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

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 (cjlm@uw.edu).

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.