Chiang, TL

Hashimoto, H

Kim, CY

Lai, ETC

Marmot, M

Woo, J

English

UCL Discovery

COMMENTAR YThe determinants of longevity: The perspectives from EastAsian economiesEric T. C. Lai PhD1,2 | Tung-Liang Chiang PhD3 | Chang-yup Kim PhD4 |Hideki Hashimoto PhD5 | Michael Marmot PhD6 | Jean Woo MD1,21Institute of Health Equity, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong2Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong3Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan4School of Public Health, Department of Health Policy and Management, Seoul National University, Seoul, South Korea5Department of Health and Social Behavior, School of Public Health, University of Tokyo, Tokyo, Japan6Department of Epidemiology and Public Health, Institute of Health Equity, University College London, London, UKCorrespondenceEric T. C. Lai, Suite 602, 6/F, Yasumoto International Academic Park, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.Email: etclai@cuhk.edu.hkHome to approximately one-fifth of the world'spopulation,1 the East Asian region has recently beenbrought to attention in the public health and social sci-ences literature regarding its successes in health out-comes in comparison to other settings. In the late 20thcentury this region of the world has shown vast improve-ment in life expectancy (LE) and infant mortality rates—to standards that were comparable to the western devel-oped counterparts. A notable example in this region isHong Kong, which in 2010 has overtaken Japan to havethe world's longest LE. A male baby who was born inHong Kong in 2020 could be expected to live on averageto age 83.4 years, while that for a female is 87.7. Therehas thus been sustained interests in the search of an“Asian model” in the hope that such feat could be repli-cated in other settings.Patterns of mortality have been extensively investi-gated by previous studies, mainly stemming from the dis-advantage of longevity and mortality of the United Stateswhen compared internationally.2 Although relevantresearch in Asia is relatively limited, two observationsapparently could explain the Asian advantage. First, mor-tality in young age was drastically reduced in the latterhalf of the 20th century. During this period, burgeoningpublic health infrastructure and medical advancementhas helped prevent deaths from infectious diseases atvery young ages, boosting the LE. The infant mortalityrates (IMR) of the East Asia region now become theworld's lowest—the IMR for Hong Kong in 2018 was 1.5deaths per 1000 live births, while it was 1.9 and 2.1respectively for Japan and Singapore, whereas theUnited Kingdom and the United States stood respectivelyat 3.9 and 5.7. Paradoxically perhaps, Japan andSingapore had relatively high prevalence of low birthweight, which is closely related to higher risk of infantand child mortality.3 Despite such trend could not befully explained by secular trend of gestational age, mater-nal smoking and BMI, this could reflect that pathwayslinking low birth weight and infant or early deaths couldhave been mitigated by medical resources and social fac-tors.4 Second, the reduction of deaths from chronic dis-eases at older age helped increase LEs since the 1960s.Given 94%–96% of new-borns in high-income countriescould survive to and beyond age 50, variations in LE atbirth is largely dominated by what happens over age50 and the extent to which cardiovascular mortality iscontrolled.5,6 Ni and colleagues recently reported that thelead contributor to Hong Kong's survival advantage is theReceived: 16 April 2023 Accepted: 23 April 2023DOI: 10.1111/jgs.18418Journal of the American Geriatrics SocietyThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in anymedium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.J Am Geriatr Soc. 2023;1–4. wileyonlinelibrary.com/journal/jgs 1lower mortality from cardiovascular diseases in malesand females, possibly due to low smoking prevalence.7Mortality from ischemic heart disease in Japan has neverreached levels seen in western high-income countries.8Taiwan and South Korea also maintained a relatively lowprevalence of hypertension.9Dahlgren and Whitehead posited that factors thatdetermine population health could be conceptualized asstacked layers from individual to the macro environ-ment.10 In addition to constitutional factors such as age,sex or genetics, access and quality of medical care areoften assumed to be a primary determinant of health. Buteven health care does play a role, decades of researchshowed that with as vast spending on health care as theUnited States, the health dividend is not always propor-tionate.11 The unique characteristics of the East Asiansetting in terms of factors at the macro and meso levelare potentially important explanations. We name a fewexamples here, each of which could be a hypothesis onits own leading to more comprehensive investigation.Diets have long been proposed to result in the healthdifferences between east and west. Soy and soy productsare regularly consumed in the East Asia; previous evi-dence suggested that soy products might be protectiveagainst cancers and other chronic diseases.12 Diets in thehigh-income East Asian region also feature exceptionallyhigh intake of omega-3 fatty acids, vegetables, wholegrains and low intake of sugar-sweetened beverages com-pared to other regions of the world; and it has the lowestrate of dietary-related cardiovascular diseases.13 How-ever, as of recently such dietary habit has been increas-ingly changing to a more westernized style to becomelower in fiber content but higher in fat and carbohy-drates.14 Insufficient physical activities in high-incomeAsia Pacific economies has also been on the similar levelof the west in the last decade.15 These observations syn-chronized with the rising trend of obesity in the devel-oped East Asian economies, which could haveimplications for LE in the future.Regarding the more upstream factors, the social poli-cies in the Asian economies traditionally feature low pub-lic expenditure on social welfare and a productivisticmodel that focuses on economic growth. The redistribu-tion effects due to taxation and social insurance pre-miums are relatively low.16 Family and communitynetworks play central roles in providing care and safetynets for those in need, possibly a reflection of Confucian-ism.17 Moreover, women empowerment in East Asia hasFIGURE 1 Life expectancies in selected cities stratified by sex. Data of London were the rolling average of every 2 years from year 1991onwards and data for Tokyo was in non-overlapping 5-year groups from year 1975 (i.e., 1975–1979, 1980–1984) onwards.2 COMMENTARY 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18418 by University College London UCL Library Services, Wiley Online Library on [25/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licenselong been relatively weak. According to a recent genderequality report published by the World Economic Forum,Japan and Korea respectively ranked 121 and 108 out of153 nations surveyed.18 Intriguingly, Japanese andKorean women defied conventional sociological theoriesby having among the world's longest LEs. Workers in theEast Asian economies have also been traditionally work-ing longer hours than in the West. Nonetheless, longerworking hours have recently been shown by the WorldHealth Organization (WHO) to be related to higher risksof heart disease and stroke.19 It is perhaps a conundrumas to how the underlying social forces in the East Asiansocieties could mitigate these health risks. One of suchpossibilities could be the high urbanicity of the region,implying that urban dwellers could easily get access toessential utilities and medical services easily. However,when compared similarly highly urbanized cities in theEast Asian region and the western counterparts, theadvantage in longevity remains, suggesting that other fac-tors could well be at play (Figure 1). Spectacular eco-nomic development from the 1960s without massiveincreases in income inequalities, or termed “shared pros-perity” by the World Bank, was also proposed to play arole in health improvements particularly for those socio-economically disadvantaged.20Moreover, a more salient concern for public healthpolicies is whether the extent to which the lengthening ofLE is keeping pace with improving quality of life duringolder ages. In 2020, the WHO and the United Nationmember states adopted the Decade of Healthy Ageing(2021–2030) resolution, targeting to implement collabora-tive actions to ensure that all older people could live longand healthy lives.21 Central to this initiative is the con-cept that “healthy aging” is more than just absence of dis-eases, but to build and maintain the abilities of olderpeople to be or to do things they have reason to value. Arelated measure in this regard is the healthy life expec-tancy (HLE), which measures the number of yearsexpected to be in good health. While it is useful as a stan-dalone measure of population health, the changes in theHLE/LE ratio over time reflects expansion or compres-sion of morbidity toward older ages and hence thechanges in long-term care needs following the addedyears to life. According the to the WHO global healthobservatory, Japan, Singapore, and South Korea toppedthe HLE league table in 2019 (Appendix S1), suggestingthat the factors driving the secular trend of increasing LEmight as well influenced HLE. However, as we see fromthe HLE/LE ratio, the share of years of life spent in goodhealth in the East Asia remain fairly similar to the devel-oped west. Data collection of HLE has not been system-atic and underdeveloped in some places, making itdifficult to monitor the status of healthy aging acrosstime and space. Studies of determinants of HLE are alsosurprisingly limited comparing with that of LE.The studies of mortality have become increasingly rel-evant because, in addition to social and cultural values,different forces of globalization, such as the recent Covid-19 pandemic, warfare, geopolitics and trade agreements,have shown themselves to lead to profound consequencesin people's health in today's world. The good perfor-mance in health in the East Asia region has been attrib-uted to the vast reduction of early deaths andcardiovascular mortality in older ages, but the East Asianhealth advantage might become less prominent whenquality of life is considered. The unique combination ofcultural practice and values and social policies, as well asthe lagged effects of previous public health interventionshave contributed to the longevity in this part of theworld. In the face of an aging world, efforts to discern theunderlying pathways leading to higher quality of thoseadded years is urgently needed.“The unique combination ofcultural practice and valuesand social policies, as well asthe lagged effects of previouspublic health interventionshave contributed to the lon-gevity in this part of theworld. In the face of an agingworld, efforts to discern theunderlying pathways leadingto higher quality of thoseadded years is urgentlyneeded.”AUTHOR CONTRIBUTIONSEric T. C. Lai, Michael Marmot, and Jean Woo wereresponsible for conceptualizing this manuscript. EricT. C. Lai was responsible for reviewing the literature,data curation and writing of the manuscript. All co-authors participated in critically reviewing and intellectu-ally input to the drafts of the manuscript.COMMENTARY 3 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18418 by University College London UCL Library Services, Wiley Online Library on [25/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseCONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest.SPONSOR'S ROLEThe funding body does not play any role in the develop-ment of this manuscript.FINANCIAL DISCLOSUREThis work is supported by the CUHK Vice Chancellor'sDiscretionary Fund (136604080).ORCIDEric T. C. Lai https://orcid.org/0000-0002-1229-9471REFERENCES1. United Nations Department of Economic and Social AffairsPopulation Division. World Population Prospects 2022. UnitedNations; 2022.2. Avendano M, Kawachi I. Why do Americans have shorterlife expectancy and worse health than do people in otherhigh-income countries? Annu Rev Public Health. 2014;35:307-325.3. Blencowe H, Krasevec J, De Onis M, et al. National, regional,and worldwide estimates of low birthweight in 2015, withtrends from 2000: a systematic analysis. Lancet Glob Health.2019;7(7):e849-e860.4. Kato N, Sauvaget C, Yoshida H, Yokoyama T, Yoshiike N. Fac-tors associated with birthweight decline in Japan (1980–2004).BMC Pregnancy Childbirth. 2021;21(1):1-8.5. Klenk J, Keil U, Jaensch A, Christiansen MC, Nagel G.Changes in life expectancy 1950–2010: contributions from age-and disease-specific mortality in selected countries. PopulHealth Metr. 2016;14(1):1-11.6. National Research Council Committee on Population. 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Goodman R, White G, Kwon H-J. The East Asian WelfareModel. Routledge; 1998.18. World Economic Forum. Global Gender Gap Report 2020.World Economic Forum; 2020.19. Pega F, Nafradi B, Momen NC, et al. Global, regional, andnational burdens of ischemic heart disease and stroke attribut-able to exposure to long working hours for 194 countries,2000–2016: a systematic analysis from the WHO/ILO JointEstimates of the Work-related Burden of Disease and Injury.Environ Int. 2021;154:106595.20. The World Bank. Inclusion Matters: The Foundation for SharedProsperity. The World Bank; 2013.21. Amuthavalli Thiyagarajan J, Mikton C, Harwood RH, et al.The UN Decade of Healthy Ageing: strengthening measure-ment for monitoring health and wellbeing of older people. AgeAgeing. 2022;51(7):1-5.SUPPORTING INFORMATIONAdditional supporting information can be found onlinein the Supporting Information section at the end of thisarticle.Appendix S1. Life expectancies and healthy life expec-tancies in selected countries.How to cite this article: Lai ETC, Chiang T-L,Kim C, Hashimoto H, Marmot M, Woo J. Thedeterminants of longevity: The perspectives fromEast Asian economies. J Am Geriatr Soc. 2023;1‐4.doi:10.1111/jgs.184184 COMMENTARY 15325415, 0, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18418 by University College London UCL Library Services, Wiley Online Library on [25/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

The determinants of longevity: The perspectives from East Asian economies

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The determinants of longevity: The perspectives from East Asian economies

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