We’ve known for some time now that Americans are increasingly dying younger, but the scale and nature of the problem has been a little bit murky. There was speculation that the downturn in American life expectancy was all thanks to “deaths of despair,” but some experts have said that might not be the full story, and that obesity and tobacco are still major factors in American mortality.

A new study out today in the Journal of the American Medical Association drills down into which states are showing increases in deaths among the young, and why. In doing so, it reveals a profound disparity among the states when it comes to both life expectancy and disability.

Most startlingly, since 1990, 21 states have seen an increase in the death rate among people aged 20 to 55. In five states—Kentucky, Oklahoma, New Mexico, West Virginia, and Wyoming—the probability of early death among young adults rose by more than 10 percent in that time frame. Meanwhile, in New York and California, young and middle-aged people became much less likely to die in the same time period. The authors note that opioids, alcoholism, suicide, and kidney disease—which can be brought on by diabetes and alcoholism—were the main factors leading to the increases in early deaths.

In 2016, the 10 states with the highest probability of premature death among 20- to 55-year-olds were West Virginia, Mississippi, Alabama, Oklahoma, Kentucky, Arkansas, New Mexico, Louisiana, Tennessee, and South Carolina.

Meanwhile, the 10 states with lowest probability of premature death among this age group were Minnesota, California, New York, Connecticut, New Jersey, Washington, Massachusetts, Vermont, New Hampshire, and Hawaii.

“Overall the nation and some of our states are falling behind other, less developed countries,” Ali Mokdad, a University of Washington epidemiologist who co-wrote the study, said in a statement. “The strain on America’s health resources is getting worse, and the need for prevention services and greater access to and quality of medical care is increasing.”

Though not an immediate cause of death, major depression increased by more than 27 percent across the country between 1990 and 2016, and anxiety rose by 31 percent.

Some of the findings track with the “diseases of despair” hypothesis—the idea that Americans are self-medicating their misery with alcohol and drugs—but it’s also clear that Americans’ poor diets are a major part of the problem. Between 1990 and 2016, Alzheimer’s disease and opioid abuse became more prominent causes of death and disability, but so did diabetes. A poor diet was the leading cause of death, followed by tobacco use and high blood pressure.

“To an increasing degree, overweight, obesity, and sugary diets are driving up health-care costs and are costing Americans years of healthy life,” said the University of Washington’s Chris Murray, who also authored the study, in a statement. “They are undermining progress toward better health.”

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