Lancet. 2024 Dec 7;404(10469):2314-2340. doi: 10.1016/S0140-6736(24)01446-6.
The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides a comprehensive assessment of health and risk factor trends at global, regional, national, and subnational levels. This study aims to examine the burden of diseases, injuries, and risk factors in the USA and highlight the disparities in health outcomes across different states.
GBD 2021 analysed trends in mortality, morbidity, and disability for 371 diseases and injuries and 88 risk factors in the USA between 1990 and 2021. We used several metrics to report sources of health and health loss related to specific diseases, injuries, and risk factors. GBD 2021 methods accounted for differences in data sources and biases. The analysis of levels and trends for causes and risk factors within the same computational framework enabled comparisons across states, years, age groups, and sex. GBD 2021 estimated years lived with disability (YLDs) and disability-adjusted life-years (DALYs; the sum of years of life lost to premature mortality and YLDs) for 371 diseases and injuries, years of life lost (YLLs) and mortality for 288 causes of death, and life expectancy and healthy life expectancy (HALE). We provided estimates for 88 risk factors in relation to 155 health outcomes for 631 risk-outcome pairs and produced risk-specific estimates of summary exposure value, relative health risk, population attributable fraction, and risk-attributable burden measured in DALYs and deaths. Estimates were produced by sex (male and female), age (25 age groups from birth to ≥95 years), and year (annually between 1990 and 2021). 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws (ie, 500 random samples from the estimate's distribution). Uncertainty was propagated at each step of the estimation process.
We found disparities in health outcomes and risk factors across US states. Our analysis of GBD 2021 highlighted the relative decline in life expectancy and HALE compared with other countries, as well as the impact of COVID-19 during the first 2 years of the pandemic. We found a decline in the USA's ranking of life expectancy from 1990 to 2021: in 1990, the USA ranked 35th of 204 countries and territories for males and 19th for females, but dropped to 46th for males and 47th for females in 2021. When comparing life expectancy in the best-performing and worst-performing US states against all 203 other countries and territories (excluding the USA as a whole), Hawaii (the best-ranked state in 1990 and 2021) dropped from sixth-highest life expectancy in the world for males and fourth for females in 1990 to 28th for males and 22nd for females in 2021. The worst-ranked state in 2021 ranked 107th for males (Mississippi) and 99th for females (West Virginia). 14 US states lost life expectancy over the study period, with West Virginia experiencing the greatest loss (2·7 years between 1990 and 2021). HALE ranking declines were even greater; in 1990, the USA was ranked 42nd for males and 32nd for females but dropped to 69th for males and 76th for females in 2021. When comparing HALE in the best-performing and worst-performing US states against all 203 other countries and territories, Hawaii ranked 14th highest HALE for males and fifth for females in 1990, dropping to 39th for males and 34th for females in 2021. In 2021, West Virginia-the lowest-ranked state that year-ranked 141st for males and 137th for females. Nationally, age-standardised mortality rates declined between 1990 and 2021 for many leading causes of death, most notably for ischaemic heart disease (56·1% [95% UI 55·1-57·2] decline), lung cancer (41·9% [39·7-44·6]), and breast cancer (40·9% [38·7-43·7]). Over the same period, age-standardised mortality rates increased for other causes, particularly drug use disorders (878·0% [770·1-1015·5]), chronic kidney disease (158·3% [149·6-167·9]), and falls (89·7% [79·8-95·8]). We found substantial variation in mortality rates between states, with Hawaii having the lowest age-standardised mortality rate (433·2 per 100 000 [380·6-493·4]) in 2021 and Mississippi having the highest (867·5 per 100 000 [772·6-975·7]). Hawaii had the lowest age-standardised mortality rates throughout the study period, whereas Washington, DC, experienced the most improvement (a 40·7% decline [33·2-47·3]). Only six countries had age-standardised rates of YLDs higher than the USA in 2021: Afghanistan, Lesotho, Liberia, Mozambique, South Africa, and the Central African Republic, largely because the impact of musculoskeletal disorders, mental disorders, and substance use disorders on age-standardised disability rates in the USA is so large. At the state level, eight US states had higher age-standardised YLD rates than any country in the world: West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona. Low back pain was the leading cause of YLDs in the USA in 1990 and 2021, although the age-standardised rate declined by 7·9% (1·8-13·0) from 1990. Depressive disorders (56·0% increase [48·2-64·3]) and drug use disorders (287·6% [247·9-329·8]) were the second-leading and third-leading causes of age-standardised YLDs in 2021. For females, mental health disorders had the highest age-standardised YLD rate, with an increase of 59·8% (50·6-68·5) between 1990 and 2021. Hawaii had the lowest age-standardised rates of YLDs for all sexes combined (12 085·3 per 100 000 [9090·8-15 557·1]), whereas West Virginia had the highest (14 832·9 per 100 000 [11 226·9-18 882·5]). At the national level, the leading GBD Level 2 risk factors for death for all sexes combined in 2021 were high systolic blood pressure, high fasting plasma glucose, and tobacco use. From 1990 to 2021, the age-standardised mortality rates attributable to high systolic blood pressure decreased by 47·8% (43·4-52·5) and for tobacco use by 5·1% (48·3%-54·1%), but rates increased for high fasting plasma glucose by 9·3% (0·4-18·7). The burden attributable to risk factors varied by age and sex. For example, for ages 15-49 years, the leading risk factors for death were drug use, high alcohol use, and dietary risks. By comparison, for ages 50-69 years, tobacco was the leading risk factor for death, followed by dietary risks and high BMI.
GBD 2021 provides valuable information for policy makers, health-care professionals, and researchers in the USA at the national and state levels to prioritise interventions, allocate resources effectively, and assess the effects of health policies and programmes. By addressing socioeconomic determinants, risk behaviours, environmental influences, and health disparities among minority populations, the USA can work towards improving health outcomes so that people can live longer and healthier lives.
Bill & Melinda Gates Foundation.
《2021年全球疾病、伤害及风险因素负担研究》（GBD 2021）全面评估了全球、区域、国家及次国家层面的健康与风险因素趋势。本研究旨在考察美国疾病、伤害及风险因素的负担，并突出不同州健康结果的差异。
GBD 2021分析了1990年至2021年间美国371种疾病和伤害以及88种风险因素的死亡率、发病率和残疾情况趋势。我们使用了多种指标来报告与特定疾病、伤害及风险因素相关的健康和健康损失来源。GBD 2021的方法考虑了数据来源和偏差的差异。在同一计算框架内对病因和风险因素的水平及趋势进行分析，能够在州、年份、年龄组和性别之间进行比较。GBD 2021估计了371种疾病和伤害的失能调整生命年（YLDs）和伤残调整生命年（DALYs；过早死亡损失的生命年与YLDs之和）、288种死因的寿命损失年（YLLs）和死亡率，以及预期寿命和健康预期寿命（HALE）。我们针对631个风险-结果对中的155种健康结果提供了88种风险因素的估计值，并得出了以DALYs和死亡数衡量的特定风险的汇总暴露值、相对健康风险、人群归因分数和风险归因负担的估计值。估计值按性别（男性和女性）、年龄（从出生到≥95岁的25个年龄组）和年份（1990年至2021年每年）生成。所有最终估计值均生成95%不确定性区间（UIs），即500次抽样（即从估计分布中抽取500个随机样本）的第2.5百分位数和第97.5百分位数的值。不确定性在估计过程的每个步骤中进行传播。
我们发现美国各州在健康结果和风险因素方面存在差异。我们对GBD 2021的分析突出了与其他国家相比，美国预期寿命和HALE的相对下降，以及新冠疫情头两年的影响。我们发现1990年至2021年美国的预期寿命排名下降：1990年，美国在204个国家和地区中男性排名第35位，女性排名第19位，但在2021年降至男性第46位，女性第47位。将美国表现最佳和最差的州的预期寿命与其他所有203个国家和地区（不包括整个美国）进行比较时，夏威夷（1990年和2021年排名最高的州）在1990年男性预期寿命全球排名第六，女性排名第四，到2021年降至男性第28位，女性第22位。2021年排名最差的州男性排名第107位（密西西比州），女性排名第99位（西弗吉尼亚州）。在研究期间，14个美国州的预期寿命下降，西弗吉尼亚州下降幅度最大（1990年至2021年下降2.7年）。HALE排名下降幅度更大；1990年，美国男性排名第42位，女性排名第32位，但在2021年降至男性第69位，女性第76位。将美国表现最佳和最差的州的HALE与其他所有203个国家和地区进行比较时，夏威夷在1990年男性HALE全球排名第14位，女性排名第5位，到2021年降至男性第39位，女性第34位。2021年，西弗吉尼亚州（当年排名最低的州）男性排名第141位，女性排名第137位。在全国范围内，1990年至2021年许多主要死因的年龄标准化死亡率下降，最显著的是缺血性心脏病（下降56.1%[95% UI 55.1 - 57.2]）、肺癌（41.9%[39.7 - 44.6]）和乳腺癌（40.9%[38.7 - 43.7]）。同期，其他死因的年龄标准化死亡率上升，尤其是药物使用障碍（878.0%[770.1 - 1015.5]）、慢性肾病（158.3%[149.6 - 167.9]）和跌倒（89.7%[79.8 - 95.8]）。我们发现各州之间的死亡率存在很大差异，2021年夏威夷的年龄标准化死亡率最低（每10万人433.2例[380.6 - 493.4]），密西西比州最高（每10万人867.5例[772.6 - 975.7]）。在整个研究期间，夏威夷的年龄标准化死亡率最低，而华盛顿特区改善最为明显（下降40.7%[33.2 - 47.3]）。2021年只有六个国家的年龄标准化YLD率高于美国：阿富汗、莱索托、利比里亚、莫桑比克、南非和中非共和国，主要是因为肌肉骨骼疾病、精神疾病和物质使用障碍对美国年龄标准化残疾率的影响很大。在州层面，八个美国州的年龄标准化YLD率高于世界上任何一个国家：西弗吉尼亚州、肯塔基州、俄克拉何马州、宾夕法尼亚州、新墨西哥州、俄亥俄州、田纳西州和亚利桑那州。腰痛是1990年和2021年美国YLDs的主要原因，尽管年龄标准化率比1990年下降了7.9%（1.8 - 13.0）。2021年，抑郁症（增加56.0%[48.2 - 64.3]）和药物使用障碍（287.6%[247.9 - 329.8]）是年龄标准化YLDs的第二和第三大原因。对于女性，心理健康障碍的年龄标准化YLD率最高，1990年至2021年增加了59.8%（50.6 - 68.5）。夏威夷所有性别组合的年龄标准化YLD率最低（每10万人12085.3例[9090.8 - 15557.1]），而西弗吉尼亚州最高（每10万人14832.9例[11226.9 - 18882.5]）。在国家层面，2021年所有性别组合的主要GBD 2级死亡风险因素是收缩压升高、空腹血糖升高和烟草使用。1990年至2021年，收缩压升高导致的年龄标准化死亡率下降了47.8%（43.4 - 52.5），烟草使用导致的下降了5.1%（48.3% - 54.1%），但空腹血糖升高导致的死亡率上升了9.3%（0.4 - 1）。风险因素造成的负担因年龄和性别而异。例如，对于15 - 49岁年龄组，主要死亡风险因素是药物使用、高酒精摄入和饮食风险。相比之下，对于50 - 使用障碍（287.6%[247.9 - ]）是年龄标准化YLDs的第二和第三大原因。对于女性，心理健康障碍的年龄标准化YLD率最高，1990年至2021年增加了59.8%（50.6 - 68.5）。夏威夷所有性别组合的年龄标准化YLD率最低（每10万人12085.3例[9090.8 - 15557.1]），而西弗吉尼亚州最高（每10万人14832.9例[11226.9 - 18882.5]）。在国家层面，2021年所有性别组合的主要GBD 2级死亡风险因素是收缩压升高、空腹血糖升高和烟草使用。1990年至2021年，收缩压升高导致的年龄标准化死亡率下降了47.8%（43.4 - 52.5），烟草使用导致的下降了5.1%（48.3% - 54.1%），但空腹血糖升高导致的死亡率上升了9.3%（0.4 - 18.7）。风险因素造成的负担因年龄和性别而异。例如，对于15 - 49岁年龄组，主要死亡风险因素是药物使用、高酒精摄入和饮食风险。相比之下，对于50 - 69岁年龄组，烟草是主要死亡风险因素，其次是饮食风险和高BMI。
GBD 2021为美国国家和州层面的政策制定者、医疗保健专业人员和研究人员提供了有价值的信息，以便对干预措施进行优先排序、有效分配资源并评估卫生政策和计划的效果。通过解决社会经济决定因素、风险行为、环境影响以及少数族裔人群中的健康差异问题，美国可以努力改善健康结果，使人们能够活得更长、更健康。
比尔及梅琳达·盖茨基金会。
