Where’s the best place in America to live if you want to maximize your chances of living longer?
Based on an authoritative new state-by-state study of the American burden of disease, disability and premature death, and how it has changed from 1990 to 2016, you might consider setting down roots in Hawaii, where residents have the longest life expectancy, 81.3 years.
But if your goal is to live long and stay healthy as long as you can, call Minnesota your home, which outranks every state and the District of Columbia for average length of healthy life expectancy, 70.3 years.
Perhaps I should have stayed in Minneapolis, a city I loved and still do nearly 53 years after moving to New York to work for The New York Times. But then I would not have been writing this column every week for the last 40-odd years. Win some, lose some!
Minnesotans joke that the long months of subfreezing temperatures preserve them, but Dr. Christopher J.L. Murray, the new study’s lead author, told me, “Living in cold is pretty bad for you; Minnesotans would probably be even healthier if it wasn’t so cold there.”
Of course, the biology of the native population likely plays a role in how long and how healthfully people live in various parts of the country. And the opportunities people have for a good education, financial security, quality medical care and environmental safety also make important contributions.
But the big enchilada, as this extraordinarily comprehensive study clearly demonstrates, is how people live their lives: whether they smoke, what and how much they eat, and whether they abuse alcohol or drugs. These, along with high levels of blood sugar and blood pressure, both of which are influenced by diet, are the main factors dictating poor health.
“About three-fourths of the variation in life expectancy between counties can be explained by these big risk factors,” Dr. Murray, epidemiologist and health economist at the University of Washington, said in an interview. “Much more is due to the sociocultural environment, especially what people eat, than to their genes or the physical environment.”
Alas, the study did not measure the contribution of regular exercise to longevity and long-lasting health. “There’s not as much research on the effects of physical activity as there should be,” Dr. Murray said, adding that exercise most likely contributes to the major risks that were measured.
Public policy and personal behaviors should foster the ability to live free of chronic disease and disability well into old age — in other words, to maximize the chances of adding both years to life and life to years for as many people as possible, according to Dr. Howard K. Koh, who wrote an editorial with Dr. Anand K. Parekh about the study, published in April in JAMA.
The findings of the study can and should provide a blueprint for everyone — the public, the medical profession and government agencies — to achieve this vitally important money-saving and health-saving goal. But it is a goal that depends heavily on preserving a critical component of the Affordable Care Act: full coverage, without co-pays, for “an array of counseling and screening interventions relevant to tobacco use, diet, hypertension and exercise; statin preventive medication and aspirin preventive medication; depression; and cancer (breast, lung, colon, rectal, skin, cervix),” Drs. Koh and Parekh wrote.
Do people with pounds to shed for the sake of their health know that, under Obamacare, they are now covered for many sessions of weight-loss counseling?
Or that diabetes prevention programs are being supported in many locations like YMCAs by the government’s Centers for Medicare and Medicaid Services?
“Everyone needs insurance to access health care services, that’s an essential part of health,” Dr. Koh, a professor of public health at Harvard’s T.H. Chan School of Public Health, told me. “And preventive services covered by the ACA are needed to give everyone the opportunity to achieve the highest attainable state of health,” a goal established by the World Health Organization.
“Dr. Murray’s study shows that too many people are not enjoying that opportunity,” Dr. Koh said. “It should be a call to action for the country. As a clinician who cared for patients for more than 30 years, I saw too much suffering and death that should have been prevented.”
For example, enormous progress has been made in curbing tobacco use in the last half-century. “Yet there are still 35 million adult smokers and more than half a million deaths from tobacco-related causes each year,” Dr. Koh said. “Lung cancer, 85 percent of which is preventable, remains the leading cause of cancer deaths. Why are we tolerating this?”
Dr. Murray pointed out that in the quarter-century covered by the study, smoking rates dropped by 60.5 percent in California, far greater than the 40.8 percent decline in smoking for the country as a whole, not to mention the meager 11.2 percent decline in West Virginia.
“There’s nothing to stop other states from mimicking what California has done,” he said.
Also needed is a greater commitment from the food industry to provide healthier foods and beverages that people can afford, along with easy access to such products for people in all parts of the country. There are far too many food deserts where wholesome foods like fresh fruits and vegetables at affordable prices are hard to come by.
In nine states, the study found, people were eating fewer fruits in 2016 than they were in 1990, and hardly any improvement in fruit consumption occurred in half a dozen other states.
“Diet really needs our attention, perhaps through taxes on unhealthy foods and subsidies for healthier ones,” Dr. Murray said. “We haven’t done much about diet other than providing information.”
In highlighting dietary risks individuals can control, Dr. Murray said that people should eat more whole grains, fruits and vegetables, nuts and seeds, legumes, fiber and foods rich in omega-3 fatty acids but less salt and no processed meats and trans fats.
Still, Dr. Koh said, “We need a society in which the healthy choice is the easier choice. We need to make the social drivers of health a major concern of the culture.”
Dr. Murray said that medical practice also needs some serious tweaking. “Primary care providers are too focused on diagnosing disease and treating it,” he said.
“They need to focus on the big contributors to risk, like high blood pressure and high cholesterol, which are easy to detect and easy to treat. Patients should demand it and, if they do, doctors will provide it.”