

Strategies to Reduce All-Cause Mortality in the USA

The most effective strategies to reduce all-cause mortality in the USA are controlling blood pressure to <130/80 mmHg, engaging in at least 150 minutes per week of moderate-intensity physical activity, consuming a diet rich in fruits and vegetables, and eliminating tobacco smoking—interventions that collectively could prevent 50,000-100,000 deaths annually in adults under 80 years. 1, 2, 3

Primary Prevention Through Lifestyle Modification

Physical Activity

• At least 2-2.5 hours per week of moderate-intensity physical activity significantly lowers all-cause mortality, with a 20% reduction achievable with just 1.5 hours per week of moderate-to-vigorous activity. 1
• The largest mortality gains occur when transitioning from inactive to mildly or moderately active lifestyles, following a curvilinear relationship. 1
• Even replacing sitting behaviors with any activity decreases all-cause and cardiovascular mortality; sitting ≥8 hours/day is independently associated with increased mortality in a dose-response manner. 1
• Physical activity provides strong evidence for reduced risk of Alzheimer's disease, cognitive impairment, and fall-related trauma (30-40% risk reduction) in older adults. 1

Dietary Interventions

• Each daily serving increase of fruits reduces all-cause mortality by 6% (RR 0.94; 95% CI 0.92-0.97), and vegetables by 4% (RR 0.96; 95% CI 0.95-0.98). 1
• Optimal consumption of fruits, vegetables, whole grains, nuts, and fish results in a 56% reduction in all-cause mortality. 1
• High adherence to the Healthy Eating Index (HEI) and DASH diets is associated with a 22% lower risk of all-cause mortality. 1
• The most critical dietary risks in the US population are diets low in fruits, vegetables, nuts, and seeds, and high in sodium, processed meats, and saturated fats. 1

Tobacco Cessation

• Tobacco smoking is responsible for approximately 467,000 deaths annually (95% CI 436,000-500,000), accounting for about one in five to six deaths in US adults. 2
• Pharmacotherapy interventions are recommended to maximize quit rates. 1

Cardiovascular Risk Factor Management

Blood Pressure Control

• High blood pressure is responsible for an estimated 395,000 deaths annually (95% CI 372,000-414,000). 2
• Blood pressure should be maintained below 130/80 mmHg. 1
• Every 10% increase in hypertension treatment would prevent an additional 14,000 deaths per year in those aged <80 years. 3
• Hypertension control rates peaked at 53.8% in 2013-14 but declined to 43.7% in 2017-18, representing a critical area for improvement. 1

Lipid Management

• Every 10% increase in treatment of elevated LDL cholesterol would prevent 8,000 deaths per year in those aged <80 years. 3
• Emphasis on intake of polyunsaturated fatty acids and omega-3 fatty acids (seafood) is essential; low dietary omega-3 fatty acids account for 84,000 deaths annually (95% CI 72,000-96,000). 2
• High dietary trans fatty acids are responsible for 82,000 deaths annually (95% CI 63,000-97,000). 2

Glucose Control

• Combined control of blood pressure, lipids, and glucose substantially reduces mortality and cardiovascular events. 1
• Type 2 diabetes should be controlled through diet and exercise, with metformin as primary therapy and SGLT-2 inhibitors or GLP-1 receptor agonists as secondary options. 1

Weight and Metabolic Management

• Overweight-obesity is responsible for 216,000 deaths annually (95% CI 188,000-237,000), accounting for nearly 1 in 10 deaths. 2
• Physical inactivity accounts for 191,000 deaths annually (95% CI 164,000-222,000). 2
• Weight control and adequate physical activity are the most important modifiable factors for preventing type 2 diabetes. 1

Healthcare System Interventions

Disease and Case Management

• Disease and case management in healthcare systems for persons with diabetes is strongly recommended to reduce morbidity and mortality. 1
• Multicomponent integrated care (≥2 quality improvement strategies targeting different domains) reduces all-cause death, cardiovascular mortality, and all-cause hospitalization. 1
• Transitional care interventions with hospital-initiated support reduce mortality rates at 3 months and 1 year, as well as 30-day readmission rates. 1

Clinical Preventive Services

• Optimal use of nine clinical preventive services could prevent 50,000-100,000 deaths per year in those aged <80 years and 25,000-40,000 deaths per year in those aged <65 years. 3
• Every 10% increase in aspirin prophylaxis would prevent 8,000 deaths per year in appropriate candidates aged <80 years. 3
• Low-dose aspirin for primary prevention is now reserved for select high-risk patients. 1

Population-Level Strategies

Community-Based Approaches

• Concerted efforts to organize communities, provide mass and direct education, offer risk factor screenings, and change environments through local programs and policies can change behaviors and reduce mortality. 1
• Schools, work sites, religious organizations, and healthcare facilities serve as effective sites to facilitate community-wide behavior change. 1
• Diabetes self-management education in community gathering places (community centers, faith institutions) is recommended for adults. 1

Policy and Environmental Changes

• Environmental approaches that promote health and support healthy behaviors are essential cross-cutting strategies. 4
• Establishment of community conditions to support healthy behaviors delivers healthier populations to the healthcare system. 4
• Public health campaigns using "move more and sit less" promote the concept that any amount of physical activity is better than none. 1

Common Pitfalls to Avoid

• Do not underestimate the impact of sedentary behavior: Sitting in excess of 7 MET-hours per day (after subtracting physical activity) has independent association with all-cause mortality. 1
• Do not focus solely on vigorous activity: The largest mortality gains occur when transitioning from inactive to mildly active, not from moderate to vigorous activity. 1
• Do not ignore dietary salt: High dietary salt accounts for 102,000 deaths annually (95% CI 97,000-107,000). 2
• Do not assume alcohol is universally protective: Although 26,000 deaths from ischemic heart disease, stroke, and diabetes are averted by current alcohol use, they are outweighed by 90,000 deaths from other cardiovascular diseases, cancers, liver cirrhosis, and injuries. 2

Implementation Priority

The evidence demonstrates that tobacco smoking and high blood pressure are responsible for the largest number of deaths and both have effective interventions, making them the highest priority targets. 2 Following these, overweight-obesity, physical inactivity, and dietary modifications represent the next tier of interventions with substantial mortality reduction potential. 2 Healthcare systems should maximize use of clinical preventive services while simultaneously implementing population-level environmental and policy changes to create sustainable improvements in health behaviors. 4, 3