Physiological imbalance (PI) is a situation in which physiological parameters deviate from the normal and cows consequently have an increased risk of developing production diseases and reduced production or reproduction. The objectives of this work were (1) to generate an index for PI based on several plasma metabolites and (2) to compare the use of this index with calculated energy balance (EBAL) and individual plasma metabolites in relation to risk of disease during early lactation. We used a total of 634 lactations from 317 cows consisting of 3 breeds ranging from a parity of 1 to 4. Weekly blood samples were analyzed for selected metabolites; that is, urea nitrogen, albumin, cholesterol, nonesterified fatty acids (NEFA), glucose, and β-hydroxybutyrate (BHBA). Energy intake and EBAL were calculated; veterinary treatment records and daily composite milk somatic cell counts were used to determine incidence of disease. Data were adjusted for numerous fixed effects (e.g., parity, breed, and week around calving) before further statistical analysis. The time of disease (TOD) was recorded as the day in which the signs of disease were observed (TOD=0). The week before and after TOD was ± n wk relative to TOD=0. Each week, all plasma metabolites were individually adjusted to an overall mean (=0) and variance (=1). The normalized variables were included in regression analyses by week of lactation to identify metabolites that explain the variation in calculated EBAL, as a reflection of degree of PI. Nonesterified fatty acids, BHBA, and glucose were weighted within each week based on regression coefficients (i.e., x1-x3 below) generated from a model to predict EBAL. Data from wk -1 relative to TOD were analyzed using a mixed linear model to relate degree of PI and metabolites in blood to risk of disease. The weekly PI index was defined as PI=(x1 × [NEFA])+x2 × [BHBA] - x3 × [glucose])/3. For diseases that developed ≥ 2 wk after calving, no variables were associated with risk of disease. Prepartal PI and plasma NEFA were better predictors of disease (i.e., metritis, retained placenta, and milk fever) at wk 1 than EBAL and plasma BHBA and glucose. Examining the relationship between PI and milk constituents is needed for the development of an automated in-line and real-time surveillance system for early detection of risk animals on-farm.