Premature mortality by cause

1. Key messages

The causes of premature death before 75 years with the highest burden in term of years of life lost are:
  • suicide, lung cancer, and ischemic heart diseases in men
  • breast and lung cancer and suicide in women.
Most causes of premature death decreased between the years 2000 and 2016. It is particularly the case for ischemic heart diseases and transport accidents who decreased by more than 50% in both sexes. Exceptions to this general tendency are lung cancer and Chronic Obstructive Pulmonary Disease (COPD) among women which steadily increased.

2. Background

The framework used to classify cause of deaths is the International Classification of Diseases 10th Revision (ICD-10). In this report, mortality is analyzed according to the underlying cause of death as indicated on the death certificate. The underlying cause of death is by rule preferred to the immediate and the contributing causes of death for mortality statistics because, from a public health perspective, the objective is to break the chain of events leading to death and to prevent the precipitating cause [1].

In a first step, the causes of premature death are first described according to the ICD-10 chapters i.e. the main groups of diseases. This is based on the ICD-10 using the first character. In a second step, more detailed analyzes are performed to allow drawing operational conclusions.

Premature mortality refers to deaths occurring at any age lower than the life expectancy. In the operational definition used here, the threshold was set to the mortality occurring below 75 years of age. Most of the causes of premature death are avoidable either through the health care system or by the implementation of public health policies. Reducing premature mortality is a key public health objective. The ranking of the causes of premature deaths is as a consequence a very important tool to set up public health priorities.

The premature mortality by cause can be evaluated either by using:

  • Premature mortality rates, which measure the frequency of deaths due to a specific condition occurring before 75 by 100.000 people under 75 in the population. This indicator is allowing to compare the frequency of different causes of death.
  • Potential Years of Life Lost (PYLL), which is taking into account the frequency and the age at death, is weighting each death in function of the age when the death occurred and is thus giving more weight for death occurring at younger ages. PYLL’s consequently allow to compare causes according to their burden in term of years of life lost [2].

The importance of the causes of premature deaths can be expressed in rates which reflects only the frequency of the cause or in PYLL which reflects the burden of the cause in term of years of life lost. The PYLL-based ranking ranks external causes higher than the rates-based one because external causes usually occur at a younger age than deaths due to chronic diseases.

Both indicators are adjusted for age using the structure of the European standard population 2010 as reference in order to take into account the effect of variations in the age structures between populations.

3. Belgium

Most deaths are caused by tumors, cardiovascular diseases, and external causes

In both sexes, nearly 70% of the premature deaths are caused by the same 3 groups of causes:

  • Tumours, mainly cancers
  • Cardiovascular diseases
  • External causes, mostly suicide and road accident.

The proportion of tumours among all premature deaths is higher in women than in men. Inversely, the proportion of circulatory system diseases and external causes are higher among men.

  • Men
  • Women

Distribution of the causes of premature (before 75) deaths (ICD-10 chapters) among men, ranked by age-adjusted* mortality rates, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Distribution of the causes of premature (before 75) deaths (ICD-10 chapters) among women, ranked by age-adjusted* mortality rates, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Top 10 of the specific causes of premature death

Expressed in premature mortality rates, the most frequent specific causes of premature death are:

  • In men: lung cancer followed by Ischemic Heart Disease (IHD) and suicide
  • In women: lung and breast cancer followed by cerebrovascular diseases

While expressed in PYLL, the highest burden causes of premature death are:

  • In men: suicide followed by lung cancer, IHD, and transport accidents
  • In women: breast cancer followed by lung cancer, suicide, and cerebrovascular diseases
  • Men
  • Women

Top 10 specific causes of premature death (before 75) ranked by age-adjusted* premature mortality rates among men, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Top 10 specific causes of premature death (before 75) ranked by age-adjusted* premature mortality rates among women, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

 

  • Men
  • Women

Top 10 specific causes of premature death (before 75) ranked by age-adjusted* Potential Years of Life Lost (PYLLs) among men, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Top 10 specific causes of premature death (before 75) ranked by age-adjusted* Potential Years of Life Lost (PYLLs) among women, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Trends: Improvements in most causes of deaths, worsening for lung cancer in women

All causes of premature deaths tend to decrease (or at least stay stable) over time. For instance :

  • the premature mortality due to IHD declined spectacularly (with more than 50% decrease in the age-adjusted mortality rates) in both sexes during the period 2000-2016
  • the same is observed for cerebrovascular diseases
  • premature mortality rates for lung cancer have also substantially declined in men (39% of relative decrease).

However, lung cancer premature mortality dramatically progressed in women (55% of relative increase) since 2000. From the fourth cause of death, it jumped to the first just above breast cancer. A slight increase is also observed for Chronic Obstructive Pulmonary Diseases (COPD) among women.

  • Men
  • Women

Age-adjusted* premature (before 75) mortality rates (per 100,000) for the 6 main specific causes of death among men, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Age-adjusted* premature (before 75) mortality rates (per 100,000) for the 6 main specific causes of death among women, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

4. Regions

Disparities within regions, lower premature mortality rates for most causes in Flanders

Among men, the premature mortality rates are higher in Wallonia than in Flanders for the 6 main causes of death. The ratio Wallonia versus Flanders (W/F) is particularly high for chronic liver diseases (ratio is 1.7), IHD (1.6) and COPD (1.5). The differences between Brussels and Flanders (B/F ratio) are less pronounced with the highest ratio observed for COPD (1.5) and chronic liver diseases (1.4). The B/F ratio is however higher than the W/F ratio for cerebrovascular diseases + arterial hypertension (HTA) (1.4). The suicide mortality rate in Brussels is underestimated due to the delay of the Brussels administration in confirming suicide cases.

Among women, as observed for men, the premature mortality rates are higher in Wallonia than in Flanders for the 6 main causes of death, except for breast cancer. The highest W/F ratios are observed for IHD mortality (1.9) and COPD (1.5). The B/F ratios are less pronounced with the highest ratios observed for IHD (1.5) and cerebrovascular diseases (1.2). As in men, the suicide mortality rate in Brussels is underestimated.

  • Men
  • Women

Regional rate ratios for the 6 main specific causes of premature death rates (before 75) (using Flanders as reference), among men, 2016
Source: Own calculation based on death certificates, Statbel
Note: The rates of suicide in Brussels are underestimated and not represented

Regional rate ratios for the 6 main specific causes of premature death rates (before 75) (using Flanders as reference), among women, 2016
Source: Own calculation based on death certificates, Statbel
Note: The rates of suicide in Brussels are underestimated and not represented

Ranking

The highest premature mortality rate is observed for lung cancer; this is the case in the three regions and, since 2015, in both genders. The second causes of death are common for all regions as well: IHD in men and breast cancer in women. The third cause of death is :

  • among men, suicide in Wallonia and Flanders and COPD in Brussels
  • among women, cerebrovascular diseases in Flanders and Brussels and IHD in Wallonia.

According to the potential years of life lost (PYLL):

  • among men, suicide ranks first in Flanders and Wallonia, followed by lung cancer and IHD. In Brussels, the lung cancer ranks before suicide. The 3rd cause is IHD in all the regions
  • among women, lung cancer ranks first in Wallonia, second in Flanders and Brussels after breast cancer. Suicide ranks 3rd in all regions.

It is interesting to note that transport accidents are ranking quite high in men, even if the premature mortality rate is rather low. The suicide mortality rate in Brussels is underestimated due to the delay of the Brussels administration in confirming suicide cases.

Ranking of the main causes of death by premature mortality rates and Potential Years of Life Lost (PYLL), by sex and regions of residence, Belgium, 2016
Source: Own calculation based on death certificates, Statbel
Men Ranking by rates Ranking by PYLL
Causes of death Flanders Brussels Wallonia Flanders Brussels Wallonia
Lung cancer 1 1 1 2 1 2
Ischemic Heart Diseases 2 2 2 3 3 3
Suicide 3 5 3 1 2 1
Cerebrovascular Diseases + HTA 4 4 6 5 5 7
COPD 5 3 4 10 6 6
Colorectal cancer 6 8 7 8 8 8
Chronic Liver Diseases 7 6 5 6 4 5
Transport Accident 13 23 11 4 12 4
             
Women Ranking by rates Ranking by PYLL
Causes of death Flanders Brussels Wallonia Flanders Brussels Wallonia
Lung cancer 1 1 1 2 2 1
Breast cancer 2 2 2 1 1 2
Cerebrovascular Disease + HTA 3 3 4 4 4 4
COPD 4 5 5 8 7 6
Suicide 5 10 6 3 3 3
Colorectal cancer 6 6 7 5 11 10
Ischemic Heart Diseases 7 4 3 11 5 5
Chronic Liver Diseases 10 9 11 6 6 9

Trends

For most causes of death, the premature death rates are higher in Wallonia than in Flanders. The evolutions of premature mortality are quite similar for the three regions. The focus has been put here on specific causes of death with remarkable regional differences and/or specific trends.


1. The lung cancer premature mortality rate has been decreasing among men in the three regions during the period 2000–2016 (-40% in Brussels and Flanders and -33% in Wallonia). Those rates have stayed higher in Wallonia than in Flanders over the whole period. For women, the rates steadily increased in Flanders and Wallonia while remaining stable in Brussels since 2006. Women in Brussels previously experienced the highest lung cancer premature mortality rates but it has been overtaken by Wallonia since 2010.

  • Men
  • Women

Lung cancer age-adjusted* premature (before 75) mortality rates (per 100,000) among men, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Lung cancer age-adjusted* premature (before 75) mortality rates (per 100,000) among women, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

2. IHD premature mortality rates are decreasing faster in Flanders (-65% in men and -71% in women) than in Wallonia (-52% in both sexes). This is leading to an increasing gap between the regions.

  • Men
  • Women

Coronary heart disease age-adjusted* premature (before 75) mortality rates (per 100,000) among men, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Coronary heart disease age-adjusted* premature (before 75) mortality rates (per 100,000) among women, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

3. Suicide premature mortality rates are decreasing among men in both Flanders and Wallonia (starting from 2008). Among women, the suicide mortality rates stayed stable at a much lower level than among men in both the Walloon and the Flemish regions.

  • Men
  • Women

Suicide age-adjusted* premature (before 75) mortality rates (per 100,000) among men, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010
Note: The rates of suicide in Brussels are underestimated and not represented.


Suicide age-adjusted* premature (before 75) mortality rates (per 100,000) among women, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010
Note: The rates of suicide in Brussels are underestimated and not represented.


4. In men, COPD mortality rates have decreased by 42% in Flanders and Wallonia and by 30% in Brussels over the period. On the contrary, COPD mortality rates in women have increased in Flanders and Wallonia over the period.

  • Men
  • Women

COPD age-adjusted* premature (before 75) mortality rates (per 100,000) among men, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

COPD age-adjusted* premature (before 75) mortality rates (per 100,000) among women, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

5. Colorectal cancer premature mortality rates used to be higher in Flanders than in the other regions. The premature mortality rate for colorectal cancer have decreased faster in Flanders (-46% for men and -37% for women) than in Wallonia (-10% in men and -7% in women). In 2016, Wallonia was experiencing the highest premature mortality rate.

  • Men
  • Women

Colorectal cancer age-adjusted* premature (before 75) mortality rates (per 100,000) among men, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

Colorectal cancer age-adjusted* premature (before 75) mortality rates (per 100,000) among women, by year and region of residence, Belgium, 2000-2016
Source: Own calculation based on death certificates, Statbel
(*) reference population: European standard population 2010

5. Read more

View the metadata for this indicator

Statbel: Causes of death

Sciensano: Standardized Procedures for Mortality Analysis (SPMA)

WHO: ICD-10

Definitions

Crude mortality rate
The crude mortality rate is the number of deaths registered in a population divided by the number of people in this population.
Age-standardized (or age-adjusted) mortality rate
The age-standardization is a weighted average of age-specific mortality rates to remove variations arising from differences in age structure between population groups.
International Classification of Diseases (ICD-10)
The International Classification of Diseases is an international codification for diseases and for a very wide variety of signs, symptoms, traumatic injuries, poisonings, social circumstances and external causes of injury or illness.
Potential Years of Life Lost (PYLL)
The potential years of life lost (PYLL) measures the number of years of life that have been lost due to premature death. The PYLL weights the deaths occurring at younger age groups more heavily than the ones occurring in older people. The calculation of PYLL involves summing up deaths occurring at each age and multiplying this with the number of remaining years to live up to a selected age limit (here, 75 years). Age-specific PYLL rates are calculated by dividing the number of PYLL in a given age-group by the number of people in this age group. An age-adjusted PYLL rate is then calculated as a weighted average of age-specific PYLL rates until 75 years.
Premature mortality rate
The premature mortality is defined here as deaths occurring before the age of 75; the age-standardized premature mortality rate is calculated as a weighted average of age-specific mortality rates until 75 years.
Underlying cause of death
The disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury.
Tumours
Also known as neoplasms in ICD-10. The neoplasms group includes actually 95% of malignant neoplasms (or cancers), the other 5% being tumors of benign or borderline behavior.

References

  1. World Health Organization. International statistical classification of diseases and related health problems 10th. 2016.
  2. Gardner JW, Sanborn JS. Years of Potential Life Lost (YPLL). What Does it Measure? Epidemiol 1990;1:322-9.