A report card on the nation's health from 1990 to 2016 was reported in last month's Journal of the American Medical Association (doi:101001/jama/2018.0158). Although the nation's overall health improved in that 26-year interval, some states lagged far behind the rest of the country, and some worrisome trends are evident.

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Dr. Clif Cleaveland

The Global Burden of Disease study (GBD) analyzes masses of data from multiple sources to assess the state of the nation's health. From the data, increased threats to the nation's health can be identified and, hopefully, addressed. Legislators, political leaders and public-health officials should read this study.

» Life and death: Average life expectancy at birth increased during the interval from 75.5 to 78.9 years. The death rate per 100,000 population decreased from 745.2 in 1990 to 578 in 2016. The probability of death from birth to age 20 declined in all states and Washington, D.C. The probability of death for ages 20 to 55 actually increased in 21 states. In five states — Kentucky, New Mexico, Oklahoma, West Virginia and Wyoming — the mortality probability for this age group increased by more than 10 percent. Drug abuse, cirrhosis of the liver and self-harm account for much of the increase.

» Healthy life expectancy: The GBD study assesses healthy life expectancy (HALE) — years before disabling illness or injury. For 2016, the U.S. average is 67.7 years. Minnesota has the highest HALE at 70.3 years, compared to West Virginia's lowest HALE of 63.8 years. The HALE for Tennessee in 2016 is 66.9 years, ranking 45th among the states.

» Premature death: Another prominent feature of the GBD study is the calculation of years of life lost due to premature deaths. Ischemic heart disease, cancer of trachea, bronchus and lung, emphysema, Alzheimer and other dementias, and colon-rectal cancer topped the list of causes of premature death in 2016. Opioid-use disorders rose from 52nd in 1990 to 15th place (18,200 deaths) in 2016. Self-harm by firearms rose slightly from 14th to 13th place. Other violence from firearms fell from 15th to 18th place. Deaths related to firearms totaled 34.1 thousand in 1990 vs. 36.2 thousand in 2016.

» Disabilities: Disability adjusted life-years (DALYs) is a calculation of the number of years lived with a disability. The five leading causes for DALYs in 2016 were low back pain, major depression, diabetes mellitus, other musculoskeletal disorders and migraine. Each of the following disorders accounted for 5 percent or more of DALYs: tobacco use, obesity, poor diet, alcohol and/or illicit drug use and elevated fasting blood glucose. The incidence of all but tobacco use had increased from 1990 to 2016.

» Lowest rankings: Ten states in the GBD study had poor outcomes by most measurements of health. In order of worsening health, they are: New Mexico, South Carolina, Tennessee, Kentucky, Arkansas, Oklahoma, Louisiana, Alabama, West Virginia and Mississippi.

» Underlying causes: For all states, the top three factors undermining health were tobacco use, obesity and alcohol and illicit drug use. All three can be addressed by aggressive public-health campaigns. Tobacco remains a major risk factor for lung and other cancer and emphysema. Obesity raises the risks for Type 2 diabetes, cancer, sleep apnea and degenerative arthritis. Sudden death, accidents, violent behavior and, in the case of drugs, infections related to dirty needles are the consequence of substance abuse.

Public health is seldom mentioned in political campaigns. Prospects for a brighter, more prosperous future will be undermined for a growing number of Americans unless worsening health is addressed at all levels of government and society.

Next week: State and local variations in health.

Clif Cleaveland, M.D., is a retired internist and former president of the American College of Physicians. Email him at