Working-age Americans in nineteen states faced a higher probability of premature death in 2016 compared to those in 1990, according to the most extensive state-by-state US health study ever conducted.

The study, published in JAMA, covers 1990 to 2016; it is part of the Global Burden of Disease (GBD) study, a comprehensive effort to quantify health internationally, covering 333 diseases and injuries and 84 risk factors. According to the authors, this study is the most comprehensive state-by-state health assessment ever undertaken and includes estimates of the prevalence, incidence, death, life expectancy, and several other summary health metrics for all 50 states and the District of Columbia.

The U.S. Burden of Disease Collaborators used national and state records in addition to published studies to track changes in the burden of disease, injury, and risk factors between 1990 and 2016.

National Health Trends

Although death rates in the U.S. have declined overall since 1990, the rate of improvements has been lagging other developed countries.  Life expectancy in the U.S. has improved by about three years in the past 26 years–increasing from 76 years to 79 years in 2016. The United States is among the wealthiest but we remain far from being the healthiest.  The United States ranks 43rd in life expectancy despite the highest per capita health spending rates.

This is all likely due to the significant disparities in life expectancy and health between states. In this JAMA study, researchers found the discrepancy of health widely varies between states. Many of the states in the northeast, in the west coast, and Hawaii had the best life expectancy while many states in the south, Appalachia, and “coal country” had some of the worse.  For example, Hawaii ranked first, with Mississippi last, in life expectancy at birth (81 vs.75).

The death rate from many diseases has improved since 1990. For example, heart disease remains as the number one cause of death in the nation, but the death rate has improved by 50%. Similarly, the death rate from lung, colon, and breast cancer have all decreased by about 30% since 1990.

Nationally, the three leading causes of years of life lost in the US in 2016 were ischemic heart disease, lung cancer, and COPD (Chronic Obstructive Pulmonary Disease commonly related to emphysema).  Alzheimer disease moved from seventh to fourth concerning years of life lost.

COPD was a change from 1990 when the third leading cause of was motor vehicle accidents.  This shows that decades of public health interventions aimed at preventing deaths on the nation’s roads have made a significant difference.

Nationally, the most critical risk factors that are shortening American lives are a high body-mass index (BMI), smoking, and fasting glucose (commonly related diabetes, poor diets, and obesity).  While smoking is declining, it remained the top risk factor for 34 states in 2016. Diabetes climbed from eighth to third in the leading causes of years lived with a disability.

Importantly, it is not just the length of lives that are affected but also the quality of the healthy lives that we live.  In addition to significantly worsening our mortality rates, there have been increases in lives lived with disabilities due to musculoskeletal diseases (e.g., low back pain), diabetes mellitus, poor diets, obesity, drug/alcohol abuse, and mental illnesses such as depression and anxiety.  These musculoskeletal, metabolic and mental illnesses are much more of a burden on Americans today than they were in 1990.

Screen Shot 2018-04-17 at 10.22.09 AM

Top 25 Causes of Disability-Adjusted Life-Years (DALYs) and % Change in Number of DALYs (1990-2016)
Dotted lines: a leading cause has decreased in rank between 1990 and 2016; solid lines, a cause has maintained or ascended to a higher ranking. Causes in white boxes were not among the top 25 in either 1990 or in 2016. COPD, indicates chronic obstructive pulmonary disease. (Source: JAMA)

 In the 19 states that have seen mortality reversals for adults ages, 20 to 55, has been mainly due to substance abuse, cirrhosis of the liver, suicide, and chronic kidney disease( mostly related to diabetes).  In five states–West Virginia, Mississippi, Alabama, Oklahoma, and Kentucky–mortality increased more than 10% among those between ages 20 and 55.

Screen Shot 2018-04-17 at 10.38.47 AM.png

Age-Standardized Rates of Years of Life Lost per 100 000 Persons for the 20 Leading Causes of Years of Life Lost in 2016 for the United States Overall
Boxes are colored green if significantly less than the US rate (P <.05), red if significantly more than the US rate (P <.05), and yellow if not significantly different from the US rate (P ≥.05). Note that suicide (ie “self-harm”) and drug abuse deaths are major causes of premature death at a much higher rate than 1990. 

Not surprisingly, the devastating effects of the opioid epidemic have made a significant impact on the overall health and well-being of Americans.  Opioid abuse moved from 11th to seventh in disability-adjusted life-years and from 52nd to 15th in years of life lost in 26 years. In some parts of the country, death rates from opioid abuse have increased by 1000% since 1990.  Experts who wrote accompanying editorials for this publication in JAMA, point out that only 4% of eligible physicians have received certification to prescribe medication-assisted treatment for opioid use disorders.

In 2015, the alarm of America’s increasing problem with the so-called “Deaths of Despair”–death by drugs, alcohol, and suicide— was raised by a paper published in the Proceedings of the National Academy of Sciences by two Princeton economists, Anne Case and Angus Deaton.  They found that a significant increase in midlife mortality among white non-Hispanic Americans. They found that while midlife mortality rates continue to fall among all education classes in most of the economically advanced nations, middle-aged non-Hispanic whites in the U.S. with a high school diploma or less have experienced increasing midlife mortality since the late 1990s due to increases in death from drugs, alcohol, and suicide.

 Texas Health Trends

Nationally, Texas is in the middle of the pack for life expectancy.  It is 24th in the nation for highest rates of years of life lost. It placed ahead of Montana, but immediately behind Kansas.

It is not surprising that researchers found that being overweight and obese was not only the main reason Texans are living shorter lives but also this was the main reason to cause disability in the state. In the study, a high BMI remained the number one risk factor causing both death and disability in Texas in 2016.

 Texans, too, have not been immune to the opioid epidemic.  Since 1990, years of life lost due to opioid abuse increased by 500% in Texas showing the importance of addressing this issue here in the state.

More healthcare organizations are starting to pay more attention.  Since Emergency Room prescriptions for opioids account for about 45 percent of opioids that have been involved in non-medical use, the Texas Hospital Association recently released new guidelines for emergency departments hoping to curb its misuse.

“We are seeing dangerous disparities among states,” said Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, whose organization coordinated the study. “Unless and until leaders of our healthcare system work together to mitigate risks, such as tobacco, alcohol, and diet, more Americans will die prematurely, and in many cases, unnecessarily.”

As I wrote before, fixing healthcare alone will not make us healthier.  Healthcare does not exist in a vacuum.  Addressing America’s health issues are complex and vast, and many of its solutions will likely need to come from beyond the walls of the hospitals and clinics.  As the expert editorials which accompanied this article in JAMA said about the United State’s attitude toward prevention care: it has been “dismal.”  The socioeconomic and behavioral aspects of our health and well-being are significant problems that will need to involve policymakers, leaders, and communities to help solve.  Unquestionably, as physicians, there is much we can do to work with community leaders and policymakers to help address these issues.  Furthermore, it is important to take heed from this impressive collection of health data. What we are consuming (what we are eating, drinking, and smoking), our obesity rates, and the increasing prevalence of mental illnesses will be three of our most significant challenges for our health in the 21st century.

I am a gynecologic oncologist, a husband, and a father. My blog is mostly about our healthcare system and well-being, but occasionally I get inspired to write about other "stuff" too.

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