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The State of US Health, 1990-2016Burden of Diseases, Injuries, and Risk Factors Among US States

Educational Objective
To understand the determinants of disease and injury in the United States.
1 Credit CME
Key Points

Question  How have the levels and trends of burden of diseases, injuries, and risk factors in the United States changed from 1990 to 2016 by state?

Findings  This study, involving examination of 333 causes and 84 risk factors, demonstrated that health in the United States improved from 1990 to 2016, although the drivers of mortality and morbidity have changed in some states, with specific risk factors such as drug use disorders, high body mass index (BMI), and alcohol use disorders being associated with adverse outcomes. In 5 states, the probability of death between ages 20 and 55 years has increased more than 10% between 1990 and 2016.

Meaning  Differences in health outcomes and drivers of morbidity and mortality at the state level indicate the need for greater investment in preventive and medical care across the life course. The intersection of risk, mortality, and morbidity in particular geographic areas needs to be further explored at the state level.


Introduction  Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state.

Objective  To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Design and Setting  A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year.

Main Outcomes and Measures  Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed.

Results  Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).

Conclusions and Relevance  There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

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Article Information

Accepted for Publication: February 13, 2018.

Corresponding Author: Christopher J. L. Murray, MD, DPhil, Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Ste 600, Seattle, WA 98121 (

US Burden of Disease Collaborators: Ali H. Mokdad, PhD; Katherine Ballestros, PhD; Michelle Echko, BS; Scott Glenn, MSc; Helen E. Olsen, MA; Erin Mullany, BA; Alex Lee, BS; Abdur Rahman Khan, MD; Alireza Ahmadi, MD; Alize J. Ferrari, PhD; Amir Kasaeian, PhD; Andrea Werdecker, PhD; Austin Carter, BS; Ben Zipkin, BS; Benn Sartorius, PhD; Berrin Serdar, PhD; Bryan L. Sykes, PhD; Chris Troeger, MPH; Christina Fitzmaurice, MD; Colin D. Rehm, PhD; Damian Santomauro, PhD; Daniel Kim, DrPH; Danny Colombara, PhD; David C. Schwebel, PhD; Derrick Tsoi, BS; Dhaval Kolte, MD; Elaine Nsoesie, PhD; Emma Nichols, BA; Eyal Oren, PhD; Fiona J. Charlson, PhD; George C. Patton, MD; Gregory A. Roth, MD; H. Dean Hosgood, PhD; Harvey A. Whiteford, PhD; Hmwe Kyu, PhD; Holly E. Erskine, PhD; Hsiang Huang, MD; Ira Martopullo, MPH; Jasvinder A. Singh, MD; Jean B. Nachega, PhD; Juan R. Sanabria, MD; Kaja Abbas, PhD; Kanyin Ong, PhD; Karen Tabb, PhD; Kristopher J. Krohn, MPH; Leslie Cornaby, BS; Louisa Degenhardt, PhD; Mark Moses, MHS; Maryam Farvid, PhD; Max Griswold, MA; Michael Criqui, MD; Michelle Bell, PhD; Minh Nguyen, BS; Mitch Wallin, MD; Mojde Mirarefin, MPH; Mostafa Qorbani, PhD; Mustafa Younis, DrPH; Nancy Fullman, MPH; Patrick Liu, MPH; Paul Briant, BS; Philimon Gona, PhD; Rasmus Havmoller, PhD; Ricky Leung, PhD; Ruth Kimokoti, MD; Shahrzad Bazargan-Hejazi, PhD; Simon I. Hay, DSc; Simon Yadgir, BS; Stan Biryukov, BS; Stein Emil Vollset, DrPH; Tahiya Alam, MPH; Tahvi Frank, BS; Talha Farid, MD; Ted Miller, PhD; Theo Vos, PhD; Till Bärnighausen, MD; Tsegaye Telwelde Gebrehiwot, MPH; Yuichiro Yano, MD; Ziyad Al-Aly, MD; Alem Mehari, MD; Alexis Handal, PhD; Amit Kandel, MBBS; Ben Anderson, MD; Brian Biroscak, PhD; Dariush Mozaffarian, MD; E. Ray Dorsey, MD; Eric L. Ding, ScD; Eun-Kee Park, PhD; Gregory Wagner, MD; Guoqing Hu, PhD; Honglei Chen, PhD; Jacob E. Sunshine, MD; Jagdish Khubchandani, PhD; Janet Leasher, OD; Janni Leung, PhD; Joshua Salomon, PhD; Jurgen Unutzer, MD; Leah Cahill, PhD; Leslie Cooper, MD; Masako Horino, MPH; Michael Brauer, ScD; Nicholas Breitborde, PhD; Peter Hotez, PhD; Roman Topor-Madry, PhD; Samir Soneji, PhD; Saverio Stranges, PhD; Spencer James, MD; Stephen Amrock, MD; Sudha Jayaraman, MD; Tejas Patel, MD; Tomi Akinyemiju, PhD; Vegard Skirbekk, PhD; Yohannes Kinfu, PhD; Zulfiqar Bhutta, PhD; Jost B. Jonas, MD; Christopher J. L. Murray, DPhil.

Affiliations of US Burden of Disease Collaborators: Institute for Health Metrics and Evaluation, University of Washington, Seattle (Mokdad, Ballestros, Echko, Glenn, Olsen, Mullany, Lee, Ferrari, Carter, Zipkin, Troeger, Fitzmaurice, Santomauro, Colombara, Tsoi, Nsoesie, Nichols, Charlson, Roth, Whiteford, Kyu, Erskine, Martopullo, Ong, Krohn, Cornaby, Degenhardt, Moses, Griswold, Nguyen, Mirarefin, Fullman, Liu, Briant, Hay, Yadgir, Biryukov, Vollset, Alam, Frank, Vos, Brauer, James, Murray); University of Louisville, Louisville, Kentucky (Khan, Farid); Kermanshah University of Medical Sciences, Kermanshah, Iran (Ahmadi); Karolinska Institutet, Stockholm, Sweden (Ahmadi, Havmoller); School of Public Health, University of Queensland, Brisbane, Australia (Ferrari, Santomauro, Charlson, Whiteford, Erskine); Queensland Centre for Mental Health Research, Brisbane, Australia (Ferrari, Santomauro, Charlson, Whiteford, Erskine); Hematology-Oncology and Stem Cell Transplantation Research Center, and Hematologic Malignancies Research Center, Tehran University of Medical Sciences, Tehran, Iran (Kasaeian); Competence Center Mortality-Follow-Up of the German National Cohort, Federal Institute for Population Research, Wiesbaden, Hessen, Germany (Werdecker); Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Sartorius); UKZN Gastrointestinal Cancer Research Centre, South African Medical Research Council, Durban, South Africa (Sartorius); University of Colorado, Aurora (Serdar); Departments of Criminology, Law & Society, Sociology, and Public Health, University of California, Irvine (Sykes); Division of Hematology, Department of Medicine, University of Washington, Seattle, and Fred Hutchinson Cancer Research Center, Seattle (Fitzmaurice); Montefiore Medical Center, Bronx, New York (Rehm); Department of Health Sciences, Northeastern University, Boston, Massachusetts (Kim); University of Alabama at Birmingham (Schwebel, Singh, Akinyemiju); Division of Cardiology, Brown University, Providence, Rhode Island (Kolte); Division of Epidemiology & Biostatistics, Graduate School of Public Health, San Diego State University, San Diego, California (Oren); Murdoch Childrens Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia (Patton); Albert Einstein College of Medicine, Bronx, New York (Hosgood); Cambridge Health Alliance, Cambridge, Massachusetts (Huang); Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Nachega); Stellenbosch University, Cape Town, Western Cape, South Africa (Nachega); Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Nachega); Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia (Sanabria); Case Western Reserve University, Cleveland, Ohio (Sanabria); Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England (Abbas); School of Social Work, University of Illinois at Urbana-Champaign (Tabb); National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia (Degenhardt); Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts (Farvid, Ding, Cahill); Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston (Farvid); University of California, San Diego, La Jolla, California (Criqui); Yale University, New Haven, Connecticut (Bell, Biroscak); VA Medical Center, Washington, DC (Wallin); Neurology Department, Georgetown University, Washington, DC (Wallin); Hunger Action Los Angeles, Los Angeles, California (Mirarefin); Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Alborz, Iran (Qorbani); Jackson State University, Jackson, Mississippi (Younis); University of Massachusetts, Boston (Gona); State University of New York, Albany, Rensselaer, New York (R. Leung); Simmons College, Boston, Massachusetts (Kimokoti); College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California (Bazargan-Hejazi); David Geffen School of Medicine, University of California at Los Angeles (Bazargan-Hejazi); Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom (Hay); Center for Disease Burden, Norwegian Institute of Public Health, and Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway (Vollset); Pacific Institute for Research & Evaluation, Calverton, Maryland (Miller); School of Public Health, Curtin University, Perth, Australia (Miller); Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts (Bärnighausen, Salomon); Africa Health Research Institute, Mtubatuba, South Africa (Bärnighausen); Institute of Public Health, Heidelberg University, Heidelberg, Germany (Bärnighausen); Jimma University, Jimma, Oromia, Ethiopia (Gebrehiwot); Department of Preventive Medicine, Northwestern University, Chicago, Illinois (Yano); Washington University in St Louis, St Louis, Missouri (Al-Aly); College of Medicine, Howard University, Washington, DC (Mehari); University of New Mexico, Albuquerque (Handal); University at Buffalo, Buffalo, New York (Kandel); University of Washington, Seattle (Anderson, Sunshine, J. Leung, Unutzer); University of South Florida, Tampa (Biroscak); Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts (Mozaffarian); University of Rochester Medical Center, Rochester, New York (Dorsey); Department of Medical Humanities and Social Medicine, College of Medicine, Kosin University, Busan, South Korea (Park); Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts (Wagner); Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan, China (Hu); Michigan State University, East Lansing (Chen); Department of Nutrition and Health Science, Ball State University, Muncie, Indiana (Khubchandani); College of Optometry, Nova Southeastern University, Fort Lauderdale, Florida (Leasher); School of Public Health, University of Queensland, Brisbane, Australia (J. Leung); Dalhousie University, Halifax, Canada (Cahill); Mayo Clinic, Jacksonville, Florida (Cooper); Bureau of Child, Family & Community Wellness, Nevada Division of Public and Behavioral Health, Carson City (Horino); University of British Columbia, Vancouver, Canada (Brauer); The Ohio State University, Columbus (Breitborde); College of Medicine, Baylor University, Houston, Texas (Hotez); Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland (Topor-Madry); Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland (Topor-Madry); Dartmouth College, Hanover, New Hampshire (Soneji); Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada (Stranges); Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg (Stranges); Oregon Health & Science University, Portland (Amrock); Department of Surgery, Virginia Commonwealth University, Richmond (Jayaraman); White Plains Hospital, White Plains, New York (Patel); Norwegian Institute of Public Health, Oslo, Norway (Skirbekk); Columbia University, New York, New York (Skirbekk); Centre for Research and Action in Public Health, University of Canberra, Canberra, Australia (Kinfu); Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan (Bhutta); Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada (Bhutta); Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany (Jonas).

Author Contributions: Dr Murray had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Murray, Mokdad, Troeger, Bell, Vos, Sykes, Dorsey, Cooper, Ahmadi, Kinfu, Younis, James.

Acquisition, analysis, or interpretation of data: Murray, Mokdad, Olsen, Mullany, Echko, Glenn, Ballesteros, Sartorius, Serdar, Troeger, Fitzmaurice, Rehm, Santomauro, Hosgood, Patton, Roth, Kyu, Martopullo, Nichols, Charlson, Degenhardt, Farvid, Criqui, Mirarefin, Huang, Gona, Havmoeller, Nachega, Hay, Biryukov, Vollset, Miller, Vos, Bärnighausen, Yano, Biroscak, Mozaffarian, Ding, Hu, Leasher, J. Leung, Salomon, Unützer, Horino, Bhutta, Al-Aly, Nsoesie, Schwebel, Kasaeian, Werdecker, Sykes, Colombara, Tsoi, Kolte, Sunshine, R. Leung, Erskine, Krohn, Whiteford, Oren, Kim, Singh, Ferrari, Khan, Carter, Sanabria, Abbas, Ong, Tabb, Moses, Cornaby, Fullman, Liu, Bazargan-Hejazi, Kimokoti, Breitborde, Hotez, Brauer, Dorsey, Cooper, Topor-Madry, Stranges, Amrock, Jayaraman, Patel, Akinyemiju, Ahmadi, Nguyen, Wallin, Qorbani, Yadgir, Frank, Farid, Alam, Kandel, Anderson, Park, Wagner, Chen, Khubchandani, Cahill, Soneji, James, Gebrehiwot.

Drafting of the manuscript: Murray, Mokdad, Olsen, Mullany, Glenn, Ballesteros, Roth, Vos, Horino, Krohn, Sanabria, Fullman, Ahmadi, Frank.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mokdad, Glenn, Troeger, Fitzmaurice, Rehm, Santomauro, Roth, Kyu, Martopullo, Nichols, Charlson, Hay, Biryukov, Vos, J. Leung, Kasaeian, Sykes, Colombara, Tsoi, Erskine, Ferrari, Carter, Ong, Moses, Cornaby, Liu, Nguyen, Qorbani, Yadgir, Frank, Khubchandani.

Obtained funding: Murray, Mokdad.

Administrative, technical, or material support: Murray, Mokdad, Olsen, Echko, Nachega, Hay, Mozaffarian, Unützer, R. Leung, Krohn, Whiteford, Singh, Akinyemiju, Ahmadi, Wallin, Alam, Park, James.

Supervision: Murray, Mokdad, Olsen, Mullany, Criqui, Bell, Vos, Salomon, Stranges, Ahmadi, Alam.

Other (created custom analyses, tables, and figures, and fact checked the analysis): Echko, Ballesteros, Lee, Glenn.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Singh reports receipt of grants and personal fees from Savient, Takeda, and Crealta/Horizon; personal fees from Regeneron, Merz, Iroko, Bioiberica, Allergan, UBM LLC, WebMD, and the American College of Rheumatology during the conduct of the study; personal fees from DINORA; and nonfinancial support from Outcomes Measures in Rheumatology outside the submitted work. Dr Degenhardt reports receipt of grants from Mundipharma, Indivior, and Seqirus outside the submitted work. Dr Bell reports receipt of grants from the US Environmental Protection Agency and the National Institutes of Health (NIH) during the conduct of the study, and honorarium and/or travel reimbursement from NIH, the American Journal of Public Health, Columbia University, Washington University, Statistical Methods and Analysis of Environmental Health Data Workshop, North Carolina State University, and Global Research Laboratory and Seoul National University. Dr Mozaffarian reports receipt of personal fees from Acasti Pharma, GOED, DSM, Haas Avocado Board, Nutrition Impact, Pollock Communications, Boston Heart Diagnostics, and Bunge; other for serving on a scientific advisory board from Omada Health and Elysium Health; a grant from NIH and the National Heart, Lung, and Blood Institute; a grant from the Bill and Melinda Gates Foundation; and royalties from UpToDate outside the submitted work.

Funding/Support: This study was supported in part by the Intramural Program of the National Institutes of Health, the National Institute of Environmental Health Sciences, and in part by the Bill and Melinda Gates Foundation.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contribution: We thank Ashkan Afshin for assistance with revisions to the risk factor section of this article.

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