Why are more Americans dying in their prime?

After decades of rising life expectancy among Americans, average life expectancy is now going down in the United States. The reason? An increasing number of deaths among American working-age adults (aged 25 to 64 years)—a trend that began years ago—according to researchers of a recent study published in JAMA.

“Working-age Americans are more likely to die in the prime of their lives,” said lead author Steven Woolf, MD, MPH, director emeritus, Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond, VA. “For employers, this means that their workforce is dying prematurely, impacting the US economy. More importantly, this trend means that children are losing their parents and our children are destined to live shorter lives than us.”

But, why are more Americans dying in middle age?

All-cause mortality

For this study, Dr. Woolf and co-author Heidi Schoomaker obtained 1959-2016 life expectancy data from the US Mortality Database and 1999-2017 cause-specific mortality rates from CDC WONDER, an epidemiologic database. After analyzing the data, the researchers found that average US life expectancy had increased by 9 years during the last 6 decades, from 69.9 years in 1959 to 78.9 years in 2014, with the fastest increase occurring in the 1970s.

But starting in 2014, life expectancy declined significantly for 3 consecutive years, reaching an average of 78.6 years in 2017. The researchers determined that this decline wasn’t due to greater mortality in most age groups, including infants, children (age 1-14 years), and older adults (age 65-84 years)—all of whom had decreases in mortality from 1999 to 2017.

But, all-cause mortality increased 6% in midlife adults between 2010 to 2017. Even more dire, all-cause mortality increased 29% in adults aged 25 to 34 years during this period.

Again, why are deaths in working-age adults increasing?

Cause-specific mortality

A picture began to emerge when the investigators turned from examining all-cause mortality to specific causes of mortality.

“Although all-cause mortality in midlife did not begin increasing in the United States until 2010, midlife mortality rates for a variety of specific causes…began increasing earlier,” wrote Dr. Woolf and Schoomaker.

Beginning in the 1990s, these cause-specific increases didn’t decrease all-cause mortality because they were offset by large increases in life expectancy thanks to lower rates of leading causes of death, including ischemic heart disease, cancer, HIV infection, motor vehicle injuries, and other causes. However, increases in cause-specific mortality rates did slow the rate at which all-cause mortality decreased and life expectancy increased—a trend that eventually reversed. In 2010, all-cause mortality began to rise, pushing down life expectancy since 2014.

Mortality rates increased for 35 causes of death between 1999 and 2017, primarily in midlife adults. The most striking cause-specific increases were due to drug overdoses, alcohol abuse, and suicides, but mortality rates also increased from a number of organ system diseases.

Specifically, deaths in midlife adults increased by:

• 386.5% from drug overdoses

• 40.6% from alcoholic liver disease

• 38.3% from suicide

• 78.9% from hypertension

• 114.0% from obesity

In particular age groups, things were much worse. In adults aged 25 to 34 years, deaths from alcoholic liver disease increased 157.6%. Adults aged 55 to 64 years had a 909.2% increase in overdose deaths as well as a 55.9% increase in suicides. (Across all age groups, the largest relative increase in suicide—113.4%—occurred among children aged 5 to 14 years.)

Regional differences

“The notion that US death rates are increasing for working-age adults is particularly disturbing because it is not happening like this in other countries,” Dr. Woolf said. “This is a distinctly American phenomenon.”

In the years leading up to 2017, 37 states had increases in midlife mortality. But the largest increases occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%; Massachusetts, 12.1%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%).

Four states that make up only 10.8% of the US population (Ohio, Pennsylvania, Indiana, and Kentucky) accounted for nearly one-third (32.8%) of excess deaths since 2010. (“Excess deaths” is the number of deaths greater than the number of deaths projected by US mortality rates.)

In general, rural counties had greater increases in all-cause midlife mortality than urban counties. Overall, 8 of the 10 states with the largest number of excess deaths were in the industrial Midwest or Appalachia.

Women’s deaths increasing from certain causes

Men generally had higher cause-specific mortality rates and larger increases in mortality than women, but this didn’t hold true for certain causes of death. For example, between 1999 and 2017, the increase in midlife fatal drug overdoses was 1.4 times higher among women than among men. Similarly, the increase in midlife mortality was 3.4 times higher for alcoholic liver disease and 1.5 times higher for suicide among women than among men.

A call to action

This study represents “a call to action,” according to experts from the Harvard T.H. Chan School of Public Health, Boston, MA, and the Bipartisan Policy Center, Washington DC, in a related editorial in JAMA.

“Further research must explore how income inequality, unstable employment, divergent state policies and other social dimensions affect disease,” they wrote. “Broad and committed collaboration with sectors beyond health to reverse US health disadvantage could restore well-being opportunities for millions. Otherwise, the nation risks life expectancy continuing downward in future years to become a troubling new norm.”