• Yu-Tzu Wu, Albert Sanchez Niubo, Christina Daskalopoulou, Dario Moreno-Agostino, Denes Stefler, Martin Bobak, Sian Oram, Martin Prince, and Matthew Prina.
• Department of Health Service and Population Research (Wu, Daskalopoulou, Moreno-Agostino, Oram, Prince, Prina), Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Population Health Sciences (Wu), Newcastle University, Newcastle upon Tyne, UK; Research, Innovation and Teaching Unit (Sanchez Niubo), Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain; Centro de Investigación Biomédica en Red de Salud Mental (Sanchez Niubo), Madrid, Spain; Department of Epidemiology and Public Health (Stefler, Bobak), University College London, London, UK yu-tzu.wu@kcl.ac.uk.
• CMAJ. 2021 Mar 15; 193 (11): E361E370E361-E370.

BackgroundWomen generally have longer life expectancy than men but have higher levels of disability and morbidity. Few studies have identified factors that explain higher mortality in men. The aim of this study was to identify potential factors contributing to sex differences in mortality at older age and to investigate variation across countries.MethodsThis study included participants age ≥ 50 yr from 28 countries in 12 cohort studies of the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. Using a 2-step individual participant data meta-analysis framework, we applied Cox proportional hazards modelling to investigate the association between sex and mortality across different countries. We included socioeconomic (education, wealth), lifestyle (smoking, alcohol consumption), social (marital status, living alone) and health factors (cardiovascular disease, diabetes, mental disorders) as covariates or interaction terms with sex to test whether these factors contributed to the mortality gap between men and women.ResultsThe study included 179 044 individuals. Men had 60% higher mortality risk than women after adjustment for age (pooled hazard ratio [HR] 1.6; 95% confidence interval 1.5-1.7), yet the effect sizes varied across countries (I 2 = 71.5%, HR range 1.1-2.4). Only smoking and cardiovascular diseases substantially attenuated the effect size (by about 22%).InterpretationLifestyle and health factors may partially account for excess mortality in men compared with women, but residual variation remains unaccounted for. Variation in the effect sizes across countries may indicate contextual factors contributing to gender inequality in specific settings.© 2021 Joule Inc. or its licensors.

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