Rising US Midlife Death Rates Point to Systemic Issues

Steven H Woolf, MD, MPH

“Life expectancy in the United States has been decreasing since 2014.”

It’s a bleak statement, but a study of changes in midlife death rates in the US has the data to back it up. Investigators analyzed data about deaths among people ages 25 to 64 from 1999 to 2016 and found that midlife mortality rates from various causes have risen across racial-ethnic groups in the US.

Drug overdoses were a leading cause, but deaths due to alcohol-related disorders and suicides were important contributors as well, according to lead author Steven H Woolf, MD, MPH, director emeritus, Center on Society and Health, Virginia Commonwealth University, and professor, Department of Family Medicine and Population Health, Virginia Commonwealth University.

“It’s not supposed to be this way,” said Woolf in an interview with MD Magazine®. “In other industrialized countries, mortality rates are decreasing and life expectancy is increasing. But in the US, people are facing a growing risk of dying before age 65, despite being a country that spends more on health care than any other.”

Across the 20 broad categories of causes of deaths, the study reported that mortality rates increased in 13 categories during the study period. Among these, the largest proportional increases were in deaths due to external causes, such as drug overdoses and suicides.

While the so-called “deaths of despair” have received much attention, the rise in midlife mortality extends beyond these, says Woolf, and includes heart disease, liver cancer, pulmonary disease, obesity, neurologic disorders, and more.

“The larger takeaway from our study is that the diverse impact on mortality—cutting across multiple body systems—suggests a systemic cause,” emphasized Woolf. “Something about modern American life may be responsible for this trend, but this is unlikely to be something the health care system or individual clinicians can address at the bedside. Society, policymakers, and voters have greater control over these factors.”

The study also compares racial-ethnic groups including non-Hispanic (NH) whites, NH blacks, NH American Indians and Alaskan Natives, NH Asians and Pacific Islanders, and Hispanics of all races.

Over the study period, all-cause mortality increased by 5.2% (average annual percentage change [AAPC] 0.2%, 95% confidence interval 0.1% to 0.4%) among NH whites and by 26.6% (AAPC 1.5%, 1.0% to 1.9%) among non-Hispanic American Indians and Alaskan Natives. All-cause mortality did not increase among other racial-ethnic groups. However, among NH Asians and Pacific Islanders, NH blacks, Hispanics, and NH whites, all-cause mortality exhibited retrogression, declining until 2009-2012 before leveling out or beginning to rise again.

Investigators also reported troubling increases in mortality due to more specific causes of death for the various racial-ethnic groups. From 1999-2016, NH American Indians and Alaskan Natives experienced alarming increases in midlife mortality not only due to drug overdoses (411.4%), but also due to hypertensive diseases (269.3%), liver cancer (115.1%), viral hepatitis (112.1%), and diseases of the nervous system (99.8%). NH blacks experienced increases in midlife mortality due to drug overdoses (149.6%), homicides (21.4%), hypertensive diseases (15.5%), obesity (120.7%), and liver cancer (49.5%). Among Hispanics, the largest increases were in drug overdoses (80.0%), hypertensive diseases (40.6%), liver cancer (41.8%), suicides (21.9%), obesity (106.6%), and metabolic disorders (60.0%). Finally, NH Asians and Pacific Islanders also experienced increases in midlife mortality from drug overdoses (300.6%), alcohol related liver disease (62.9%), hypertensive diseases (28.3%), and brain cancer (56.6%).

While drug overdoses accounted for the largest increases in midlife deaths for each racial-ethnic group, other diseases have played a significant role in the overall rising midlife death rates in the US.

“The opioid epidemic is only the tip of the iceberg,” said Woolf. “The rise in mortality from organ diseases requires clinicians to bring their A game to the management of chronic illnesses like hypertension, obesity, viral hepatitis, and other conditions that are claiming lives at higher rates.”

The study also highlighted the disproportionate impact rising midlife mortality has had on women in the US.

“Although men tended to have higher mortality rates than women, we found that the relative increase in midlife mortality was often greater among women than men,” noted Woolf. “Women appear to be more vulnerable to the social stresses responsible for this public health crisis.”

For deaths due to overdoses and suicides, men had higher absolute rates, but relative increases were higher among women. The relative increase in deaths due to drug overdoses was higher for women than for men among NH American Indians and Alaskan Natives (457.0% v 386.8%), NH blacks (201.7% v 127.8%), NH whites (611.5% v 445.9%), and Hispanics (158.9% v 64.2%). There were not sufficient data for NH Asians and Pacific Islanders.

A similar pattern was seen in deaths due to suicide. The increases were greater for women than men for NH blacks (40.5% v 5.7%), NH whites (69.6% v 43.4%), and Hispanics (41.9% v 17.5%). The only group for which this was reversed was NH American Indians and Alaskan Natives (77.6% v 94.8%), and among NH Asians and Pacific Islanders the rates were nearly equal for women and men (7.3% v 7.4%).

In the face of these dismal trends, Woolf suggested that physicians can try to help patients address food insecurity, unstable housing, unemployment, and poverty. However, he also acknowledged that providers rarely receive training for this and that the health care system is not set up to encourage physicians to connect patients with case managers and social workers.

Such support, even when it is possible, is “band-aid solution” said Woolf, “if we—as a society—do not address the root causes, such as income inequality and social division.” He especially called out physicians in this exhortation, saying that while politicians and journalists have lost much public respect, physicians remain highly respected and have a role in public discourse.

“Whether they are testifying to the city council or the US Senate, physicians can sway public opinion and help “connect the dots”—they can help the public and politicians see how health is linked to policies on education, jobs, transportation, and housing,” said Woolf.

Whether these trends continue or begin to improve over the coming years remains to be seen. What is clear is that policy changes, social changes, and more research are needed, and that providers have a role to play in leading those efforts.

The study, “Changes in midlife death rates across racial and ethnic groups in the United States: systematic analysis of vital statistics,” was published in The BMJ.