Amy Z. Fan

Surveillance for certain health behaviors and conditions among states and selected local areas — Behavioral Risk Factor Surveillance System, United States, 2015

Problem Chronic conditions and disorders (e.g., diabetes, cardiovascular diseases, arthritis, and depression) are leading causes of morbidity and mortality in the United States. Healthy behaviors (e.g., physical activity, avoiding cigarette use, and refraining from binge drinking) and preventive practices (e.g., visiting a doctor for a routine check-up, tracking blood pressure, and monitoring blood cholesterol) might help prevent or successfully manage these chronic conditions. Monitoring chronic diseases, health-risk behaviors, and access to and use of health care are fundamental to the development of effective public health programs and policies at the state and local levels. Reporting Period January–December 2015. Description of the System The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit–dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to and use of health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico (Puerto Rico), and Guam and for 130 metropolitan and micropolitan statistical areas (MMSAs) (N = 441,456 respondents) for 2015. Results The age-adjusted prevalence estimates of health-risk behaviors, self-reported chronic health conditions, access to and use of health care, and use of preventive health services varied substantially by state, territory, and MMSA in 2015. Results are summarized for selected BRFSS measures. Each set of proportions refers to the median (range) of age-adjusted prevalence estimates for health-risk behaviors, self-reported chronic diseases or conditions, or use of preventive health care services by geographic jurisdiction, as reported by survey respondents. Adults with good or better health: 84.6% (65.9%–88.8%) for states and territories and 85.2% (66.9%–91.3%) for MMSAs. Adults with ≥14 days of poor physical health in the past 30 days: 10.9% (8.2%–17.2%) for states and territories and 10.9% (6.6%–19.1%) for MMSAs. Adults with ≥14 days of poor mental health in the past 30 days: 11.3% (7.3%–15.8%) for states and territories and 11.4% (5.6%–20.5%) for MMSAs. Adults aged 18–64 years with health care coverage: 86.8% (72.0%–93.8%) for states and territories and 86.8% (63.2%–95.7%) for MMSAs. Adults who received a routine physical checkup during the preceding 12 months: 69.0% (58.1%–79.8%) for states and territories and 69.4% (57.1%–81.1%) for MMSAs. Adults who ever had their blood cholesterol checked: 79.1% (73.3%–86.7%) for states and territories and 79.5% (65.1%–87.3%) for MMSAs. Current cigarette smoking among adults: 17.7% (9.0%–27.2%) for states and territories and 17.3% (4.5%–29.5%) for MMSAs. Binge drinking among adults during the preceding 30 days: 17.2% (11.2%–26.0%) for states and territories and 17.4% (5.5%–24.5%) for MMSAs. Adults who reported no leisure-time physical activity during the preceding month: 25.5% (17.6%–47.1%) for states and territories and 24.5% (16.1%–47.3%) for MMSAs. Adults who reported consuming fruit less than once per day during the preceding month: 40.5% (33.3%–55.5%) for states and territories and 40.3% (30.1%–57.3%) for MMSAs. Adults who reported consuming vegetables less than once per day during the preceding month: 22.4% (16.6%–31.3%) for states and territories and 22.3% (13.6%–32.0%) for MMSAs. Adults who have obesity: 29.5% (19.9%–36.0%) for states and territories and 28.5% (17.8%–41.6%) for MMSAs. Adults aged ≥45 years with diagnosed diabetes: 15.9% (11.2%–26.8%) for states and territories and 15.7% (10.5%–27.6%) for MMSAs. Adults aged ≥18 years with a form of arthritis: 22.7% (17.2%–33.6%) for states and territories and 23.2% (12.3%–33.9%) for MMSAs. Adults having had a depressive disorder: 19.0% (9.6%–27.0%) for states and territories and 19.2% (9.9%–27.2%) for MMSAs. Adults with high blood pressure: 29.1% (24.2%–39.9%) for states and territories and 29.0% (19.7%–41.0%) for MMSAs. Adults with high blood cholesterol: 31.8% (27.1%–37.3%) for states and territories and 31.4% (23.2%–42.0%) for MMSAs. Adults aged ≥45 years who have had coronary heart disease: 10.3% (7.2%–16.8%) for states and territories and 10.1% (4.7%–17.8%) for MMSAs. Adults aged ≥45 years who have had a stroke: 4.9% (2.5%–7.5%) for states and territories and 4.7% (2.1%–8.4%) for MMSAs. Interpretation The prevalence of health care access and use, health-risk behaviors, and chronic health conditions varied by state, territory, and MMSA. The data in this report underline the importance of continuing to monitor chronic diseases, health-risk behaviors, and access to and use of health care in order to assist in the planning and evaluation of public health programs and policies at the state, territory, and MMSA level. Public Health Action State and local health departments and agencies and others interested in health and health care can continue to use BRFSS data to identify groups with or at high risk for chronic conditions, unhealthy behaviors, and limited health care access and use. BRFSS data also can be used to help design, implement, monitor, and evaluate health-related programs and policies.

Smoking status and common carotid artery intima-medial thickness among middle-aged men and women based on ultrasound measurement: a cohort study

BackgroundCigarette smoking is an established causal factor for atherosclerosis. However, the smoking effect on different echogenic components of carotid arterial wall measured by ultrasound is not well elucidated.MethodsMiddle-aged men and women who had IMT measurement ≥ 0.7 mm at baseline and follow-up were included (N = 413, age 40–60 years at baseline in 1995). Intima-media thickness of common carotid artery (CCA-IMT) and its components (echogenic and echolucent layers) were measured at baseline and in the follow-up examination 3 years later. IMT and its components were compared across current, former and never smokers. Individual growth models were used to examine how smoking status was related to the baseline and progression of overall IMT and IMT components.ResultsFor both men and women, current smoking was associated with thicker echogenic layer than never smokers; former smokers exhibited thinner echogenic layer than current smokers after adjustment for cigarette pack-years. Among women, current smoking was also associated with a thinned echolucent layer that resulted in a non-significant overall association of current smoking with IMT for women.ConclusionCigarette smoking is associated with carotid artery morphological changes and the association is sex-dependent. The atherogenic effect of smoking appears to be partly reversible among former smokers. IMT measurement alone may not be adequate to detect carotid atherosclerosis associated with cigarette smoking among middle-age women.

Drinking Patterns and Myocardial Infarction: A Linear Dose-Response Model

BACKGROUND The relation of alcohol intake to cardiovascular health is complex, involving both protective and harmful effects, depending on the amount and pattern of consumption. Interpretation of data available on the nature of these relations is limited by lack of well-specified, mathematical models relating drinking patterns to alcohol-related consequences. Here we present such a model and apply it to data on myocardial infarction (MI). METHODS The dose-response model derived assumes: (1) each instance of alcohol use has an effect that either increases or decreases the likelihood of an alcohol-related consequence, and (2) greater quantities of alcohol consumed on any drinking day add linearly to these increases or decreases in risk. Risk was reduced algebraically to a function of drinking frequency and dosage (volume minus frequency, a measure of the extent to which drinkers have more than 1 drink on days when they drink). In addition to estimating the joint impact of frequency and dosage, the model provides a method for calculating the point at which risk related to alcohol consumption is equal to background risk from other causes. A bootstrapped logistic regression based on the dose-response model was conducted using data from a case-control study to obtain the predicted probability of MI associated with current drinking patterns, controlling for covariates. RESULTS MI risk decreased with increasing frequency of drinking, but increased as drinking dosage increased. Rates of increasing MI risk associated with drinking dosage were twice as high among women as they were among men. Relative to controls, lower MI risk was associated with consuming < 4.55 drinks per drinking day for men (95% CI: 2.77 to 7.18) and < 3.08 drinks per drinking day for women (95% CI: 1.35 to 5.16), increasing after these cross-over points were exceeded. CONCLUSIONS Use of a well-specified mathematical dose-response model provided precise estimates for the first time of how drinking frequency and dosage each contribute linearly to the overall impact of a given drinking pattern on MI risk in men and women.

Trends in cigarette smoking rates and quit attempts among adults with and without diagnosed diabetes, United States, 2001-2010.

Introduction Quitting smoking is a critical step toward diabetes control. It is not known whether smoking rates in adults with diabetes are similar to rates among adults who do not have the disease or whether people with diabetes have increased motivation to quit. We examined prevalence trends of current smoking and quit attempts among US adults with and without diagnosed diabetes from 2001 through 2010. Methods We used data from the 2001 through 2010 Behavioral Risk Factor Surveillance System, a state-based telephone survey of noninstitutionalized US adults, and conducted linear trend analysis and log linear regression. Results The adjusted prevalence of cigarette smoking among adults with diagnosed diabetes was 9% less than adults without diagnosed diabetes (adjusted prevalence ratio [APR], 0.91; 99% confidence interval [CI], 0.89−0.93). Declines in smoking prevalence were greater among adults without diabetes than adults with diagnosed diabetes (P < .001). Among smokers, the adjusted prevalence of quit attempts among adults with diagnosed diabetes was 13% higher than among adults without diagnosed diabetes (APR, 1.13; 99% CI, 1.11−1.15). Among adult smokers with diagnosed diabetes, quit attempts were stable over time for those aged 18 to 44 years and those with a high school education or less. Quit attempts were also stable for older smokers, non-Hispanic African Americans, and Hispanic smokers, regardless of diagnosed diabetes status. Conclusion A large proportion of smokers with diagnosed diabetes seemed to have quit smoking, but more research is needed to confirm success and how difficult it was to achieve.

State Socioeconomic Indicators and Self-Reported Hypertension Among US Adults, 2011 Behavioral Risk Factor Surveillance System

Introduction Hypertension is the leading cause of chronic disease and premature death in the United States. To date, most risk factors for hypertension have been identified at the individual (micro) level. The association of macro-level (area) socioeconomic factors and hypertension prevalence rates in the population has not been studied extensively. Methods We used the 2011 Behavioral Risk Factor Surveillance System to examine whether state socioeconomic status (SES) indicators predict the prevalence of self-reported hypertension. Quintiles of state median household income, unemployment rate among the population aged 16 to 64 years, and the proportion of the population under the national poverty line were used as the proxy for state SES. Hypertension status was determined by the question “Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?” Logistic regression was used to assess the relationship between state SES and hypertension with adjustment for individual covariates (demographic and socioeconomic factors and lifestyle behaviors). Results States with a median household income of

Gender Differences in Intermediate Atherogenic Pathways by Cigarette Smoking among Middle-Aged US Adults

43,225 or less (odds ratio [95% confidence interval] = 1.16 [1.08–1.25]) and states with 18.7% or more of residents living below the poverty line (odds ratio [95% confidence interval] = 1.14 [1.04–1.24]) had a higher prevalence of hypertension than states with the most residents in the most advantageous quintile of the indicators. Conclusion The observed state SES–hypertension association indicates that area SES may contribute to the burden of hypertension in community-dwelling adults.

Experience of Stroke Warning Symptoms is Associated with an Adverse Cardiovascular Risk Profile

Objective: This study investigates mediating atherogenic pathways caused by cigarette smoking (anthropometric, metabolic, hemodynamic, inflammatory factors) among middle-aged adults and whether there are gender differences in these pathways. Methods: The data were obtained from the Los Angeles Atherosclerosis Study. The sample consists of 573 middle-aged healthy U.S. adults (age 40-60 yrs). Common carotid arterial intima-medial thickness (IMT) measured by B-mode ultrasound was used as a surrogate indicator for subclinical atherosclerosis. Results and Conclusion: Besides high levels of low-density lipoprotein cholesterol and total cholesterol, cigarette smoking was also associated with manifestations of metabolic syndrome (central obesity, atherogenic dyslipidemia, sympathetic overactivity, elevated inflammation markers). Most intermediate physiologic profiles for former smokers were similar to those for never smokers, suggesting that smoking effects are partly reversible after quitting. The common atherogenic mediating pathways by smoking for men and women was central obesity. The unique pathway for women was dyslipidemia (low HDL cholesterol and high triglycerides), and the unique pathways for men were elevated levels of LDL cholesterol and total cholesterol, sympathetic overactivity, and elevated inflammation markers.

Letter by Stranges et al Regarding Article, “To Drink or Not to Drink? That Is the Question”

Population-based studies may provide convincing evidence on whether persons experiencing stroke warning symptoms manifest an adverse cardiovascular risk profile regardless of a history of stroke. Data were analyzed for 9728 US adults aged � 40 years from the National Health and Nutrition Examination Survey1988-1994. Stroke warning symptoms were defined as experiencing one or more of the following for more than 5 minutes: sudden onset of weakness or paralysis of face, arm, or leg; numbness on one side of the face or body; loss of vision in one or both eyes; severe dizziness; or problem with ability to speak or understand. In an analysis excluding those with a history of diagnosed stroke, compared with those who had never experienced stroke symptoms, persons who had experienced symptoms manifested significantly (P<0.05) greater prevalence of diabetes, other cardiovascular diseases, and had significantly higher diastolic blood pressure, body mass index, waist circumference, serum triglycerides, ratio of total to high-density lipoprotein (HDL) cholesterol, C-reactive protein, and fibrinogen and significantly lower HDL cholesterol after adjustment for age, sex, and race/ethnicity. Persons who experienced stroke warning symptoms during their lifetime manifested more adverse cardiovascular profiles even though they may not have had a diagnosed stroke. Further risk assessment is recommended for these persons and actions are needed to improve their cardiovascular health.

Lifetime alcohol drinking pattern is related to the prevalence of metabolic syndrome. The Western New York Health Study (WNYHS)

To the Editor: In a recently published article in Circulation ,1 Drs Kloner and Rezkalla reported an extensive review of the literature in the attempt to answer the pending question on whether or not patients and the general public should be advised to drink moderate amounts of alcohol on the basis of the existing evidence of beneficial effects on total mortality and cardiovascular disease. This is a question of considerable clinical and public health significance that is still waiting for a definitive answer. Although we appreciate the efforts made by the authors1 in their scrutiny of the literature, we …