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Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice

Volume 37 · Number 3 · March 2017


Reducing premature mortality among young and middle-aged adults

Joel G. Ray, MD, FRCPCFootnote 1,Footnote 2,Footnote 3

Author references:

Footnote 1
Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
Footnote 2
Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
Footnote 3
Institute of Health Policy, Management and Evaluation, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada

Correspondence: Joel G. Ray, Departments of Medicine, Obstetrics and Gynecology, and Health Policy Management and Evaluation, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8; Tel: 416-864-6060 ext. 77442; Fax: 416-864-5485; Email:

The death of an individual in early and middle adulthood is an untimely event whose tragic effects are experienced by the parents, siblings, partners, childrenFootnote 1,Footnote 2,Footnote 3 and friends of the deceased individual. Preventing premature death is a foremost goal of health care and public health programs, and of society at large.

Premature mortality is a measure of unfulfilled life expectancy. While conventional definitions of premature mortality and Years of Potential Life LostFootnote 4 include all people from birth to age 65Footnote 5 or 75Footnote 6 years, such designations obscure our understanding of factors preventable in adulthood. For example, deaths in childhood largely occur in infancy—due to birth defects and preterm birth. At the other end of the lifespan, by including seniors aged 65 to 75 years—who account for the greatest number of deaths—the cause of death is skewed toward cancer and cardiovascular disease. Among Canadians of all ages, the top five causes of death are cancer (30%), heart disease (21%), stroke (6%), lung disease (5%) and unintentional injury (4%).Footnote 7 However, upon restricting to Canadians aged 25 to 34 years, the top five leading causes of death shift to unintentional injury (29%), suicide (20%), cancer (12%), heart disease (5%) and homicide (5%).Footnote 7 For those aged 35 to 44 years, the top five leading causes of death include unintentional injury, suicide and liver disease, the latter often due to alcohol overuse and injection drug use. In Toronto, the causes of premature death follow the same pattern.Footnote 8

Of all deaths occurring among Canadians aged 20 to 64 years, 20% are among those aged 20 to 44 years.Footnote 9 Most premature deaths in young and middle-aged adults are also highly preventable. About 6% of all these deaths in Canada are alcohol-related—more than twice as much for men (7.6%) as for women (3.5%).Footnote 10 In Russia, where alcohol consumption has emerged as a major public health concern, it is estimated that 43% of reported deaths among males aged 25 to 54 years are attributable to hazardous drinking.Footnote 11 In Ontario, in 2010, one in eight deaths among adults aged 25 to 34 years was opioid-related,Footnote 12 and across the country we see the unfolding of an opioid epidemic that has consumed, and then ended, the lives of so many Canadians.

Mental illness and criminal behaviour are also interconnected in their effect on premature mortality. Within two large Swedish studies of 15 337 adults with bipolar disorder, age- and sex-matched to 20 adults randomly sampled from the general population, 22% engaged in suicidal or criminal acts after bipolar disorder diagnosis, compared with 4.6% of those in the general population (adjusted relative risk [RR] 3.0, 95% confidence interval [CI] 2.9–3.2).Footnote 13 People with bipolar disorder had a risk of suicide 14.6 (95% CI: 12.1–17.6) times higher, especially those with a history of attempted suicide, or an alcohol- or drug-use disorder.Footnote 13 Among 475 delinquent and 456 matched nondelinquent boys followed from age 14 to age 65 years, 6.1% versus 2.4%, respectively, died unnatural deaths before age 40 years. This outcome was predicted by juvenile antisocial behaviour and alcohol overuse, and the deaths were most likely from homicide and poor self-care.Footnote 14 Among repeat criminal offenders in Finland, the risk of death before age 30 years is 29 times higher than that for nonoffenders.Footnote 15 Of those who experience incarceration within a Canadian provincial correctional facility, the standardized mortality ratio is 4.0 (95% CI: 3.9–4.1), with injury and poisoning accounting for 38% of all deaths,Footnote 16 and the most pronounced RRs among the youngest offenders, especially women.Footnote 16 We see similar statistics for those in a Canadian federal correctional facility.Footnote 17 Thus, it is apparent that some adults prone to premature death are caught in a web of mental illness, substance use and criminality, often starting from youth.

There are some "generic risk factors" for premature mortality due to intentional and unintentional causes, especially risk factors clustered around mental illness. Neeleman systematically examined 163 cohorts and found that several known risk factors for suicide—including prior deliberate self-harm, alcohol and drug misuse and severe mental illness—were also associated with nonsuicidal death.Footnote 18 Lai et al. evaluated 22 epidemiological survey studies of the prevalence of psychiatric illness in people with a substance-use disorder.Footnote 19 Those with an illicit drug-use disorder had higher odds of major depression (3.8 times higher [95% CI: 3.0–4.8]) and higher odds of an anxiety disorder (2.9 times higher [95% CI: 2.6-3.3]). The odds ratios among people with an alcohol-use disorder were 2.4 (95% CI: 2.2–2.6) and 2.1 (95% CI: 2.0–2.2), respectively. Hence, we can use these generic risk factors – including prior deliberate self-harm, substance use and severe mental illness – to identify adults at risk for premature mortality, of which several are amenable to intervention, even starting in childhood.Footnote 18

It is no coincidence that the increasing prevalence of addiction to hyperpalatable obesogenic foodsFootnote 20 and the emergence of "globesity"Footnote 21 have led many to view obesity as a noncommunicable disease, and one whose major impact on premature mortality has yet to be realized.Footnote 22 Those predisposed to food addiction also tend to have higher depression scores,Footnote 20 a greater likelihood of having been abused as a childFootnote 23 and less access to physical activity facilities, especially in areas with low socioeconomic status and among certain minority groups,Footnote 24 including Indigenous children and youth.Footnote 25 Certainly, acknowledgement of and proper accounting for these and other inequities can help young adult populations to achieve a healthier body mass, as highlighted in the current issue of Health Promotion and Chronic Disease Prevention in Canada, by Bhawra et al.,Footnote 25 Frankish et al.Footnote 26 and Rao et al.Footnote 27

In another paper published in the current issue, Steensma and colleagues present national data on health-adjusted life expectancy (HALE)—a hybrid measure not only of quantity of life, but of quality of life as well.Footnote 28 Across Canada, about 45% of the variation of HALE by health region was previously explained by differences in socioeconomic status,Footnote 29 and Steensma et al. suggest that things may be worse in Newfoundland and Labrador and Prince Edward Island, especially among males.Footnote 28 This analysis may in fact be conservative, considering that the data were available only up to 2010, and the study could not include people living on Indian reserves, certain remote areas of Ontario and Quebec and within the three Canadian territories—areas where disability-free life expectancy (a metric similar to HALE) tends to be worse.Footnote 29 Certainly, a consideration of HALE that specifically focusses on those aged 20 to 45 years can reveal the degree to which some of the factors that influence premature loss of life also concomitantly reduce quality of life in early and middle adulthood.

Dealing with premature mortality among young and middle-aged Canadians starts with a clear definition of who is at highest risk, the likely predisposing factors and some sensible solutions that are multipronged, evidence-based and realistic. Alongside completed and ongoing research in the treatment of mental illness and addictions, as well as the primary and secondary prevention of intentional and unintentional injury, we should expect not only to reduce the number of premature deaths in Canada, but to enhance the well-being of those whose lives are spared from such an untimely fate.


Footnote 1
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Footnote 2
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Footnote 3
Guldin MB, Li J, Pedersen HS, Obel C, Agerbo E, Gissler M, Cnattingius S, Olsen J, Vestergaard M. Incidence of suicide among persons who had a parent who died during their childhood: a population-based cohort study. JAMA Psychiatry 2015;72(12):1227-34.
Footnote 4
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Footnote 5
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Footnote 6
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Footnote 7
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Footnote 8
Matheson FI, Creatore MI, Gozdyra P, Park AL, Ray JG. A population-based study of premature mortality in relation to neighbourhood density of alcohol sales and cheque cashing outlets in Toronto, Canada. BMJ Open. 2014;4(12):e006032.
Footnote 9
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Footnote 10
Rehm J, Patra J, Popova S. Alcohol-attributable mortality and potential years of life lost in Canada 2001: implications for prevention and policy. Addiction. 2006;101(3):373-84.
Footnote 11
Leon DA, Shkolnikov VM, McKee M. Alcohol and Russian mortality: a continuing crisis. Addiction. 2009;104(10):1630-36.
Footnote 12
Gomes T, Mamdani MM, Dhalla IA, Cornish S, Paterson JM, Juurlink DN. The burden of premature opioid-related mortality. Addiction. 2014;109(9):1482-8.
Footnote 13
Webb RT, Lichtenstein P, Larsson H, Geddes JR, Fazel S. Suicide, hospital-presenting suicide attempts, and criminality in bipolar disorder: examination of risk for multiple adverse outcomes. J Clin Psychiatry. 2014;75:e809-16.
Footnote 14
Laub JH, Vaillant GE. Delinquency and mortality: a 50-year follow-up study of 1,000 delinquent and nondelinquent boys. Am J Psychiatry. 2000;157(1):96-102.
Footnote 15
Elonheimo H, Sillanmäki L, Sourander A. Crime and mortality in a population-based nationwide 1981 birth cohort: results from the FinnCrime study [Internet]. Crim Behav Ment Health. 2015 Aug 25 [cited 2017 Jan 2]. Available from
Footnote 16
Kouyoumdjian FG, Kiefer L, Wobeser W, Gonzalez A, Hwang SW. Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study. CMAJ Open 2016;4:E153-61.
Footnote 17
Wobeser WL, Datema J, Bechard B, Ford P. Causes of death among people in custody in Ontario, 1990-1999. CMAJ. 2002;167(10):1109-13.
Footnote 18
Neeleman J. A continuum of premature death. Meta-analysis of competing mortality in the psychosocially vulnerable. Int J Epidemiol. 2001;30(1):154-62.
Footnote 19
Lai HM, Cleary M, Sitharthan T, Hunt GE. Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990-2014: A systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:1-13.
Footnote 20
Pursey KM, Stanwell P, Gearhardt AN, Collins CE, Burrows TL. The prevalence of food addiction as assessed by the Yale Food Addiction Scale: a systematic review. Nutrients. 2014;6(10):4552-90.
Footnote 21
Lifshitz F, Lifshitz JZ. Globesity: the root causes of the obesity epidemic in the USA and now worldwide. Pediatr Endocrinol Rev. 2014;12(1):17-34.
Footnote 22
Kontis V, Mathers CD, Bonita R, et al. Regional contributions of six preventable risk factors to achieving the 25 × 25 non-communicable disease mortality reduction target: a modelling study. Lancet Glob Health. 2015;3(12):e746-57.
Footnote 23
Mason SM, Flint AJ, Roberts AL, Agnew-Blais J, Koenen KC, Rich-Edwards JW. Posttraumatic stress disorder symptoms and food addiction in women by timing and type of trauma exposure. JAMA Psychiatry. 2014;71(11):1271-8.
Footnote 24
Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics. 2006;117(2):417-24.
Footnote 25
Bhawra J, Cooke MJ, Guo Y, Wilk P. The association of household food security, household characteristics and school environment with obesity status among off-reserve First Nations and Métis children and youth in Canada: results from the 2012 Aboriginal Peoples Survey. Health Promot Chronic Dis Prev Can. 2017;37(3):77-86.
Footnote 26
Frankish CJ, Kwan B, Gray DE, Simpson A, Jetha N. Identifying equity-focussed interventions to promote healthy weights. Health Promot Chronic Dis Prev Can. 2017;37(3):94-101.
Footnote 27
Rao DP, Kropac E, Do MT, Roberts KC, Jayaraman GC. Childhood overweight and obesity in Canada: an integrative assessment. Health Promot Chronic Dis Prev Can. 2017;37(3):87-93.
Footnote 28
Steensma C, Loukine L, Choi BCK. Editorial - Reducing premature mortality among young and middle-aged adults. Health Promot Chronic Dis Prev Can. 2017;37(3):68-76.
Footnote 29
Mayer F, Ross N, Berthelot J, Wilkins R. Disability-free life expectancy by health region. Health Rep. 2002;13(4):49-60.