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. 2006 Oct 18;4:11. doi: 10.1186/1478-7954-4-11

The burden of disease and injury in the United States 1996

Catherine M Michaud 1,, Matthew T McKenna 2, Stephen Begg 3, Niels Tomijima 4, Meghna Majmudar 5, Maria T Bulzacchelli 6, Shahul Ebrahim 2, Majid Ezzati 1, Joshua A Salomon 1, Jessica Gaber Kreiser, Mollie Hogan 3, Christopher JL Murray 1
PMCID: PMC1635736  PMID: 17049081

Abstract

Background

Burden of disease studies have been implemented in many countries using the Disability-Adjusted Life Year (DALY) to assess major health problems. Important objectives of the study were to quantify intra-country differentials in health outcomes and to place the United States situation in the international context.

Methods

We applied methods developed for the Global Burden of Disease (GBD) to data specific to the United States to compute Disability-Adjusted Life Years. Estimates are provided by age and gender for the general population of the United States and for each of the four official race groups: White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Several adjustments of GBD methods were made: the inclusion of race; a revised list of causes; and a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease. We compared the results of this analysis to international estimates published by the World Health Organization for developed and developing regions of the world.

Results

In the mid-1990s the leading sources of premature death and disability in the United States, as measured by DALYs, were: cardiovascular conditions, breast and lung cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse. In addition, motor vehicle-related injuries and the HIV epidemic exacted a substantial toll on the health status of the US population, particularly among racial minorities. The major sources of death and disability in these latter populations were more similar to patterns of burden in developing rather than developed countries.

Conclusion

Estimating DALYs specifically for the United States provides a comprehensive assessment of health problems for this country compared to what is available using mortality data alone.

Background

This paper presents the results of a study conducted cooperatively by scientists from the Centers for Disease Control and Prevention (CDC) and the Harvard School of Public Health. The study essentially applied the methods used in the Global Burden of Disease analysis to data specific to the United States in order to calculate Disability-Adjusted Life Year (DALY) values for major health conditions and risk factors [1].

The genesis of the US Burden of Disease and Injury study (USBODI) was the release of the 1993 World Development Report: Investing in Health published by the World Bank. This landmark report in international health policy introduced a new summary measure of population health – the Disability-Adjusted Life Year (DALY) [2]. In contrast to the traditional reliance on death counts and rates to assess the burden of health events, the DALY attempted to combine the impact of non-fatal health outcomes with mortality. Though originally developed for comparative analyses of disease burden in different regions of the world, this perspective seemed particularly appropriate to inform policy in a country such as the United States. In industrialized country settings, where death rates are low relative to developing countries, the majority of deaths occur after the age of 75 years. Yet too many deaths still occur at younger ages and many could be prevented. Therefore, information for health policy deliberations needs to emphasize the burden of premature mortality as well as disability. As stated in a recent Institute of Medicine report on summary health measures, "Mortality measures, although important, provide decision makers incomplete and insensitive information about overall population health." [3].

From the outset, this study had three major goals. The first goal was to incorporate non-fatal conditions into assessments of health status in the United States. So far most discussions about the relative importance of various health conditions centered on the number of deaths attributed to specific diseases, injuries or risk factors [4]. The focus on deaths has important implications for policy and great influence on resource allocation. As the average life expectancy continues to rise in economically developed countries, more and more deaths are attributed to chronic conditions that are recalcitrant to treatment and may have limited preventability [5]. Prioritization of research and health care expenditures based on such data tends to result in a focus on rescue-oriented, life-saving, and technologically advanced approaches rather than adequate consideration of interventions that promote healthy life-styles and improve overall physical and emotional function [6]. The DALY offers a rational methodology for weighing the relative importance of fatal and non-fatal health events. Hence, a much broader range of health conditions that are rarely identified as causes of death, such as mental health disorders and musculoskeletal diseases, can be introduced into data-based deliberations on health policy.

The second major goal was to develop a comprehensive set of internally consistent and scientifically credible epidemiological estimates for the major health conditions in the United States. This is greatly facilitated by a plethora of population-based surveys, registries and administrative data systems that attempt to capture information on a wide range of health events [7]. The major challenge is to impose a consistent and conceptually rigorous analytic approach so that the estimates are internally consistent. Reviews of cost-effectiveness ratios that depend on epidemiologic data and statistical modeling have demonstrated that it is very difficult to compare results from one study to the next because of major variations in methods, underlying assumptions, data sources and conceptual frameworks [8]. A major source of these inconsistencies is that most such models are developed on a case by case, disease by disease basis, with little attention to conceptual consistency and integration of data from multiple sources [9]. Estimates developed with an adherence to conceptual consistency for the United States can serve not only as a useful source of epidemiologic information, but can also stimulate further analyses and refinements by other investigators.

The third and final goal of the US Burden of Disease and Injury study was to provide a set of internationally comparable health statistics that place the United States public health situation in a global context. World population growth and technological developments over the last few decades in telecommunications, industrial pollution and transportation have effectively made the earth a much smaller planet [10]. This dynamic has major implications for the importation and exportation of health related vectors that include infectious diseases, manufactured products (e.g. energy rich foods, tobacco), and health system organization and practices [11-13]. Given the emergence of this global public health "village," and the growing importance of the DALY as a metric for assessing population health, it seems critical to provide an analysis of the public health situation in the United States that uses methods being adopted by international organizations and health ministries throughout the world.

The Global Burden of Disease (GBD) study developed health statistics for 8 large regions of the world. It includes the United States, which possesses substantial intra-national racial, ethnic and cultural variability. Generating a set of estimates specific to the United States not only provides an opportunity to frame the major health problems in this country in a global context, but also facilitates explication of intra-national disparities. For example, a previously published monograph that resulted from this project identified differences between race, sex and county-specific life expectancies that rivaled differences seen between the nations with the highest (Japan) and lowest (Sierra Leone) life expectancy values in the world [14].

The overall purpose of this study is to expand the understanding of the major determinants of ill and good health in the United States. The ultimate goal of such understanding should be policies and programs that decrease the overall impact and disparities in disease, disability and premature death.

Methods

The study was patterned after the GBD and applied methods used in the GBD analysis to compute years of life lost due to premature mortality (YLL), years of life lost due to disability (YLD), and disability-adjusted life years (DALYs). The conceptual and computational details of how these parameters were estimated for individual conditions have been presented in the GBD. A summary overview of GBD methods is provided [see Additional file 1].

The detailed mortality data file for 1996 provided deaths by age, sex and race to compute YLL [15]. The National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), National Longitudinal Alcohol Epidemiologic Survey (NLAES), the National Hospital Discharge Database, disease registers, and epidemiological studies provided the epidemiological parameters needed to compute YLD for 72 conditions that account for at least 90 per cent of the DALY total in the United States. If data on race and gender specific subgroups were too sparse to derive reasonable epidemiological parameters for particular conditions, YLD were estimated for these subgroups using YLD to YLL ratios for the overall population. For the remaining 26 conditions, YLD were calculated using YLD to YLL ratios from Established Market Economies (EME) countries in the GBD, applied to US specific estimates of YLL. A detailed presentation of analytic methods, data sources, and data sets used to develop estimates for major causes of diseases and injuries is provided [see Additional file 2].

Below we describe adjustments that were made to GBD methods in the context of the United States. These were 1) the inclusion of race; 2) a revised list of causes; and 3) a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease (IHD).

Selection of population groups

Estimates of the burden of disease and injury were done by gender and seven age groups (0–4; 5–14; 15–24; 25–44; 45–64; 65–74 and 75+) for the total US population, as well as for each of the four official race groups specified by the Office of Management and Budget (OMB): White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Whites were the largest population group (82.8 per cent, or 219.7 million). Blacks represented 12.6 per cent of the population (33.5 million); American Indians – 0.9 per cent (2.3 million), and Asians – 3.7 per cent (9.7 million). Estimates by ethnicity were not included in this report because reliable estimates were only available for a subset of the Hispanic population.

The inclusion of race in the analysis posed particular challenges for minority populations because of race misclassification. Two independent data sets were combined to calculate death rates: the number of deaths in the numerator comes from the detailed mortality file, and population numbers in the denominator are from the census. There was no discrepancy in reporting of race in both data sets for Whites and Blacks, but race misclassification was found to be problematic for Asians and American Indians. Self-reporting of race in the census tended to be higher, particularly for American Indians, than was the attribution of race (by a third party) on death certificates – which will yield an underestimate of death rates [16]. However, we did not correct for race misclassification in American Indians and Asians because evaluations showed that discrepancies in race reporting varied from year to year and thus provided supportive evidence that there may be no systematic bias. Therefore race differentials expressed as rates may have been slightly overestimated. Death and DALY rates were age-standardized to the general population.

There were also important gaps in the available epidemiological data for Asians and American Indians. In order to fill information gaps, we assumed that ratios of YLL to YLD by cause, gender and age were similar to that of the total population. Such assumptions introduce a certain level of uncertainty in the estimates, and call for caution in the interpretation of rankings for causes that have small differences in the number of DALYs. For simplicity, American Indians or Alaskan Natives are referred to as "American Indians," and Asians or Pacific Islanders as "Asians" in the text, tables and figures below.

USBODI cause list

Even though essentially all deaths in the United States are registered and medically certified, a detailed assessment of mortality data was conducted as part of the USBODI. This was done to further explore and refine the utility of the adjustment procedures for misclassification that were used in the GBD, and to provide a contrast to the overall results using the DALY.

The International Statistical Classification of Disease and Related Health Problems, Version 9, (ICD-9) [17] code listed as the underlying cause for each death recorded in the United States in 1996 was attributed to corresponding disease categories listed in the GBD. The GBD classification scheme was developed as a tool to better inform the health policy debate (Table 1). The list of causes selected for the USBODI was amended based on the distribution of causes of deaths in the United States. All ICD-9 reported codes accounting for more than 0.1 per cent of total deaths were examined. This process identified modifications that were needed from the GBD cause list. Several causes of little relevance to the United States were dropped, i.e. malaria and other tropical diseases. Other causes were added, i.e. Sudden Infant Death Syndrome (SIDS), and septicemia. For those codes accounting for more than 0.1 per cent of deaths that were not included in the GBD list the choice was made in consultation with CDC based on two major criteria. If the code represented a true cause of death with significance for health policy, it was added to the cause list. If the code more likely represented a "garbage category," then after consultation with experts in that disease and a review of published autopsy studies on this subject, a redistribution algorithm was proposed and applied. For example, careful consideration was given to the nearly 10.9 per cent of cancer deaths assigned to "unknown primary." There were another 4% of cancers that did not have a code that corresponded to the GBD classification system. The race and sex specific age distribution of cancers attributed to an ill-defined primary source were compared to all other cancer deaths. These distributions were generally similar. Therefore, cancers attributed to an ill-defined primary source were redistributed proportionally to all defined primary sources based on age, race and sex specific distributions. The detailed list of causes selected for the USBODI is provided [see Additional file 3].

Table 1.

Global burden of disease classification system – main categories

Communicable, maternal, perinatal and nutritional conditions (Group I)
 A. Infectious and parasitic diseases
 B. Respiratory infections
 C. Maternal conditions
 D. Conditions arising during the perinatal period
 E. Nutritional deficiencies
Noncommunicable diseases (Group II)
 A. Malignant neoplasms
 B. Other neoplasms
 C. Diabetes mellitus
 D. Endocrine disorders
 E. Neuro-psychiatric conditions
 F. Sense organ diseases
 G. Cardiovascular diseases
 H. Respiratory diseases
 I. Digestive diseases
 J. Genito-urinary diseases
 K. Skin diseases
 L. Musculo-skeletal diseases
 M. Congenital anomalies
 N. Oral conditions
Injuries (Group III)
 A. Unintentional injuries
 B. Intentional injuries

Source: Global Burden of Disease and Injury 1990

Redistribution algorithm for cardiovascular garbage codes

The most problematic aspect of cause of death coding pertains to coding of ischaemic heart disease (IHD) (ICD-9 codes 410–414), which is one of the leading causes of premature mortality. The wide cross-national variations that exist in IHD reported mortality rates were explored in the context of the GBD and were convincingly attributed to variations across countries in coding practices. Physicians may use several ICD-9 codes that are actually due to IHD when they assign the cause of death. These include heart failure (428), ventricular dysrhythmias (427.1, 427.4, 427.5), general atherosclerosis (440.9), and ill-defined descriptions and complications of heart disease (429.0, 429.1, 429.2 and 429.9). IHD deaths may be assigned to these ill-defined cardiovascular codes, or "garbage codes" because of insufficient clinical information at the time of death, local medical diagnostic practices or simply by error. The statistical approach developed to correct for likely undercoding resulting from different coding practices in the GBD included a two-step procedure comprising an ordinary least squares (OLS) regression equation predicting the proportion of cardiovascular death for each age group assigned to ill-defined codes as a function of the proportion of deaths assigned to IHD, and the correction of proportions for each country within set constraints, based on the assumption that the cluster of countries where ill-defined coding was low defined the standard coding practices.

An exploration of cardiovascular death coding in the United States showed important differences in coding practices between states. Indeed, the proportion of all cardiovascular deaths (minus stroke) coded to cardiovascular "garbage" codes ranged from 14% in New Mexico to 37% in Alabama and New Jersey (Table 2). Figure 1 illustrates the enormous variation across US states in coding practices with respect to these ill-defined cardiovascular codes. For each state, the fraction of cardiovascular deaths (excluding stroke) that are assigned to ICD-9 codes 410–414 is shown on the y-axis. On the x-axis the fraction of cardiovascular deaths (excluding stroke) that are assigned to the ill-defined cardiovascular codes is measured. The strong negative relation between IHD mortality and that from ill-defined cardiovascular codes supports the suggestion that the quality of IHD death certification varies substantially across states, as it does across countries in the world.

Table 2.

Proportion of all cardiovascular deaths (except stroke) coded to cardiovascular "garbage codes" by state – United States 1996

State name % CV garbage State name % CV garbage State name % CV garbage
Alabama 37 Kentucky 25 North Dakota 19
Alaska 22 Louisiana 23 Ohio 25
Arizona 22 Maine 24 Oklahoma 18
Arkansas 21 Maryland 24 Oregon 23
California 18 Massachusetts 22 Pennsylvania 15
Colorado 26 Michigan 19 Rhode Island 20
Connecticut 29 Minnesota 35 South Carolina 21
Delaware 29 Mississippi 17 South Dakota 19
DC 28 Missouri 29 Tennessee 21
Florida 16 Montana 31 Texas 24
Georgia 30 Nebraska 34 Utah 24
Hawaii 28 Nevada 20 Vermont 26
Idaho 17 New Hampshire 17 Virginia 24
Illinois 19 New Jersey 37 Washington 26
Indiana 18 New Mexico 14 West Virginia 17
Iowa 20 New York 19 Wisconsin 21
Kansas 24 North Carolina 21 Wyoming 19

Figure 1.

Figure 1

Proportion of cardiovascular disease deaths (excluding stroke) assigned to selected codes for ill-defined causes and directly assigned to ischemic heart disease in the United States.

This preliminary analysis confirmed the need to correct for under-registration of IHD in the US. To estimate the fraction of IHD deaths assigned to ill-defined cardiovasular codes, the regression equation applied in the GBD was revised. Age and sex specific lung cancer death rates were added to the model. Lung cancer mortality rates measure the cumulative effects of tobacco exposure as a risk factor for IHD [18].

The regression model for the US included age and sex specific lung cancer death rates, and ill-defined cardiovascular disease (CVD) rates for Blacks and Whites. These regression equations predicted the proportion of ill-defined CVD deaths by age and sex for Whites and Blacks. We applied results of regression equations for Whites to American Indians and Asians, which were not included in the regressions due their small population size.

The finding that the extent of miscoding increased in older age groups is consistent with GBD regression results: R-square increases with increasing age, which provides further evidence that ill-defined codes are indeed being used for IHD which is more common in older ages. Differences in coding practices observed by race as well as gender are not fully explained (Table 3). A recent study concluded that "the greater presence of medical knowledge at the time of death, reflected by place of death and cardiologist per capita, reduces the use of ill-defined cardiovascular clusters. Racial and gender effects on coronary heart disease (CHD) assignment may reflect disparities in access to care and quality of care." [19]

Table 3.

R-squared values applied to the redistribution of cardiovascular garbage codes

WHITES
Male Lung Cancer CVGarbageCodes R-squared
Coefficient Pvalue Coefficient Pvalue
15 -0.499 0.273 0.557 .000 26.17%
30 2.396 .000 -0.193 0.424 52.10%
45 1.495 .000 -0.741 .000 77.77%
65 1.235 .000 -0.833 .000 69.02%
75 2.73 .000 -1.122 .000 47.64%
Female
15 0.348 0.0324 0.097 0.395 3.53%
30 0.727 .000 0.539 0.008 37.82%
45 0.869 .000 -0.315 0.283 31.41%
65 -0.459 0.206 0.752 0.018 11.47%
75 2.011 0.123 -0.679 0.021 12.25%

BLACKS
Male Lung Cancer CV GarbageCodes R-squared
Coefficient Pvalue Coefficient Pvalue

15 0.592 0.314 -0.0393 0.792 4.13%
30 1.575 0.013 0.0735 0.785 23.40%
45 1.211 .000 -0.403 0.025 47.27%
65 0.435 0.082 -0.551 .000 40.73%
75 0.183 0.769 -0.7207 0.005 26.34%
Female
15 -0.829 0.042 0.256 0.047 16.06%
30 -0.846 0.0127 0.532 0.03 12.85%
45 0.02 0.942 -0.11 0.634 8.30%
65 0.695 0.42 -1.369 0.059 13.60%
75 1.015 0.524 -0.772 0.013 16.67%

International comparisons

Ten countries with comparable levels of development and a population greater than 10 million: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom, were selected for international comparisons. YLL by cause were obtained directly from the World Health Organization (WHO). YLD and DALY estimates were only available at the regional level, with the exception of Australia, where a national burden of disease study applying the GBD methodology had been conducted [21].

International comparisons may address two sets of issues – the difference in the magnitude of YLL (expressed as YLL rates), or differences in the distribution of major causes of YLL. We examined differences in rankings of major causes of YLL and YLL rates between the United States and other comparable countries.

Rankings for the twenty leading causes of mortality burden in the United States were compared to rankings for these conditions in the ten selected countries. We made one change in the list of conditions adopted for the United States to ensure comparability among countries, which was to combine mortality burden due to lymphomas and multiple myelomas. These two conditions are different forms of reticuloendothelial malignancies. Estimates were not available for these conditions separately in several of the selected countries. This change slightly altered rankings in the United States for several conditions, as the two conditions combined had a higher mortality burden than lymphomas alone. Lymphomas and multiple myelomas ranked 14th for males and 13th for females, and the mortality burden for lymphomas ranked 19th and 17th respectively. We plotted the rankings for each of the twenty leading causes of mortality burden in the United States (horizontal bars) against the range of rankings observed for each of these conditions in the selected countries (vertical bars), for each sex. The lowest and highest rankings observed in the countries other than the US define the bounds of vertical bars for each condition. Rankings, from one to twenty, are inversely related to the magnitude of mortality burden. Thus, IHD, which caused the largest number of YLL in the United States, ranked 1st. We also compared YLL rankings for the twenty leading causes of YLL for each race and sex against the ranges observed in the ten selected countries.

Results

Detailed tabulations of deaths, YLL, YLD and DALYs for the 73 causes included in the USBODI by age, gender and race are provided [see Additional file 4]. Epidemiological parameters (incidence, prevalence, age at onset, duration, remission rates) and disability weights for each condition are provided [see Additional file 5].

Below we report key findings for the burden of disease and injury (DALYs); the mortality burden due to premature deaths (YLL); and the disability burden due to non-fatal health outcomes (YLD).

Burden of disease and injury

Leading causes of DALYs

The burden of disease and injury resulting from premature deaths and disability was an estimated 33 million DALYs in 1996. Premature mortality contributed 55 per cent of the total (18 million YLL), and disability – 45 per cent (15 million YLD). Noncommunicable diseases (Group II) caused 80 per cent of total DALYs, the balance being almost equally divided between communicable diseases, maternal, perinatal and nutritional causes (Group I) and injuries (Group III). Cardiovascular diseases, neuropsychiatric conditions, cancers and injuries caused approximately two thirds of the total DALYs (Figure 2). Ischaemic heart disease (IHD) was the leading and single largest cause of deaths and DALYs causing almost 10 per cent of DALYs. The three other causes ranking in the top five-cerebrovascular diseases, motor vehicle accidents, unipolar major depression – contributed almost equally to the total burden, with shares ranging between 4.1 and 4.6 per cent (Table 6).

Figure 2.

Figure 2

Burden of Disease (DALYs) by sex and major disease groups, US, 1996.

Table 6.

Twenty leading causes of DALYs and deaths, US 1996

DALY % of total Deaths % of total
Total DALYs 33,090,212 Total Deaths 2,314,689
Ischemic heart disease 3,134,732 9.5 Ischemic heart disease 536,314 23.17
Cerebrovascular Disease 1,510,287 4.6 Lung trachea or bronchial cancer 168,206 7.27
Motor vehicle accidents 1,393,278 4.2 Cerebrovascular Disease 161,678 6.98
Unipolar major depression 1,370,285 4.1 COPD 99,982 4.32
Lung trachea or bronchial cancer 1,362,712 4.1 Lower respiratory infections 84,319 3.64
COPD 1,253,491 3.8 Diabetes mellitus 62,452 2.70
Alcohol use 1,141,193 3.4 Cancer colon or rectum 61,189 2.64
HIV 956,418 2.9 Breast cancer 46,649 2.02
Diabetes mellitus 946,291 2.9 Motor vehicle accidents 43,735 1.89
Osteoarthritis 942,682 2.8 Dementia and other degenerative and hereditary CNS disorders 43,190 1.87
Dementia and other degenerative and hereditary CNS disorders 889,242 2.7 Hypertension and hypertensive heart disease 39,589 1.71
Congenital Abnomalities 761,951 2.3 Prostate cancer 36,667 1.58
Homicide and Violence 714,621 2.2 Self-inflicted 31,725 1.37
Self-inflicted 674,443 2.0 HIV 31,188 1.35
Asthma 665,103 2.0 Cancer pancreas 29,494 1.27
Drug use 543,841 1.6 Inflammatory Cardiac 29,066 1.26
Breast cancer 514,786 1.6 Lymphomas 26,443 1.14
Conditions arising during the perinatal period 493,958 1.5 Cirrhosis of the liver 25,488 1.10
Cancer colon or rectum 483,931 1.5 Nephritis or nephrosis 24,569 1.06
Cirrhosis of the liver 411,539 1.2 Homicide and Violence 22,351 0.01

Sex and age patterns

The total disease burden for males (17.9 million DALYs) exceeded that for females (15 million DALYs). The excess disease burden for males was mostly due to the much larger number of premature deaths in young adult males. IHD resulted in twice the number of DALYs for males as it did for females, and was equal to the combined disease burden due to the three major causes of injuries that took a high toll in young adult males – motor vehicle accidents, homicide and violence, and self-inflicted injuries. Unipolar major depression caused almost the same disease burden for females that did motor vehicle accidents for males (Table 7).

Table 7.

Twenty leading causes of DALYs, by sex, US 1996

Males
Cause list DALY % total
Total DALY 17,860,393
1 Ischaemic heart disease 1,958,184 11.0%
2 Motor vehicle accidents 933,798 5.2%
3 Lung trachea or bronchial cancer 812,804 4.6%
4 HIV 763,816 4.3%
5 Alcohol use 731,890 4.1%
6 Cerebrovascular Disease 673,928 3.8%
7 COPD 641,701 3.6%
8 Homicide and Violence 567,717 3.2%
9 Self-inflicted 541,399 3.0%
10 Unipolar major depression 469,929 2.6%
11 Diabetes mellitus 442,051 2.5%
12 Osteoarthritis 434,856 2.4%
13 Drug use 411,780 2.3%
14 Congenital Abnomalities 410,388 2.3%
15 Dementia and other degenerative and hereditary CNS disorders 382,392 2.1%
16 Asthma 303,088 1.7%
17 Cirrhosis of the liver 280,632 1.6%
18 Conditions arising during the perinatal period 273,577 1.5%
19 Cancer colon or rectum 249,462 1.4%
20 Prostate cancer 238,889 1.3%
sub-total 11,522,281 64.5%

Females

Cause list DALY % total
Total DALY 15,229,819
1 Ischaemic heart disease 1,176,548 7.7%
2 Unipolar major depression 900,356 5.9%
3 Cerebrovascular Disease 836,359 5.5%
4 COPD 611,790 4.0%
5 Lung trachea or bronchial cancer 549,908 3.6%
6 Breast cancer 514,786 3.4%
7 Osteoarthritis 507,826 3.3%
8 Dementia and other degenerative and hereditary CNS disorders 506,849 3.3%
9 Diabetes mellitus 504,240 3.3%
10 Motor vehicle accidents 459,480 3.0%
11 Alcohol use 409,303 2.7%
12 Asthma 362,015 2.4%
13 Congenital Abnomalities 351,563 2.3%
14 Cancer colon or rectum 234,469 1.5%
15 Conditions arising during the perinatal period 220,382 1.4%
16 Lower respiratory infections 195,448 1.3%
17 PTSD 193,533 1.3%
18 HIV 192,602 1.3%
19 Panic disorder 182,218 1.2%
20 Bipolar disorder 165,236 1.1%

Half of the total disease burden in the United States occurred in adults between the ages of 25 and 64 years, the other half being almost evenly split between younger and older age groups: 23 per cent under the age of 25 years, and 27 per cent for ages 65 years and above. In sharp contrast, the number of deaths gradually increased with age. More than half of all deaths occurred in adults aged 75 years and older (Table 8).

Table 8.

Ten leading causes of DALYs by age, US 1996

Rank All ages DALYs % of total 0–4 DALYs % of total
Total 33,090,212 Total 2,123,767
1 Ischaemic heart disease 3,134,732 9.5 Congenital abnomalities 679,542 32.0
2 Cerebrovascular disease 1,510,287 4.6 Perinatal conditions 492,486 23.2
3 Motor vehicle accidents 1,393,278 4.2 Sudden infant death syndrome 102,255 4.8
4 Unipolar major depression 1,370,285 4.1 Asthma 77,323 3.6
5 Lung, trachea or bronchial cancer 1,362,712 4.1 Diarrhoeal diseases 60,438 2.8
6 COPD 1,253,491 3.8 Motor vehicle accidents 48,630 2.3
7 Alcohol use 1,141,193 3.4 Falls 41,289 1.9
8 HIV 956,418 2.9 Homicide and violence 35,055 1.7
9 Diabetes mellitus 946,291 2.9 Lower respiratory infections 30,640 1.4
10 Osteoarthritis 942,682 2.8 Fires 22,090 1.0

Rank 5–14 DALYs % of total 15–24 DALYs % of total

Total 1,136,989 Total 3,884,235
1 Asthma 236,494 20.8 Motor vehicle accidents 499,505 12.9
2 Motor vehicle accidents 128,357 11.3 Alcohol use 433,515 11.2
3 Unipolar major depression 61,622 5.4 Drug use 291,844 7.5
4 Epilepsy 42,461 3.7 Homicide and violence 282,746 7.3
5 Schizophrenia 41,254 3.6 Schizophrenia 237,967 6.1
6 Falls 39,886 3.5 Bipolar disorder 221,134 5.7
7 Homicide and violence 28,242 2.5 Unipolar major depression 197,309 5.1
8 Fires 19,514 1.7 Panic disorder 158,379 4.1
9 Congenital abnomalities 17,860 1.6 Asthma 157,997 4.1
10 Drowning 16,472 1.4 Self-inflicted 157,281 4.0

Rank 25–44 DALYs % of total 45–64 DALYs % of total

Total 8,364,608 Total 8,478,954
1 Unipolar major depression 823,548 9.8 Ischaemic heart disease 1,154,002 13.6
2 HIV 751,598 9.0 Lung, trachea or bronchial cancer 630,224 7.4
3 Alcohol use 549,949 6.6 COPD 504,418 5.9
4 Motor vehicle accidents 523,203 6.3 Cerebrovascular Disease 492,918 5.8
5 Self-inflicted 352,241 4.2 Diabetes mellitus 395,612 4.7
6 Homicide and violence 308,550 3.7 Osteoarthritis 361,774 4.3
7 Ischaemic heart disease 274,704 3.3 Breast cancer 250,963 3.0
8 Diabetes mellitus 238,472 2.9 Unipolar major depression 237,590 2.8
9 COPD 234,552 2.8 Cirrhosis of the liver 208,861 2.5
10 Drug use 222,535 2.7 Cancer colon or rectum 190,453 2.2

Rank 65–74 DALYs % of total 75+ DALYs % of total

Total 4,710,335 Total 4,391,323
1 Ischaemic heart disease 820,583 17.4 Ischaemic heart disease 876,239 20.0
2 Lung, trachea or bronchial cancer 448,452 9.5 Dementias 469,035 10.7
3 Cerebrovascular disease 373,629 7.9 Cerebrovascular disease 420,278 48.0
4 COPD 282,397 6.0 Lung, trachea or bronchial cancer 200,620 4.6
5 Osteoarthritis 266,685 5.7 COPD 186,379 4.2
6 Dementias 224,484 4.8 Osteoarthritis 161,077 3.7
7 Diabetes mellitus 168,605 3.6 Lower respiratory infections 146,631 3.3
8 Cancer colon or rectum 138,630 2.9 Cancer colon or rectum 106,111 2.4
9 Prostate cancer 97,033 2.1 Diabetes mellitus 106,061 2.4
10 Breast cancer 94,919 2.0 Prostate cancer 81,456 1.9

The share of total DALYs was very similar for both sexes up to the age of 14 years, but increased in adult males between 15 and 64 years. In older adults, the share of total DALYs for females exceeded that for males (Table 9). Differentials in DALY rates between males and females were greatest between 25 and 44 years, when motor vehicle accidents, alcohol use and abuse, HIV/AIDS and major unipolar depression took the highest toll.

Table 9.

Distribution of burden of disease (DALYs) by age group and sex, US, 1996

Total Males Females
Age Group DALYs % of total DALYs % of total DALYs % of total

0–4 years 2,123,767 6.4% 1,164,600 6.5% 959,167 6.3%
5–14 years 1,136,989 3.4% 623,416 3.5% 513,573 3.4%
15–24 years 3,884,235 11.7% 2,279,895 12.8% 1,604,340 10.5%
25–44 years 8,364,608 25.3% 4,800,710 26.9% 3,563,898 23.4%
45–64 years 8,478,954 25.6% 4,754,166 26.6% 3,724,788 24.5%
65–74 years 4,710,335 14.2% 2,455,407 13.7% 2,254,928 14.8%
75 years and over 4,391,323 13.3% 1,782,198 10.0% 2,609,125 17.1%
Total 33,090,212 17,860,393 15,229,819

Patterns by race

Blacks and American Indians suffered disproportionate shares of total burden relative to their population size: DALY rates per thousand were 165.7 for Blacks; 128.7 for American Indians; 120.6 for Whites, and 75.3 for Asians. The proportional distribution of Groups I, II, and III varied between races, pointing to important differences in prevailing patterns of burden of disease. Group I and III combined caused one fifth of total DALYs for Whites and Asians, and one third of total DALYs for Blacks and American Indians. The excess was due to Group I (17 per cent of total DALYs) for Blacks and Group III for American Indians (19 per cent of total DALYs) (Figure 3).

Figure 3.

Figure 3

Groups I, II, and III as a percentage of total burden of disease (DALY) by race, US, 1996.

IHD was among the three leading causes of DALYs for all races. The two other causes were cerebrovascular diseases and lung cancer for Whites; HIV/AIDS and homicide and violence for Blacks; alcohol use and motor vehicle accidents for American Indians; and unipolar major depression and cerebrovascular diseases for Asians (Table 10).

Table 10.

Ten leading causes of DALYs by race, US 1996

Whites DALYs % total American Indians DALYs % total
Rank Total 26,510,011 Rank Total 294,474
1 Ischaemic heart disease 2,710,918 10.2% 1 Alcohol use 46,419 15.8%
2 Cerebrovascular Disease 1,201,246 4.5% 2 Motor vehicle accidents 23,112 7.8%
3 Lung trachea or bronchial cancer 1,170,492 4.4% 3 Ischaemic heart disease 14,598 5.0%
4 Motor vehicle accidents 1,148,293 4.3% 4 Unipolar major depression 11,815 4.0%
5 Unipolar major depression 1,127,045 4.3% 5 Cirrhosis of the liver 9,293 3.2%
6 COPD 1,111,489 4.2% 6 Diabetes mellitus 9,070 3.1%
7 Alcohol use 857,509 3.2% 7 Self-inflicted 8,336 2.8%
8 Osteoarthritis 820,284 3.1% 8 Cerebrovascular Disease 8,241 2.8%
9 Dementia and other degenerative and hereditary CNS disorders 791,780 3.0% 9 Homicide and Violence 7,754 2.6%
10 Diabetes mellitus 727,575 2.7% 10 Congenital Abnormalities 7,489 2.5%
Sub-total 11,666,630 44.0% sub-total 146,128 49.6%

Blacks DALYs % total Asians DALYs % total

Rank Total 5,552,448 Rank Total 733,279
1 HIV/AIDS 429,383 7.7% 1 Unipolar major depression 54,264 7.4%
2 Ischaemic heart disease 370,170 6.7% 2 Ischaemic heart disease 39,046 5.3%
3 Homicide and Violence 336,215 6.1% 3 Cerebrovascular Disease 33,883 4.6%
4 Cerebrovascular Disease 266,918 4.8% 4 COPD 29,040 4.0%
5 Alcohol use 230,780 4.2% 5 Osteoarthritis 29,027 4.0%
6 Motor vehicle accidents 193,159 3.5% 6 Motor vehicle accidents 28,714 3.9%
7 Diabetes mellitus 189,656 3.4% 7 Congenital Abnormalities 28,238 3.9%
8 Unipolar major depression 177,162 3.2% 8 Asthma 26,137 3.6%
9 Conditions arising during the perinatal period 174,558 3.1% 9 Diabetes mellitus 19,989 2.7%
10 Lung trachea or bronchial cancer 172,425 3.1% 10 Dementia and other degenerative and hereditary CNS disorders 17,831 2.4%
sub-total 2,540,426 45.8% sub-total 306,170 41.8%

Sex differentials in total burden by race increased with higher DALY rates. Male to female DALY ratios were 1.23 for Blacks, 1.21 for American Indians, 1.10 for Whites, 1.05 for Asians, and 1.17 overall. Although patterns of disease burden differed between races, leading causes were common to both sexes. Premature deaths contributed the largest share of total burden for males in all races, with the exception of Asian males. Non-fatal health outcomes contributed the largest share for females in all races, with the exception of Black females (Figure 4).

Figure 4.

Figure 4

Distribution of YLL and YLD by sex and race, US, 1996.

DALY rates by age, sex, and race for HIV/AIDS, IHD and cerebrovascular diseases; hypertension and hypertensive heart disease, inflammatory cardiac diseases; and major causes of injuries capture changes in DALY rates over the lifespan as well as differences by race and sex in these important causes of disease burden (Figures 5, 6, 7, 8). DALY rates peaked in young adults for HIV/AIDS and injuries, and increased with age for cardiovascular diseases. DALY rates for Black males and females exceeded rates for the other race groups for HIV/AIDS, hypertension, cerebrovascular diseases, inflammatory cardiac diseases, motor vehicle accidents, homicide and violence, and self-inflicted injuries. Differentials between Blacks and the other races were always greater for males than for females, and were greatest in young adult males for HIV/AIDS, homicide and violence, hypertension and inflammatory cardiac diseases. Asian males and females had the lowest DALY rates for all major causes of burden. Differentials between races were least pronounced for IHD for both sexes.

Figure 5.

Figure 5

HIV/AIDS: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 6.

Figure 6

IHD and cerebrovascular diseases: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 7.

Figure 7

Hypertension and inflammatory cardiac diseases: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 8.

Figure 8

Major causes of injuries: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Mortality burden

Leading causes of YLL

In 1996, 2.3 million people died in the United States, causing the loss of 18.1 million YLL (55 per cent of total DALYs). Age patterns of deaths and YLL differ: the number of deaths increased with age, the resulting number of YLL was greater for children and young adults than it was for older ages (Figure 9). The number of deaths and resulting number of YLL from any cause are not equivalent (Figure 10).

Figure 9.

Figure 9

Distribution of deaths and YLL by age, US 1996.

Figure 10.

Figure 10

Ten leading causes of mortality burden and death, as per cent of total, both sexes, US 1996.

IHD was the unequivocal lead cause of death and YLL, causing almost one of every four deaths and 16 per cent of total YLL. The mortality burden due to IHD was more than double the mortality burden due to lung cancer, and almost three times that due to motor vehicle accidents (Table 11). The share of YLL exceeded that of YLD for cardiovascular diseases, cancers, injuries, respiratory infections, and conditions arising during the perinatal period.

Table 11.

Leading causes of death and YLL, both sexes, all races combined

Deaths %total
Total Deaths 2,314,689
1 Ischaemic heart disease 536,314 23.2%
2 Lung trachea or bronchial cancer 168,206 7.3%
3 Cerebrovascular Disease 161,678 7.0%
4 COPD 99,982 4.3%
5 Lower respiratory infections 84,319 3.6%
6 Diabetes mellitus 62,452 2.7%
7 Cancer colon or rectum 61,189 2.6%
8 Breast cancer 46,649 2.0%
9 Motor vehicle accidents 43,735 1.9%
10 Dementia and other degenerative and hereditary CNS disorders 43,190 1.9%
11 Hypertension and hypertensive heart disease 39,589 1.7%
12 Prostate cancer 36,667 1.6%
13 Self-inflicted 31,725 1.4%
14 HIV 31,188 1.3%
15 Cancer pancreas 29,494 1.3%
16 Inflammatory Cardiac 29,066 1.3%
17 Lymphomas 26,443 1.1%
18 Cirrhosis of the liver 25,488 1.1%
19 Nephritis or nephrosis 24,569 1.1%
20 Homicide and Violence 22,351 1.0%
Sub-total 1,604,297 69.3%

YLL % total

Total YLL 18,066,099
1 Ischaemic heart disease 2,858,744 15.8%
2 Lung trachea or bronchial cancer 1,301,182 7.2%
3 Motor vehicle accidents 1,027,005 5.7%
4 Cerebrovascular Disease 784,443 4.3%
5 HIV 718,975 4.0%
6 Self-inflicted 660,917 3.7%
7 Homicide and Violence 615,332 3.4%
8 COPD 526,219 2.9%
9 Conditions arising during the perinatal period 464,131 2.6%
10 Diabetes mellitus 450,913 2.5%
11 Breast cancer 450,327 2.5%
12 Cancer colon or rectum 409,534 2.3%
13 Lower respiratory infections 388,441 2.2%
14 Cirrhosis of the liver 321,588 1.8%
15 Congenital Abnomalities 318,948 1.8%
16 Inflammatory Cardiac 258,328 1.4%
17 Hypertension and hypertensive heart disease 241,073 1.3%
18 Lymphomas 233,048 1.3%
19 Poisoning 221,906 1.2%
20 Cancer pancreas 205,972 1.1%
Sub-total 12,457,024 69.0%

Sex and age patterns

The number of deaths and the age at death is driving differentials in mortality burden observed by age, sex and race. The mortality burden for males (10.5 million YLL) was 40 per cent greater than that for females (7.5 million YLL) (Table 12). The excess male mortality burden was largely due to the higher mortality burden resulting from IHD, injuries (motor vehicle accidents, homicide and violence, self-inflicted injuries), and HIV/AIDS. These causes combined resulted in 40 per cent of total YLL (4.1 million YLL) for males, but only in 24 per cent of total YLL for females (1.8 million YLL), and accounted for 80 per cent of the total sex differential. The female mortality burden exceeded that of males only for cerebrovascular diseases. Also noteworthy was the toll due to breast cancer (450 thousand YLL), which was almost equal to that of lung cancer (523 thousand YLL). YLL rates were higher for all leading causes for males than they were for females, with the exception of cerebrovascular diseases (Figure 11). The pattern of mortality burden shifted from a predominance of injuries between ages 5 and 44 years, to a gradual increase in chronic diseases (cancers and cardiovascular diseases) among older adults (Tables 13, 14, 15, 16, 17, 18).

Table 12.

Leading causes of YLL, by sex, all races combined

Cause list YLL % total
All males 10,529,540
1 Ischaemic heart disease 1,806,420 17.2%
2 Lung trachea or bronchial cancer 777,726 7.4%
3 Motor vehicle accidents 701,111 6.7%
4 HIV 575,297 5.5%
5 Self-inflicted 533,874 5.1%
6 Homicide and Violence 486,129 4.6%
7 Cerebrovascular Disease 356,563 3.4%
8 COPD 268,774 2.6%
9 Conditions arising during the perinatal period 259,581 2.5%
10 Diabetes mellitus 220,494 2.1%
11 Cirrhosis of the liver 219,876 2.1%
12 Cancer colon or rectum 212,958 2.0%
13 Lower respiratory infections 202,668 1.9%
14 Congenital Abnomalities 172,399 1.6%
15 Poisoning 168,131 1.6%
16 Inflammatory Cardiac 167,316 1.6%
17 Prostate cancer 160,019 1.5%
18 Lymphomas 134,145 1.3%
19 Hypertension and hypertensive heart disease 127,968 1.2%
20 Leukemias 114,710 1.1%
Sub-total 7,666,158 72.8%

Cause list YLL % total

All females 7,536,559
1 Ischaemic heart disease 1,052,325 14.0%
2 Lung trachea or bronchial cancer 523,456 6.9%
3 Breast cancer 450,327 6.0%
4 Cerebrovascular Disease 427,881 5.7%
5 Motor vehicle accidents 325,894 4.3%
6 COPD 257,445 3.4%
7 Diabetes mellitus 230,419 3.1%
8 Conditions arising during the perinatal period 204,550 2.7%
9 Cancer colon or rectum 196,575 2.6%
10 Lower respiratory infections 185,774 2.5%
11 Congenital Abnomalities 146,548 1.9%
12 HIV 143,678 1.9%
13 Homicide and Violence 129,202 1.7%
14 Self-inflicted 127,043 1.7%
15 Ovarian cancer 122,350 1.6%
16 Hypertension and hypertensive heart disease 113,105 1.5%
17 Cirrhosis of the liver 101,712 1.3%
18 Cancer pancreas 99,766 1.3%
19 Lymphomas 98,902 1.3%
20 Inflammatory Cardiac 91,012 1.2%
Sub-total 5,027,963 66.7%
Figure 11.

Figure 11

Leading causes of mortality burden (YLL) by sex, US, 1996.

Table 13.

Five leading causes of mortality burden (YLL) by sex and age, US, 1996

Males
Rank All ages YLL % of total 0–4 YLL % of total

Total 10,529,540 Total 652,949
1 Ischaemic heart disease 1,806,420 17.16% Perinatal conditions 258,750 39.63%
2 Lung/Trachea/Bronchial cancer 777,726 7.39% Congenital abnormalities 127,080 19.46%
3 Motor vehicle accidents 701,111 6.66% Sudden infant death syndrome 61,101 9.36%
4 HIV/AIDS 575,297 5.46% Motor vehicle accidents 17,505 2.68%
5 Suicide 1,028,947 9.77% Lower respiratory infections 17,259 2.64%

Rank 5–14 YLL % of total 15–24 YLL % of total

Total 185,702 Total 845,157
1 Motor vehicle accidents 42,534 22.90% Motor vehicle accidents 263,631 31.19%
2 Homicide and violence 15,729 8.47% Homicide and violence 210,534 24.91%
3 Drowning 12,290 6.62% Suicide 131,075 15.51%
4 Congenital abnormalities 10,634 5.73% Drowning 20,807 2.46%
5 Suicide 8,483 4.57% Poisoning 18,087 2.14%

Rank 25–44 YLL % of total 45–64 YLL % of total

Total 2,548,913 Total 3,150,157
1 HIV/AIDS 444,123 17.42% Ischaemic heart disease 763,334 24.23%
2 Motor vehicle accidents 279,389 10.96% Lung/Trachea/Bronchial cancer 372,984 11.84%
3 Suicide 277,467 10.89% Cerebrovascular disease 115,851 3.68%
4 Homicide and violence 207,217 8.13% Cirrhosis of the liver 113,739 3.61%
5 Ischaemic heart disease 171,437 6.73% HIV/AIDS 111,874 3.55%

Rank 65–74 YLL % of total 75+ YLL % of total

Total 1,786,501 Total 1,360,161
1 Ischaemic heart disease 484,267 27.11% Ischaemic heart disease 382,495 28.12%
2 Lung/Trachea/Bronchial cancer 253,281 14.18% Lung/Trachea/Bronchial cancer 104,020 7.65%
3 Chronic obstructive pulmonary disease 103,012 5.77% Cerebrovascular disease 99,208 7.29%
4 Cerebrovascular disease 84,904 4.75% Chronic obstructive pulmonary disease 85,031 6.25%
5 Colon/Rectum cancer 62,395 3.49% Prostate cancer 64,236 4.72%
Table 14.

Five leading causes of mortality burden (YLL) by sex and age, US, 1996

Females
Rank All ages YLL % of total 0–4 YLL % of total

Total 7,536,559 Total 512,861
1 Ischaemic heart disease 1,052,325 13.96% Perinatal conditions 203,909 39.76%
2 Lung/Trachea/Bronchial cancer 523,456 6.95% Congenital abnormalities 109,458 21.34%
3 Breast cancer 450,327 5.98% Sudden infant death syndrome 41,154 8.02%
4 Cerebrovascular disease 427,881 5.68% Motor vehicle accidents 14,795 2.88%
5 Motor vehicle accidents 325,894 4.32% Homicide and violence 13,612 2.65%

Rank 5–14 YLL % of total 15–24 YLL % of total

Total 123,888 Total 285,089
1 Motor vehicle accidents 28,952 23.37% Motor vehicle accidents 117,878 41.35%
2 Homicide and violence 8,134 6.57% Homicide and violence 32,799 11.50%
3 Congenital abnormalities 7,226 5.83% Suicide 22,517 7.90%
4 Leukemias 6,120 4.94% Leukemias 6,726 2.36%
5 Brain cancer 5,611 4.53% HIV/AIDS 5,830 2.05%

Rank 25–44 YLL % of total 45–64 YLL % of total

Total 1,192,947 Total 2,053,395
1 Motor vehicle accidents 117,878 9.88% Ischaemic heart disease 524,172 25.53%
2 HIV/AIDS 109,310 9.16% Lung/Trachea/Bronchial cancer 234,241 11.41%
3 Breast cancer 95,818 8.03% Breast cancer 220,350 10.73%
4 Suicide 67,035 5.62% Cerebrovascular disease 99,565 4.85%
5 Homicide and violence 60,074 5.04% Diabetes mellitus 81,366 3.96%

Rank 65–74 YLL % of total 75+ YLL % of total

Total 1,503,549 Total 1,864,830
1 Ischaemic heart disease 277,053 18.43% Ischaemic heart disease 459,396 24.63%
2 Lung/Trachea/Bronchial cancer 172,116 11.45% Cerebrovascular disease 186,468 10.00%
3 Chronic obstructive pulmonary disease 97,759 6.50% Chronic obstructive pulmonary disease 88,838 4.76%
4 Cerebrovascular disease 90,698 6.03% Lung/Trachea/Bronchial cancer 84,492 4.53%
5 Breast cancer 82,227 5.47% Lower respiratory infections 83,467 4.48%
Table 15.

Leading causes of YLL by sex and race – Whites

Cause list YLL % total
Total White males 8,293,920
1 Ischaemic heart disease 1,584,087 19.1%
2 Lung trachea or bronchial cancer 656,850 7.9%
3 Road Traffic Accidents 573,953 6.9%
4 Self-inflicted 469,430 5.7%
5 HIV 334,425 4.0%
6 Cerebrovascular Disease 276,544 3.3%
7 COPD 244,401 2.9%
8 Homicide and Violence 221,000 2.7%
9 Cirrhosis of the liver 183,600 2.2%
10 Cancer colon or rectum 180,184 2.2%
11 Diabetes mellitus 173,405 2.1%
12 Conditions arising during the perinatal period 158,462 1.9%
13 Lower respiratory infections 158,231 1.9%
14 Congenital Abnomalities 135,970 1.6%
15 Poisoning 134,929 1.6%
16 Prostate cancer 128,058 1.5%
17 Inflammatory Cardiac 121,438 1.5%
18 Lymphomas 116,804 1.4%
19 Leukemias 99,137 1.2%
20 Cancer pancreas 89,780 1.1%
Sub-total 6,040,688 72.8%

Cause list YLL % total

Total White females 6,018,361
1 Ischaemic heart disease 895,819 14.9%
2 Lung trachea or bronchial cancer 460,651 7.7%
3 Breast cancer 370,855 6.2%
4 Cerebrovascular Disease 342,620 5.7%
5 Road Traffic Accidents 268,996 4.5%
6 COPD 240,803 4.0%
7 Diabetes mellitus 169,449 2.8%
8 Cancer colon or rectum 163,068 2.7%
9 Lower respiratory infections 153,465 2.5%
10 Conditions arising during the perinatal period 124,599 2.1%
11 Congenital Abnomalities 112,925 1.9%
12 Self-inflicted 112,621 1.9%
13 Ovarian cancer 108,262 1.8%
14 Lymphomas 87,677 1.5%
15 Cancer pancreas 83,238 1.4%
16 Cirrhosis of the liver 81,843 1.4%
17 Dementia and other degenerative and hereditary CNS disorders 76,867 1.3%
18 Leukemias 74,069 1.2%
19 Homicide and Violence 72,469 1.2%
20 Hypertension and hypertensive heart disease 72,258 1.2%
Sub-total 4,072,553 67.7%
Table 16.

Leading causes of YLL by sex and race – Blacks

Cause list YLL % total
Total Black males 1,978,704
1 Homicide and Violence 250,257 12.6%
2 HIV 234,400 11.8%
3 Ischaemic heart disease 189,031 9.6%
4 Lung trachea or bronchial cancer 109,191 5.5%
5 Motor vehicle accidents 99,734 5.0%
6 Conditions arising during the perinatal period 92,854 4.7%
7 Cerebrovascular Disease 69,225 3.5%
8 Self-inflicted 47,940 2.4%
9 Hypertension and hypertensive heart disease 44,841 2.3%
10 Inflammatory Cardiac 41,409 2.1%
11 Diabetes mellitus 40,795 2.1%
12 Lower respiratory infections 38,675 2.0%
13 Congenital Abnomalities 30,182 1.5%
14 Cirrhosis of the liver 30,182 1.5%
15 Poisoning 30,101 1.5%
16 Prostate cancer 30,075 1.5%
17 Cancer colon or rectum 28,380 1.4%
18 COPD 21,382 1.1%
19 Sudden Infant Death Syndrome 19,017 1.0%
20 Nephritis or nephrosis 17,092 0.9%
Sub-total 1,464,762 74.0%

Cause list YLL % total

Total Black females 1,342,205
1 Ischaemic heart disease 141,305 10.5%
2 HIV 89,973 6.7%
3 Cerebrovascular Disease 74,323 5.5%
4 Conditions arising during the perinatal period 73,969 5.5%
5 Breast cancer 70,421 5.2%
6 Lung trachea or bronchial cancer 55,561 4.1%
7 Diabetes mellitus 54,669 4.1%
8 Homicide and Violence 52,280 3.9%
9 Motor vehicle accidents 42,499 3.2%
10 Hypertension and hypertensive heart disease 39,005 2.9%
11 Cancer colon or rectum 28,896 2.2%
12 Congenital Abnomalities 28,218 2.1%
13 Lower respiratory infections 28,108 2.1%
14 Inflammatory Cardiac 25,707 1.9%
15 Nephritis or nephrosis 15,811 1.2%
16 Cirrhosis of the liver 15,701 1.2%
17 COPD 14,858 1.1%
18 Cancer pancreas 14,132 1.1%
19 Sudden Infant Death Syndrome 13,841 1.0%
20 Cancer cervix 13,786 1.0%
Sub-total 893,064 66.5%
Table 17.

Leading causes of YLL by sex and race – American Indians

Cause list YLL % total
Total American Indian males 83,713
1 Motor vehicle accidents 13,665 16.3%
2 Ischaemic heart disease 8,804 10.5%
3 Self-inflicted 6,472 7.7%
4 Homicide and Violence 5,287 6.3%
5 Cirrhosis of the liver 3,982 4.8%
6 Alcohol use 2,849 3.4%
7 Lung trachea or bronchial cancer 2,792 3.3%
8 Diabetes mellitus 2,610 3.1%
9 Lower respiratory infections 2,168 2.6%
10 Conditions arising during the perinatal period 2,078 2.5%
11 Poisoning 2,009 2.4%
12 HIV 1,952 2.3%
13 Cerebrovascular Disease 1,919 2.3%
14 Congenital Abnomalities 1,658 2.0%
15 Drowning 1,489 1.8%
16 Sudden Infant Death Syndrome 1,239 1.5%
17 Inflammatory Cardiac 1,193 1.4%
18 Cancer colon or rectum 816 1.0%
19 Falls 755 0.9%
20 COPD 719 0.9%
Sub-total 64,456 77.0%

Cause list YLL % total

Total Amerian Indian females 54,732
1 Motor vehicle accidents 6,429 11.7%
2 Ischaemic heart disease 4,247 7.8%
3 Cirrhosis of the liver 3,311 6.0%
4 Diabetes mellitus 2,970 5.4%
5 Cerebrovascular Disease 2,057 3.8%
6 Breast cancer 1,901 3.5%
7 Lung trachea or bronchial cancer 1,788 3.3%
8 Self-inflicted 1,786 3.3%
9 Homicide and Violence 1,534 2.8%
10 Conditions arising during the perinatal period 1,531 2.8%
11 Lower respiratory infections 1,523 2.8%
12 Congenital Abnomalities 1,182 2.2%
13 Alcohol use 1,156 2.1%
14 Sudden Infant Death Syndrome 907 1.7%
15 Cancer colon or rectum 851 1.6%
16 Poisoning 809 1.5%
17 COPD 731 1.3%
18 Ovarian cancer 678 1.2%
19 Inflammatory Cardiac 651 1.2%
20 Drowning 633 1.2%
Sub-total 36,675 67.0%
Table 18.

Leading causes of YLL by sex and race – Asians

Cause list YLL % total
Total Asian males 173,201
1 Ischaemic heart disease 24,497 14.1%
2 Motor vehicle accidents 13,759 7.9%
3 Self-inflicted 10,032 5.8%
4 Homicide and Violence 9,584 5.5%
5 Lung trachea or bronchial cancer 8,892 5.1%
6 Cerebrovascular Disease 8,875 5.1%
7 Cancer liver 6,330 3.7%
8 Conditions arising during the perinatal period 6,188 3.6%
9 Congenital Abnomalities 4,590 2.7%
10 HIV 4,520 2.6%
11 Diabetes mellitus 3,684 2.1%
12 Lower respiratory infections 3,593 2.1%
13 Cancer colon or rectum 3,578 2.1%
14 Inflammatory Cardiac 3,276 1.9%
15 Drowning 3,256 1.9%
16 Cancer stomach 2,935 1.7%
17 Leukemias 2,601 1.5%
18 Hypertension and hypertensive heart disease 2,365 1.4%
19 COPD 2,272 1.3%
20 Cirrhosis of the liver 2,113 1.2%
Sub-total 126,941 73.3%

Cause list YLL % total

Total Asian females 121,261
1 Ischaemic heart disease 10,953 9.0%
2 Cerebrovascular Disease 8,881 7.3%
3 Road Traffic Accidents 7,970 6.6%
4 Breast cancer 7,150 5.9%
5 Lung trachea or bronchial cancer 5,455 4.5%
6 Conditions arising during the perinatal period 4,451 3.7%
7 Congenital Abnomalities 4,223 3.5%
8 Self-inflicted 4,112 3.4%
9 Cancer colon or rectum 3,761 3.1%
10 Diabetes mellitus 3,331 2.7%
11 Homicide and Violence 2,920 2.4%
12 Cancer stomach 2,873 2.4%
13 Ovarian cancer 2,776 2.3%
14 Lower respiratory infections 2,677 2.2%
15 Cancer liver 2,210 1.8%
16 Leukemias 2,126 1.8%
17 Cancer cervix 1,892 1.6%
18 Cancer pancreas 1,888 1.6%
19 Inflammatory Cardiac 1,602 1.3%
20 Lymphomas 1,479 1.2%
Sub-total 82,729 68.2%

Patterns by race

The share of YLL due to communicable diseases (which include HIV/AIDS), maternal causes, perinatal and nutritional conditions was twofold larger for Blacks (20 per cent) than it was for any of the other races. Injuries predominated among American Indians, causing one third of the total mortality burden, and one fifth or less in the other races.

The mortality burden was highest for Blacks and lowest for Asians, for both sexes and all ages. A few causes contributed about one third of total YLL in each race. These were IHD, lung cancer and motor vehicle accidents for Whites; IHD, HIV/AIDS and homicide and violence for Blacks; motor vehicle accidents, IHD and self-inflicted injuries for American Indians; and IHD, motor vehicle accidents, cerebrovascular diseases, and lung cancer for Asians (Tables 15, 16, 17, 18; Figures 12, 13).

Figure 12.

Figure 12

Ten leading causes of mortality burden (YLL) and death, as a per cent of total, by race, US, 1996.

Figure 13.

Figure 13

Ten leading causes of mortality burden (YLL) and death, as a per cent of total, by race, US, 1996.

Comparative rankings of mortality burden in the United States and selected industrialized countries

Relative YLL rankings observed in the United States and in ten selected industrialized countries (Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom) were similar for IHD, lung cancer and motor vehicle accidents for males, and IHD, breast cancer and cerebrovascular diseases for females, which ranked among the top five leading causes of YLL in all countries. In contrast, the range of rankings observed was widest for HIV/AIDS and inflammatory cardiac diseases (cardiomyopathy and endocarditis) for both sexes, appearing to cause a very high mortality burden in some countries, and a much lower mortality burden in others (Figures 14 and 15). The wide range observed for these two conditions may point to real differences in causes of death and their important risk factors, but may also indicate differences in cause of death reporting practices, particularly for inflammatory cardiac disease, which ultimately leads to congestive heart failure, and may not have been diagnosed as the underlying cause.

Figure 14.

Figure 14

Comparative rankings for the twenty leading causes of YLL for males, US compared with selected non-US OECD countries. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected non-US OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom.

Figure 15.

Figure 15

Comparative rankings for the twenty leading causes of YLL for females, US compared with selected non-US OECD countries. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom.

US YLL rankings by race compared to selected industrialized countries

The higher share of YLL due to homicide and violence in the general population in the United States was observed in all races and both sexes (Figures 16 and 17). YLL rankings for all races and both sexes fell outside those observed in other countries for inflammatory cardiac diseases, pointing to a higher burden in the United States. Rankings for cerebrovascular diseases, on the other hand, pointed to a lower share of burden for males in all races. YLL rates exceeded rates for other countries for HIV/AIDS, homicide and violence, and inflammatory cardiac disease in both sexes, confirming findings based on the comparison of YLL rankings (Tables 19 and 20).

Figure 16.

Figure 16

YLL rankings by race in the US compared with selected non-US OECD countries, males. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom

Figure 17.

Figure 17

YLL rankings by race in the US compared with non-US OECD countries, females. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom

Table 19.

Twenty leading causes of YLL in the United States: comparison of YLL rates per 100,000 between the United States and selected countries – Male

Twenty leading causes of YLL in the United States United States Australia Canada France Germany Greece Italy Japan Netherlands Spain United Kingdom
IHD 1,392 269 950 578 1,249 1,337 974 504 942 826 2,154
Trachea, bronchus, lung cancer 599 105 469 666 611 756 683 387 595 638 714
MVA 547 106 292 515 325 690 438 242 233 550 350
HIV/AIDS 443 9 62 60 26 11 67 1 31 176 18
Self-inflicted 411 140 414 459 367 101 184 582 221 218 410
homicide and violence 375 15 57 21 19 37 38 14 38 35 55
Cerebroavascular disease 275 72 205 307 377 723 421 546 319 356 566
COPD 207 51 145 142 182 88 168 57 234 247 371
Perinatal conditions 200 43 115 120 87 115 90 39 116 78 215
Diabetes 170 33 146 97 125 54 144 76 120 93 99
Cirrhosis of the liver 169 25 104 281 372 85 228 161 85 195 258
Colon and rectum 164 68 187 213 267 160 225 231 220 235 338
Lower respiratory infections 156 19 66 134 99 49 80 281 152 97 524
Congenital anomalies 133 33 95 101 78 104 78 66 113 86 125
poisonings 130 51 87 12 28 104 11 12 30 71 111
Inflammatory heart disease 129 21 52 68 116 3 67 45 65 87 84
Prostate 123 41 118 145 142 119 110 50 151 121 241
Lymphoma and multiple myeloma 103 36 125 114 108 92 130 77 128 106 176
Hypertesive heart disease 99 7 21 51 77 48 117 15 24 38 54
Leukemia 88 25 82 91 87 105 100 70 78 86 115
Table 20.

Twenty leading causes of YLL in the United States: comparison of YLL rates per 100,000 between the United States and selected countries – Female

Twenty leading causes of YLL in the United States United States Australia Canada France Germany Greece Italy Japan Netherlands Spain United Kingdom
IHD 777 462 475 228 753 570 491 562 466 383 868
Trachea, bronchus, lung cancer 386 186 354 140 201 125 154 328 288 86 357
Breast cancer 332 285 326 389 404 313 363 396 457 288 492
Cerebroavascular disease 316 253 213 253 405 826 426 943 378 362 510
MVA 241 125 124 157 105 178 117 167 71 151 73
COPD 190 108 114 67 90 41 66 39 152 57 227
Diabetes 170 80 109 76 123 55 151 102 115 108 66
Perinatal conditions 151 108 87 89 64 75 70 70 94 63 115
Colon and rectum 145 164 145 155 217 153 171 381 189 174 201
Lower respiratory infections 137 50 56 91 79 34 61 418 147 71 412
Congenital anomalies 108 89 73 71 64 76 59 136 100 73 84
HIV/AIDS 106 2 13 16 6 2 17 0 8 43 4
homicide and violence 95 32 21 12 16 11 11 25 19 13 20
sel-inflicted 94 120 119 155 106 27 55 473 107 63 90
Ovarian cancer 90 69 79 90 114 82 88 148 99 74 144
Hypertesive heart disease 83 27 21 50 94 50 137 34 27 53 32
Cirrhosis of the liver 75 32 45 113 156 28 115 99 44 71 113
Cancer pancreas 74 56 67 66 94 73 85 187 78 62 84
Lymphoma and multiple myeloma 73 88 97 80 83 71 103 126 90 84 110
Inflammatory heart disease 67 31 29 24 44 3 30 53 42 45 32

The largest differentials between races for males pertained to COPD, cirrhosis of the liver, poisoning, hypertension and hypertensive heart disease. Rankings indicate a higher mortality burden due to COPD and cirrhosis of the liver in American Indians; hypertension and hypertensive heart disease in Blacks; and a lower mortality burden for poisoning in Asians. The largest rank differentials between races were observed in females for HIV/AIDS, self-inflicted injuries, COPD, hypertension and hypertensive heart disease, and cirrhosis of the liver. Rankings for Black females pointed to a higher mortality burden for HIV/AIDS, hypertension and hypertensive heart disease, and a lower mortality burden for self-inflicted injuries and ovarian cancer compared to White, American Indian and Asian females.

Morbidity burden

Leading causes of YLD

Non-fatal health outcomes resulted in 15 million YLD, which was only slightly less than the mortality burden (17 million YLL). For neuropsychiatric conditions, musculoskeletal conditions, chronic respiratory diseases, YLD contributed more than YLL. Neuropsychiatric conditions were the predominant cause of disability, causing 44 per cent of total YLD, regardless of sex and race (Figure 18). They comprise a wide array of conditions, sub-divided into mental disorders and diseases of the nervous system (DSM IV). Mental disorders include mood disorders (unipolar major depression, bipolar disorders), schizophrenia, anxiety disorders (PTSD, obsessive compulsive disorders, and panic disorders) affecting mostly young adults, and substance related disorders (alcohol and drug use) that increase in older adults. Nervous system disorders include Alzheimer's disease and other degenerative and hereditary CNS disorders, Parkinson's disease, epilepsy, and multiple sclerosis (Figure 19).

Figure 18.

Figure 18

Distribution of YLD for non-communicable cause groupings.

Figure 19.

Figure 19

Age patterns of mental disorders and diseases of the nervous system.

Unipolar major depression, alcohol use, osteoarthritis, dementia and other degenerative disorders of the CNS and cerebrovascular diseases were the five leading causes of YLD (Table 21). Unipolar major depression and alcohol use combined (2.4 million YLD) caused 16 per cent of total YLD, which represented almost the same burden as IHD (2.9 million YLL).

Table 21.

Twenty leading causes of YLD, both sexes and all races combined

Rank YLD % of total
Total 15,024,113
1 Unipolar major depression 1,370,070 9.1%
2 Alcohol use 1,037,529 6.9%
3 Osteoarthritis 940,612 6.3%
4 Dementia and other degenerative and hereditary CNS disorders 755,925 5.0%
5 COPD 727,272 4.8%
6 Cerebrovascular Disease 725,844 4.8%
7 Asthma 593,233 3.9%
8 Drug use 504,718 3.4%
9 Diabetes mellitus 495,377 3.3%
10 Congenital Abnomalities 443,004 2.9%
11 Motor vehicle accidents 366,273 2.4%
12 Bipolar disorder 363,298 2.4%
13 Schizophrenia 315,720 2.1%
14 Ischaemic heart disease 275,988 1.8%
15 PTSD 260,337 1.7%
16 Panic disorder 259,904 1.7%
17 HIV 237,443 1.6%
18 Falls 221,036 1.5%
19 Rheumatoid arthritis 189,421 1.3%
20 Obsessive-compulsive disorders 169,067 1.1%
Sub-total 10,252,070 68.2%

Sex and age patterns

Sex differentials were much smaller for YLD than for YLL. The morbidity burden was slightly larger for females (7.7 million YLD) than for males (7.3 million YLD). The five leading causes of YLD were alcohol use, unipolar major depression, osteoarthritis, drug use, and chronic obstructive pulmonary disease (COPD) for males, and unipolar major depression, osteoarthritis, dementia and other degenerative and hereditary CNS disorders, and alcohol use for females (Table 22).

Table 22.

Twenty leading causes of YLD by sex, US 1996

MALES
Rank YLD % total YLD
Total 7,330,853
1 Alcohol use 651,223 8.9%
2 Unipolar major depression 469,861 6.4%
3 Osteoarthritis 434,200 5.9%
4 Drug use 384,319 5.2%
5 COPD 372,927 5.1%
6 Dementia and other degenerative and hereditary CNS disorders 332,046 4.5%
7 Cerebrovascular Disease 317,366 4.3%
8 Asthma 272,898 3.7%
9 Congenital Abnomalities 237,988 3.2%
10 Motor vehicle accidents 232,687 3.2%
11 Diabetes mellitus 221,557 3.0%
12 Bipolar disorder 198,308 2.7%
13 HIV 188,519 2.6%
14 Schizophrenia 166,988 2.3%
15 Ischaemic heart disease 151,764 2.1%
16 Falls 132,485 1.8%
17 Obsessive-compulsive disorders 88,623 1.2%
18 Homicide and Violence 81,588 1.1%
19 Prostate cancer 78,870 1.1%
20 Panic disorder 77,701 1.1%
sub-total 5,091,918 69.5%

FEMALES

Rank YLD % total YLD
Total 7,693,260
1 Unipolar major depression 900,209 11.7%
2 Osteoarthritis 506,412 6.6%
3 Dementia and other degenerative and hereditary CNS disorders 423,878 5.5%
4 Cerebrovascular Disease 408,478 5.3%
5 Alcohol use 386,306 5.0%
6 COPD 354,345 4.6%
7 Asthma 320,336 4.2%
8 Diabetes mellitus 273,821 3.6%
9 Congenital Abnomalities 205,015 2.7%
10 PTSD 193,533 2.5%
11 Panic disorder 182,203 2.4%
12 Bipolar disorder 164,990 2.1%
13 Schizophrenia 148,732 1.9%
14 Motor vehicle accidents 133,586 1.7%
15 Rheumatoid arthritis 131,758 1.7%
16 STD's excluding HIV 125,418 1.6%
17 Ischaemic heart disease 124,224 1.6%
18 Drug use 120,399 1.6%
19 Maternal Conditions 105,155 1.4%
20 Falls 88,551 1.2%
sub-total 5,297,349 68.9%

The largest sex differentials pertained to the leading cause of YLD: alcohol use for males and unipolar major depression for females. The burden due to unipolar depression was almost double for females (900 thousand YLD) than it was for males (470 thousand YLD), whereas the burden due to alcohol was double for males (651 thousand YLD) than it was for females (386 thousand YLD). Together, alcohol use and unipolar depression caused 15 per cent of total YLD for males, and 17 per cent for females.

The share of total YLD due to neuropsychiatric conditions for males exceeded that for females. Morbidity due to substance abuse (alcohol and drug) in males was not entirely offset by the preponderance of mood and anxiety disorders in females. The slightly higher share of dementia and other degenerative and hereditary CNS disorders in females resulted from their higher life expectancy.

Major causes contributing to the morbidity burden changed with age. Mental disorders and injuries affected mostly young adults, whereas nervous system disorders, musculoskeletal conditions, cardiovascular diseases, and diabetes increased with age and were predominant among older adults. Chronic respiratory conditions affected all age groups. Congenital anomalies represented half of the non-fatal burden below age 5.

Patterns by race

Alcohol use was the leading cause of YLD for males in all races, with the exception of Asian males for whom unipolar depression was the leading cause. Unipolar major depression was the leading cause for females of all races, with the exception of American Indian females for whom alcohol use was the leading cause (Tables 23, 24, 25, 26).

Table 23.

Leading causes of YLD – Whites

WHITE MALES
Rank Cause list YLD % total YLD
Total YLD 5,963,710
1 Alcohol use 488,341 8.2%
2 Unipolar major depression 390,121 6.5%
3 Osteoarthritis 378,589 6.3%
4 Drug use 324,878 5.4%
5 COPD 319,049 5.3%
6 Dementia and other degenerative and hereditary CNS disorders 293,857 4.9%
7 Cerebrovascular Disease 258,909 4.3%
8 Asthma 216,831 3.6%
9 Motor vehicle accidents 195,590 3.3%
10 Congenital Abnomalities 189,083 3.2%
11 Diabetes mellitus 174,663 2.9%
12 Bipolar disorder 161,700 2.7%
13 Schizophrenia 134,190 2.3%
14 Ischaemic heart disease 130,502 2.2%
15 Falls 113,345 1.9%
16 HIV 111,533 1.9%
17 Obsessive-compulsive disorders 71,313 1.2%
18 Prostate cancer 68,023 1.1%
19 Panic disorder 63,735 1.1%
20 PTSD 55,968 0.9%
sub-total 4,140,220 69.4%

WHITE FEMALES

Rank Cause list YLD % total YLD
Total YLD 6,234,020
1 Unipolar major depression 736,746 11.8%
2 Osteoarthritis 439,876 7.1%
3 Dementia and other degenerative and hereditary CNS disorders 375,458 6.0%
4 Cerebrovascular Disease 323,173 5.2%
5 COPD 307,237 4.9%
6 Alcohol use 291,334 4.7%
7 Asthma 253,904 4.1%
8 Diabetes mellitus 210,058 3.4%
9 Congenital Abnomalities 162,162 2.6%
10 PTSD 159,120 2.6%
11 Panic disorder 145,888 2.3%
12 Bipolar disorder 131,835 2.1%
13 Schizophrenia 118,134 1.9%
14 Rheumatoid arthritis 110,674 1.8%
15 Motor vehicle accidents 109,754 1.8%
16 STD's excluding HIV 101,298 1.6%
17 Ischaemic heart disease 100,510 1.6%
18 Drug use 98,319 1.6%
19 Maternal Conditions 82,750 1.3%
20 Falls 76,404 1.2%
Sub-total 4,334,635 69.5%
Table 24.

Leading causes of YLD – Blacks

BLACK MALES
Rank Simple cause list YLD % total YLD
Total YLD 1,086,407
1 Alcohol use 135,346 12.5%
2 HIV 73,292 6.7%
3 Unipolar major depression 57,653 5.3%
4 Cerebrovascular Disease 49,191 4.5%
5 Drug use 44,504 4.1%
6 Asthma 42,295 3.9%
7 Diabetes mellitus 39,783 3.7%
8 COPD 38,739 3.6%
9 Osteoarthritis 38,641 3.6%
10 Congenital Abnomalities 36,030 3.3%
11 Road Traffic Accidents 31,173 2.9%
12 Dementia and other degenerative and hereditary CNS disorders 28,292 2.6%
13 Homicide and Violence 26,846 2.5%
14 Bipolar disorder 26,799 2.5%
15 Schizophrenia 24,323 2.2%
16 Ischaemic heart disease 18,148 1.7%
17 Falls 15,894 1.5%
18 Diarrhoeal diseases 15,602 1.4%
19 Inflammatory Cardiac 13,178 1.2%
20 Obsessive-compulsive disorders 12,818 1.2%
sub-total 768,546 70.7%

BLACK FEMALES

Rank Simple cause list YLD % total YLD
Total YLD 1,145,131
1 Unipolar major depression 119,471 10.4%
2 Alcohol use 74,248 6.5%
3 Cerebrovascular Disease 74,179 6.5%
4 Diabetes mellitus 54,409 4.8%
5 Asthma 50,869 4.4%
6 Osteoarthritis 48,521 4.2%
7 Dementia and other degenerative and hereditary CNS disorders 37,519 3.3%
8 HIV 31,719 2.8%
9 Congenital Abnomalities 31,654 2.8%
10 COPD 31,132 2.7%
11 PTSD 27,508 2.4%
12 Panic disorder 26,916 2.4%
13 Bipolar disorder 24,649 2.2%
14 Schizophrenia 22,823 2.0%
15 Ischaemic heart disease 21,685 1.9%
16 Road Traffic Accidents 19,754 1.7%
17 STD's excluding HIV 17,688 1.5%
18 Drug use 17,686 1.5%
19 Maternal Conditions 16,770 1.5%
20 Rheumatoid arthritis 15,521 1.4%
sub-total 764,722 66.8%
Table 25.

Leading causes of YLD – American Indians

AMERICAN INDIAN MALES
Rank Simple cause list YLD % total YLD
Total YLD 77,508
1 Alcohol use 22,997 29.7%
2 Unipolar major depression 4,160 5.4%
3 Drug use 3,042 3.9%
4 Osteoarthritis 2,940 3.8%
5 Asthma 2,745 3.5%
6 COPD 2,708 3.5%
7 Congenital Abnomalities 2,467 3.2%
8 Cerebrovascular Disease 2,014 2.6%
9 Bipolar disorder 1,948 2.5%
10 Road Traffic Accidents 1,902 2.5%
11 Schizophrenia 1,796 2.3%
12 Dementia and other degenerative and hereditary CNS disorders 1,775 2.3%
13 Diabetes mellitus 1,595 2.1%
14 HIV 1,190 1.5%
15 Cirrhosis of the liver 1,082 1.4%
16 Fires 1,027 1.3%
17 Obsessive-compulsive disorders 940 1.2%
18 Falls 921 1.2%
19 Ischaemic heart disease 881 1.1%
20 Panic disorder 743 1.0%
sub-total 58,874 76.0%

AMERICAN INDIAN FEMALES

Rank Simple cause list YLD % total YLD
Total YLD 78,522
1 Alcohol use 19,417 24.7%
2 Unipolar major depression 7,655 9.7%
3 Asthma 3,233 4.1%
4 Osteoarthritis 3,020 3.8%
5 COPD 2,692 3.4%
6 Cerebrovascular Disease 2,251 2.9%
7 Congenital Abnomalities 2,182 2.8%
8 Dementia and other degenerative and hereditary CNS disorders 2,006 2.6%
9 Diabetes mellitus 1,895 2.4%
10 Panic disorder 1,851 2.4%
11 Bipolar disorder 1,717 2.2%
12 Schizophrenia 1,625 2.1%
13 PTSD 1,251 1.6%
14 Maternal Conditions 1,178 1.5%
15 STD's excluding HIV 1,157 1.5%
16 Road Traffic Accidents 1,115 1.4%
17 Rheumatoid arthritis 958 1.2%
18 Drug use 925 1.2%
19 Cirrhosis of the liver 918 1.2%
20 Obsessive-compulsive disorders 865 1.1%
Sub-total 57,910 73.8%
Table 26.

Leading causes of YLD – Asians

ASIAN MALES
Rank Simple cause list YLD % total YLD
Total YLD 203,229
1 Unipolar major depression 17,926 8.8%
2 Osteoarthritis 14,029 6.9%
3 COPD 12,431 6.1%
4 Drug use 11,895 5.9%
5 Asthma 11,027 5.4%
6 Congenital Abnomalities 10,408 5.1%
7 Dementia and other degenerative and hereditary CNS disorders 8,122 4.0%
8 Bipolar disorder 7,862 3.9%
9 Cerebrovascular Disease 7,251 3.6%
10 Schizophrenia 6,679 3.3%
11 Diabetes mellitus 5,516 2.7%
12 Alcohol use 4,539 2.2%
13 Road Traffic Accidents 4,022 2.0%
14 Obsessive-compulsive disorders 3,552 1.7%
15 Panic disorder 2,994 1.5%
16 HIV 2,505 1.2%
17 Epilepsy 2,470 1.2%
18 Falls 2,325 1.1%
19 Ischaemic heart disease 2,234 1.1%
20 Diarrhoeal diseases 2,057 1.0%
Sub-total 139,843 68.8%

ASIAN FEMALES

Rank Simple cause list YLD % total YLD
Total YLD 235,588
1 Unipolar major depression 36,337 15.4%
2 Osteoarthritis 14,995 6.4%
3 COPD 13,285 5.6%
4 Asthma 12,329 5.2%
5 Congenital Abnomalities 9,018 3.8%
6 Dementia and other degenerative and hereditary CNS disorders 8,896 3.8%
7 Cerebrovascular Disease 8,876 3.8%
8 Panic disorder 7,548 3.2%
9 Diabetes mellitus 7,458 3.2%
10 Bipolar disorder 6,788 2.9%
11 Schizophrenia 6,150 2.6%
12 PTSD 5,654 2.4%
13 STD's excluding HIV 5,275 2.2%
14 Rheumatoid arthritis 4,605 2.0%
15 Maternal Conditions 4,456 1.9%
16 Drug use 3,469 1.5%
17 Obsessive-compulsive disorders 3,347 1.4%
18 Road Traffic Accidents 2,963 1.3%
19 Epilepsy 2,222 0.9%
20 Diarrhoeal diseases 1,745 0.7%
Sub-total 165,417 70.2%

Differentials in patterns of neuropsychiatric disorders by race were dominated by the large excess morbidity burden caused by substance abuse among American Indians, which accounted for half of total YLD, compared to approximately one third in the other race groups.

The distribution of YLD rates for selected disease groupings by age further illustrate major differences that existed between races. These were particularly prominent for neuropsychiatric conditions in young adults between the ages 15 and 44 years (Figure 20).

Figure 20.

Figure 20

Patterns of YLD by age and race, US 1996.

Discussion

Quantifying the burden of disease is not a morally neutral exercise. All summary measures of health include several value choices. A strength of the GBD was to make value choices incorporated in the calculation of DALYs transparent. These include a standard duration of life at each age, an age weighting function, and discounting for time preference. GBD values for these parameters were not changed to ensure the international comparability of the USBODI.

The validation of GBD disability weights in different national contexts is particularly important to enhance the confidence of decision-makers in key findings of national disease burden estimates. The instrument used to derive the disability weights is called the Person Trade-Off (PTO). In the GBD the full PTO was executed for a set of 22 indicator conditions.

In order to assess whether groups of people from the United States might value these indicator conditions substantially differently than the benchmark values developed for the GBD, 35 volunteers that included staff from CDC, state health departments, other US federal agencies such as the National Institutes of Mental Health, as well as members of non-profit groups such as the American Heart Association and the Arthritis Foundation, were recruited to execute a PTO (PTO1 and PTO2) exercise as part of the US study. These participants were placed in 4 small groups of 8–12 members according to the GBD PTO (PTO1 and PTO2) protocol. Consistent with results from other such groups coordinated in a variety of international settings by the Burden of Disease Unit at Harvard, there was evidence of substantial inter-individual variation between the participants for conditions associated with milder disability (Table 4). For example, the median value for vitiligo of the face was 0.00, and the average disability weight was 0.04. The standard deviation for the disability weight associated with this condition was larger than the actual point estimate. The coefficients of variation (C.V. = standard deviation/point estimate) were much smaller for conditions associated with more severe disability such as quadriplegia and severe dementia. However, despite variation between individuals within these groups, the correlation between groups for the disability weight values was very strong. Nineteen conditions were included in every exercise. For each group the median disability weight value for each of these conditions was calculated. The correlations between pairs of groups for the 19 disability weight values were very high (Table 5, Range of Pearson's correlation coefficients = 0.82–0.99).

Table 4.

Disability weights from person trade-off exercise conducted in Atlanta compared to composite scores from other exercises conducted at various international sites

Indicator Condition Atlanta PTO (N = 35) Composite scores (N = 192)
Median Mean S.D.* C.V.+ Median Mean S.D.* C.V.+


Vitiligo on Face 0 0.04 0.11 2.75 0 0.04 0.1 2.5
Watery Diarrhea 0.02 0.06 0.08 1.33 0.05 0.1 0.16 1.60
Fracture of Radius 0.06 0.1 0.11 1.10 0.09 0.13 0.16 1.23
Infertility 0.03 0.11 0.16 1.45 0.09 0.16 0.19 1.19
Erectile Dysfunction 0.09 0.19 0.22 1.16 0.17 0.22 0.23 1.05
Severe Sore Throat 0.13 0.19 0.18 0.95 0.13 0.23 0.26 1.13
Rheumatoid Arthritis 0.17 0.26 0.24 0.92 0.29 0.32 0.22 0.69
Below Knee Amputation 0.29 0.32 0.20 0.63 0.29 0.34 0.22 0.65
Deafness 0.44 0.43 0.28 0.65 0.36 0.4 0.24 0.60
Recto-vaginal Fistula 0.29 0.38 0.33 0.87 0.41 0.44 0.28 0.64
Angina 0.38 0.39 0.23 0.59 0.43 0.46 0.26 0.57
Mental Retardation 0.64 0.55 0.28 0.51 0.5 0.5 0.25 0.50
Blindness 0.5 0.53 0.25 0.47 0.63 0.58 0.21 0.36
Paraplegia 0.67 0.6 0.25 0.42 0.71 0.68 0.2 0.29
Major Depression 0.89 0.79 0.23 0.29 0.81 0.75 0.2 0.27
Severe Migraine 0.96 0.89 0.18 0.20 0.88 0.8 0.2 0.25
Dementia 0.9 0.85 0.16 0.19 0.9 0.86 0.13 0.15
Active Psychosis 0.95 0.9 0.12 0.13 0.91 0.87 0.14 0.16
Quadriplegia 0.93 0.9 0.09 0.10 0.91 0.87 0.14 0.16

* S.D. = standard deviation.

+ C.V. = Coefficient of Variation (standard deviation/mean)

Table 5.

Pearson's correlation coefficients for median disability weights for each exercise based on 19 conditions common to all person trade-off exercises

Group
International I International I
Netherlands 0.96 Netherlands
Maghreb-8 0.94 0.95 Maghreb
Japan 0.90 0.82 0.85 Japan
GBD 0.97 0.95 0.97 0.88 GBD
International II 0.99 0.97 0.94 0.89 0.97 International II
CDC 0.97 0.98 0.92 0.84 0.95 0.98 CDC
Brazil 0.90 0.91 0.87 0.83 0.87 0.90 0.90 Brazil
Mexico 0.95 0.93 0.92 0.90 0.93 0.96 0.96 0.95 Mexico
Composite 0.99 0.98 0.96 0.89 0.98 0.99 0.99 0.94 0.97

Based on the above results it seemed reasonable to use the set of disability weights from the GBD study for the US evaluation. In a few instances more detailed data on health conditions were available in the US on the distribution of severity for certain health conditions such as depression [see Additional file 2]. Disability weights for severity-specific stages were developed for many of these conditions as part of a burden of disease and injury study implemented in the Netherlands [20]. Therefore, the Dutch weights were used when stage specific information on severity was available.

In the mid-1990s chronic diseases such as cardiovascular diseases, cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse were the leading causes of death and disability in the United States. In addition, injuries from motor-vehicle accidents and the HIV epidemic exacted a substantial toll on the US population. These findings are consistent with other assessments of disease burden in developed and developing countries. However, the use of DALYs to enumerate the impact of health conditions is notably different from a simple listing of causes of death. This metric captures the importance of mental conditions, such as depression and degenerative musculoskeletal disease that cause major health problems but result in few deaths, as well as the importance of premature deaths among young adults (Tables 27, and 28).

Table 27.

Top twenty leading causes of Disability Adjusted Life Years (DALY), Years Lost to Disability (YLD), Years of Life Lost (YLL) and Deaths for Males – US 1996*

Cause DALY (%) YLD (%) YLL (%) Death (%)
1 Ischaemic heart disease 1,958 (11.0) 152 (2.1) 1,806(17.2) 287 (24.7)
2 Road traffic accidents 934 (5.2) 233 (3.2) 701 (6.7) 29 (2.5)
3 Lung trachea or bronchial cancer 813 (4.6) 35 (0.5) 778 (7.4) 102 (8.8)
4 HIV/AIDS 764 (4.3) 189 (2.6) 575 (5.5) 25 (2.2)
5 Alcohol use 732 (4.1) 651 (8.9) 81 (0.8) 5 (0.4)
6 Cerebrovascular Disease 674 (3.8) 317 (4.3) 357 (3.4) 63 (5.4)
7 COPD 642 (3.6) 373 (5.1) 269 (2.6) 52 (4.5)
8 Homicide and Violence 568 (3.2) 82 (1.1) 486 (4.6) 17 (1.5)
9 Self-inflicted injuries 541 (3.0) 8 (0.1) 534 (5.1) 26 (2.2)
10 Unipolar major depression 470 (2.6) 470 (6.4) 0 (0.0) 0 (0)
11 Diabetes mellitus 442 (2.5) 222 (3.0) 220 (2.1) 28 (2.4)
12 Osteoarthritis 435 (2.4) 434 (5.9) 1 (0.0) 0 (0)
13 Drug use 412 (2.3) 384 (5.2) 27 (0.3) 1 (0.1)
14 Congenital Abnormalities 410 (2.3) 238 (3.2) 172 (1.6) 6 (0.5)
15 Dementia and other degenerative and hereditary CNS disorders 382 (2.1) 332 (4.5) 50 (0.5) 14 (1.2)
16 Asthma 303 (1.7) 273 (3.7) 30 (0.3) 2 (0.2)
17 Cirrhosis of the liver 281 (1.6) 61 (0.8) 220 (2.1) 17 (1.4)
18 Conditions arising during the perinatal period 274 (1.5) 14 (0.2) 260 (2.5) 8 (0.7)
19 Cancer colon or rectum 249 (1.4) 37 (0.5) 213 (2.0) 30 (2.6)
20 Prostate cancer 239 (1.3) 79 (1.1) 160 (1.5) 37 (3.2)
- Total number for each measure in the top 20 causes 11,523 (64.5) 4,584 (62.5) 6,940 (65.9) 749 (64.5)
- Total number for each measure 17,861(100) 7,331(100) 10,530 (100) 1,164 (100)

*All counts for DALYs, Deaths, YLDs, and YLLs are in 1000's.

Table 28.

Top twenty leading causes of Disability Adjusted Life Years (DALY), Years Lost to Disability (YLD), Years of Life Lost (YLL) and Deaths for Females – US 1996*

Cause DALY (%) YLD (%) YLL (%) Death (%)
1 Ischaemic heart disease 1,177 (7.7) 124 (1.6) 1,052(14.0) 249 (21.7)
2 Unipolar major depression 900 (5.9) 900 (11.7) 0 (0.0) 0 (0.0)
3 Cerebrovascular disease 836 (5.5) 408 (5.3) 428 (5.7) 99 (8.6)
4 COPD 612 (4.0) 354 (4.6) 257 (3.4) 48 (4.1)
5 Lung trachea or bronchial cancer 550 (3.6) 26 (0.3) 523 (6.9) 66 (5.7)
6 Breast cancer 515 (3.4) 64 (0.8) 450 (6.0) 47 (4.1)
7 Osteoarthritis 508 (3.3) 506 (6.6) 1 (0.0) 1(0.0)
8 Dementia and other degenerative and hereditary CNS disorders 507 (3.3) 424 (5.5) 83 (1.1) 29 (2.5)
9 Diabetes mellitus 504 (3.3) 274 (3.6) 230 (3.1) 34 (3.0)
10 Road traffic accidents 459 (3.0) 134 (1.7) 326 (4.3) 15 (1.3)
11 Alcohol use 409 (2.7) 386 (5.0) 23 (0.3) 1 (0.1)
12 Asthma 362 (2.4) 320 (4.2) 42 (0.6) 4 (0.3)
13 Congenital abnormalities 352 (2.3) 205 (2.7) 147 (1.9) 6 (0.5)
14 Cancer colon or rectum 234 (1.5) 38 (0.5) 197 (2.6) 31 (2.7)
15 Conditions arising during the perinatal period 220 (1.4) 16 (0.2) 205 (2.7) 6 (0.5)
16 Lower respiratory infections 195 (1.3) 10 (0.1) 186 (2.5) 46 (4.0)
17 PTSD 194 (1.3) 194 (2.5) 0 (0.0) 0 (0.0)
18 HIV/AIDS 193 (1.3) 49 (0.6) 144 (1.9) 6 (0.5)
19 Panic disorder 182 (1.2) 182 (2.4) 0 (0.0) 0 (0.0)
20 Bipolar disorder 165 (1.1) 165 (2.1) 0 (0.0) 0 (0.0)
Total number for each measure in the top 20 causes 9,074 (59.6) 4,779 (62.1) 4,294 (57.0) 688 (59.7)
Total number for each measure 15,230 (100) 7,693 (100) 7,537 (100) 1,151 (100)

*All counts for DALYs, Deaths, YLDs, and YLLs are in 1000's

The juxtaposition of the twenty leading causes of death, YLL, YLD and DALYs illustrates the extent to which an assessment of the relative importance of various causes based simply on total number of deaths differs from the assessment of leading causes of YLL, YLD and DALYs. For example, the total number of years lived with a disability resulting from unipolar major depression (1.3 million YLD) was equal to the number of years lost due to premature death from lung cancer (1.3 million YLL); and the burden resulting from osteoarthritis and motor vehicle accidents were similar (940.6 million YLD and 1 billion YLL respectively).

Osteoarthritis of the hip and knee (OA) and rheumatoid arthritis (RA) were the two leading musculoskeletal disorders. OA is an important public health problem that affects mostly older adults causing great pain and disability, and is one of the most rapidly growing causes of disability. The estimated 40 million prevalent cases in 1996 is projected to increase to 60 million cases by 2020 [22].

Substantial differences were found in the relative impact of individual conditions by gender and race. HIV/AIDS, alcohol dependence, as well as violent and unintentional injuries accounted for most of the worse health outcomes observed among Black and American Indian populations compared to White and Asian populations. Blacks fared much worse than the other race groups with regard to pregnancy outcomes. Blacks were the only group for which perinatal conditions ranked among the top ten causes of DALYs. Relatively high perinatal mortality rates persist in this population due to the combined effect of premature delivery and poor perinatal care.

Conditions associated with social issues in younger ages were much more common among Blacks and American Indians. For instance, YLL rates for HIV/AIDS were fivefold larger for Blacks than they were for any of the other races. YLL rates for homicide and violence were seven times higher for American Indians and twice as high for Blacks than they were for Whites and Asians.

One important objective of the study was to place the United States public health situation in a global context. Non-communicable diseases are the leading causes of deaths in all industrialized countries, where child and adult mortality are low. In developing regions, where child and adult mortality are still high, Group I represents a much larger share of the total. The dominance of HIV/AIDS observed in Blacks in the United States was akin to that in developing regions of the world. It was the third leading cause among black women in the US and the fifth leading cause among females in developing regions. HIV/AIDS accounted for a much smaller proportion of DALYs in other races in the US and did not figure among the top ten causes of DALYs in developed countries. Alcohol use for males in most racial subgroups in the United States exacted a high burden. This condition also ranked among the top five in other developed regions. Only Asian males and people living in developing countries did not have a large number of DALYs attributed to alcohol use.

US rankings clearly fell outside of the range observed elsewhere for a few causes: homicide and violence, HIV/AIDS, and perinatal conditions stand out regardless of race and gender. The United States has not been as successful in reducing the mortality burden due to violent injuries and perinatal conditions as were other industrialized countries with comparable levels of development.

In spite of the extensive population-based data available in the United States, there were limitations particularly in estimating disease burden by race due to smaller populations – Asians and American Indians. The major methodological limitations pertained to the different methods used to assign race and ethnicity in the census compared to death certificates; and to the limited population-based information that was available for many conditions for Asians and American Indians. For these last two groups, ratios of YLL to YLD for the overall US population were generally used to estimate the burden due to non-fatal health conditions. Such assumptions introduce a certain level of uncertainty in the estimates and call for caution in the interpretation of small absolute differences in the number of DALYs between different causes. This study provides a benchmark against which to assess future trends in health differentials in the United States and underscores the importance of further research to improve methods, provide stronger empirical evidence and better understanding of major risk factors for poor health outcomes.

Conclusion

This study provides a comprehensive picture of conditions that contribute most to poor health outcomes, and yields new evidence to the discussion of racial health inequalities in the United States. The existence of health inequalities is widely acknowledged and lies at the core of public health policy: reducing health inequalities is the major focus of Healthy People 2010 [23]. Previous studies have documented differentials in mortality by cause and have examined socio-economic determinants – income and education – of population health outcomes and health outcomes mediated through the health system: the utilization of health services, access, and quality of care [24-26].

The main policy message emerging from this study is that cost-effective public health interventions are available to reduce the burden of the three conditions that contributed most to racial inequalities. It adds new evidence that greater investments of public health interventions have a much greater potential to reduce large health inequalities in the United States than do technology driven curative interventions. The fact that other countries, which have lower expenditures per capita have achieved better health outcomes than the United States indicates that the major goal of reducing health disparities by 2010 can be achieved.

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

CJL conceived of the study, participated in its design, and helped to draft the manuscript. CMM, MTM participated in the study's design and coordination, data analysis and helped to draft the manuscript. SB, NT, MM, MTB, EME, JS, JGK, MH contributed to data analysis. ME helped to draft the manuscript. All authors read and approved the final manuscript.

Supplementary Material

Additional File 1

Global burden of disease methodology: summary overview. A summary overview of GBD methods.

Click here for file (53.5KB, doc)
Additional File 2

Data sources and methods for developing estimates for the incidence, mortality, prevalence, and duration of selected conditions for estimation of YLD in the United States. A detailed presentation of analytic methods, data sources, and data sets used to develop estimates for major causes of diseases and injuries.

Click here for file (276.5KB, doc)
Additional File 3

US burden of disease study classification system for diseases and injuries. The detailed list of causes selected for the USBODI.

Click here for file (176.5KB, doc)
Additional File 4

US burden of disease – Detailed tabulations of deaths, YLL, YLD and DALYs. Detailed tabulations of deaths, YLL, YLD and DALYs for the 73 causes included in the USBODI by age, gender and race.

Click here for file (1.4MB, ppt)
Additional File 5

Epidemiological estimates. Detailed incidence by age, sex and race by disease and sequelae, included in the USBODI.

Click here for file (652KB, xls)

Acknowledgments

Acknowledgements

We wish to acknowledge:

James S. Marks for initiating the study and for his support throughout the study; Lee Anneston, George Cauthen and Ted Thompson who developed estimates for selected causes; William Eaton, Charles Helmick, Ronald Kessler, Alan Lopez, Colin Mathers, Wayne Rosamond, Richard Seelik and Bedirhan Ustun who contributed invaluable technical guidance and critically reviewed estimates; Yuliya Popova and J.A. Kurichety who contributed to the preparation of the final document; Emmanuela Gakidou and Stanislava Nikolova who edited the final document.

Disclaimer: "The views and opinions in this report represent those of the authors and not the Centers for Disease Control and Prevention."

This study was funded by an Association of Schools of Public Health; ASPH/Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Cooperative Agreement. The funding source had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Contributor Information

Catherine M Michaud, Email: cmichaud@hsph.harvard.edu.

Matthew T McKenna, Email: mtm1@cdc.gov.

Stephen Begg, Email: s.begg@sph.uq.edu.au.

Niels Tomijima, Email: nmt2102@columbia.edu.

Meghna Majmudar, Email: mmajmud@yahoo.com.

Maria T Bulzacchelli, Email: mbulzacc@jhsph.edu.

Shahul Ebrahim, Email: sbe2@cdc.gov.

Majid Ezzati, Email: mezzati@hsph.harvard.edu.

Joshua A Salomon, Email: jsalomon@hsph.harvard.edu.

Jessica Gaber Kreiser, Email: jessicakreiser@hotmail.com.

Mollie Hogan, Email: m.hogan@sph.uq.edu.au.

Christopher JL Murray, Email: christopher_murray@harvard.edu.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Additional File 1

Global burden of disease methodology: summary overview. A summary overview of GBD methods.

Click here for file (53.5KB, doc)
Additional File 2

Data sources and methods for developing estimates for the incidence, mortality, prevalence, and duration of selected conditions for estimation of YLD in the United States. A detailed presentation of analytic methods, data sources, and data sets used to develop estimates for major causes of diseases and injuries.

Click here for file (276.5KB, doc)
Additional File 3

US burden of disease study classification system for diseases and injuries. The detailed list of causes selected for the USBODI.

Click here for file (176.5KB, doc)
Additional File 4

US burden of disease – Detailed tabulations of deaths, YLL, YLD and DALYs. Detailed tabulations of deaths, YLL, YLD and DALYs for the 73 causes included in the USBODI by age, gender and race.

Click here for file (1.4MB, ppt)
Additional File 5

Epidemiological estimates. Detailed incidence by age, sex and race by disease and sequelae, included in the USBODI.

Click here for file (652KB, xls)

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