American morbidity: gap between lifespan and healthspan keeps widening

Clinical takeaway: The conditions driving unhealthy years, obesity, low back pain, depression and anxiety, hearing loss, and falls, are core primary care territory. This puts prevention and long-term management at the center of healthy aging.

Longevity gains have long been expected to happen alongside healthier aging. Instead, the opposite has been happening almost everywhere around the world. In 203 out of 204 countries, life expectancy grew faster than healthy life expectancy between 1990 and 2023.

The US now has the widest gap in the world, with Americans averaging 14 years in poor health, nearly 18% of their lives. And rather than piling up toward the end of life when people are elderly, those unhealthy years accumulate over time across the adult lifespan.

The finding lands squarely within what is a decades-old debate. A "compression of morbidity" hypothesis dating from at least 1980 has held that better prevention and care would delay disability more than death, so illness would crowd into a brief window before dying. This new Global Burden of Disease (GBD) analysis is the broadest test of that idea yet, and it found the reverse. The global gap grew to 10.7 years in 2023 from 8.8 in 1990, with 14.5% of life now spent in poor health.

In high-income countries like the US, most of the unhealthy years come from a handful of mostly non-fatal conditions. Musculoskeletal and mental disorders alone make up more than a third of the high-income world's 12.7-year gap. Unintentional injuries, neurological disorders, and hearing and vision loss bring the total to 61.8%. The global pattern is similar, led by low back pain, depression and anxiety, age-related hearing loss, and falls, at 57.4% of unhealthy years.

Women lived longer than men everywhere but spent more of those years in poor health, 12.1 versus 9.3 in 2023. The gaps for both sexes have grown at nearly the same pace since 1990, when women stood at 10.0 years and men at 7.6. Musculoskeletal disorders and mental health conditions disproportionately affect women, the authors note.

The leading risk factors are familiar to primary care: high fasting plasma glucose, high BMI, and tobacco use. In high-income countries, high BMI is the leading contributor. Low bone mineral density, dietary risks, and high systolic blood pressure also rank highly. Drug and alcohol use registered as notable contributors only in high-income settings. In lower-income countries the profile shifts, with child and maternal malnutrition and air pollution becoming leading contributing factors.

Researchers calculated the morbidity gap, life expectancy minus healthy life expectancy, for 204 countries and territories using GBD 2023 estimates spanning 1990 to 2023, then split it by cause, risk factor, sex, and development level. Contributions were based on years lived with disability, adjusted so overlapping conditions were not counted twice.

With high BMI and high fasting plasma glucose topping the risk list in high-income countries, the obvious question is now: what will the introduction of GLP-1s and their ilk mean for population health over time? The morbidity gap is a chronic disease problem, so tools that rein in its leading metabolic drivers could shift the story again in the coming decades.

"Improving healthy aging will require greater focus on the conditions and risk factors that drive years lived with disability. Addressing these earlier through prevention and better long-term care could have meaningful social, health system, and economic impacts," said said Catherine Bisignano, MPH, senior scientific writer at the Institute for Health Metrics and Evaluation and co-author of the study.

Source: Hay SI, et al. (2026 Jul 21) Lancet Public Health. Global, regional, and national trends in the morbidity gap and contributing diseases, injuries, and risk factors, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023