Wayne H. Giles

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.

Prevalence of Hypertension in Rural West Africa

The prevalence of hypertension in rural African communities has been reported previously to be relatively low, with prevalence rates ranging between 2.5% and 10.9%. The authors obtained blood pressure recordings in 3,588 adult residents (age > 20 years) of the Liberian Agricultural Company rubber plantation, located in rural Liberia, West Africa. Blood pressures were obtained using automated digital blood pressure machines in a house-to-house survey. Individuals with a systolic blood pressure greater than 139 mm Hg or a diastolic blood pressure greater than 89 mm Hg were referred to a central site, where three subsequent blood pressure determinations were made, the mean of which was used to determine whether people were hypertensive. The overall prevalence of hypertension (blood pressure > 139/89 mm Hg) was 12.5%. Hypertension was most common in the older women (prevalence 5.7% in women age 20–24 years old, 50% in women older than 55). Using more stringent criteria for hypertension, systolic blood pressure greater than 159 mm Hg or diastolic blood pressure greater than 94 mm Hg, 20% of women between 50–54 had hypertension and 26% of the women older than 55 had hypertension. In some ethnic groups, the prevalence of hypertension was as high as 25%. Based on these results, the prevalence of hypertension in some rural African communities may be higher than reported previously, particularly in older women and among certain ethnic groups, possibly suggesting a strong hereditary component.

Co-occurrence of leading lifestyle-related chronic conditions among adults in the United States, 2002-2009.

Introduction Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions. Methods We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis. Results In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million. Conclusion The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.

Vital Signs: Racial Disparities in Age-Specific Mortality Among Blacks or African Americans — United States, 1999–2015

Background Although the overall life expectancy at birth has increased for both blacks and whites and the gap between these populations has narrowed, disparities in life expectancy and the leading causes of death for blacks compared with whites in the United States remain substantial. Understanding how factors that influence these disparities vary across the life span might enhance the targeting of appropriate interventions. Methods Trends during 1999–2015 in mortality rates for the leading causes of death were examined by black and white race and age group. Multiple 2014 and 2015 national data sources were analyzed to compare blacks with whites in selected age groups by sociodemographic characteristics, self-reported health behaviors, health-related quality of life indicators, use of health services, and chronic conditions. Results During 1999–2015, age-adjusted death rates decreased significantly in both populations, with rates declining more sharply among blacks for most leading causes of death. Thus, the disparity gap in all-cause mortality rates narrowed from 33% in 1999 to 16% in 2015. However, during 2015, blacks still had higher death rates than whites for all-cause mortality in all groups aged <65 years. Compared with whites, blacks in age groups <65 years had higher levels of some self-reported risk factors and chronic diseases and mortality from cardiovascular diseases and cancer, diseases that are most common among persons aged ≥65 years. Conclusions and Implications for Public Health Practice To continue to reduce the gap in health disparities, these findings suggest an ongoing need for universal and targeted interventions that address the leading causes of deaths among blacks (especially cardiovascular disease and cancer and their risk factors) across the life span and create equal opportunities for health.

Health-Related Behaviors by Urban-Rural County Classification — United States, 2013

Problem/Condition Persons living in rural areas are recognized as a health disparity population because the prevalence of disease and rate of premature death are higher than for the overall population of the United States. Surveillance data about health-related behaviors are rarely reported by urban-rural status, which makes comparisons difficult among persons living in metropolitan and nonmetropolitan counties. Reporting Period 2013. Description of 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 health care, and use of preventive health services related to the leading causes of death and disability. BRFSS data were analyzed for 398,208 adults aged ≥18 years to estimate the prevalence of five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations) by urban-rural status. For this report, rural is defined as the noncore counties described in the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Results Approximately one third of U.S. adults practice at least four of these five behaviors. Compared with adults living in the four types of metropolitan counties (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan), adults living in the two types of nonmetropolitan counties (micropolitan and noncore) did not differ in the prevalence of sufficient sleep; had higher prevalence of nondrinking or moderate drinking; and had lower prevalence of current nonsmoking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations. The overall age-adjusted prevalence of reporting at least four of the five health-related behaviors was 30.4%. The prevalence among the estimated 13.3 million adults living in noncore counties was lower (27.0%) than among those in micropolitan counties (28.8%), small metropolitan counties (29.5%), medium metropolitan counties (30.5%), large fringe metropolitan counties (30.2%), and large metropolitan centers (31.7%). Interpretation This is the first report of the prevalence of these five health-related behaviors for the six urban-rural categories. Nonmetropolitan counties have lower prevalence of three and clustering of at least four health-related behaviors that are associated with the leading chronic disease causes of death. Prevalence of sufficient sleep was consistently low and did not differ by urban-rural status. Public Health Action Chronic disease prevention efforts focus on improving the communities, schools, worksites, and health systems in which persons live, learn, work, and play. Evidence-based strategies to improve health-related behaviors in the population of the United States can be used to reach the Healthy People 2020 objectives for these five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations). These findings suggest an ongoing need to increase public awareness and public education, particularly in rural counties where prevalence of these health-related behaviors is lowest.

Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states

Purpose Adverse childhood experiences (ACEs) before age 18 have been repeatedly associated with several chronic diseases in adulthood such as depression, heart disease, cancer, diabetes, and stroke. We examined sex-specific relationships between individual ACEs and the number of ACEs with chronic obstructive pulmonary disease (COPD) in the general population. Materials and methods Data from 26,546 women and 19,015 men aged ≥18 years in five states of the 2011 Behavioral Risk Factor Surveillance System were analyzed. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for the relationship of eight ACEs with COPD after adjustment for age group, race/ethnicity, marital status, educational attainment, employment, asthma history, health insurance coverage, and smoking status. Results Some 63.8% of women and 62.2% of men reported ≥1 ACE. COPD was reported by 4.9% of women and 4.0% of men. In women, but not in men, there was a higher likelihood of COPD associated with verbal abuse (PR =1.30, 95% CI: 1.05, 1.61), sexual abuse (PR =1.69, 95% CI: 1.36, 2.10), living with a substance abusing household member (PR =1.49, 95% CI: 1.23, 1.81), witnessing domestic violence (PR =1.40, 95% CI: 1.14, 1.72), and parental separation/divorce (PR =1.47, 95% CI: 1.21, 1.80) during childhood compared to those with no individual ACEs. Reporting ≥5 ACEs (PR =2.08, 95% CI: 1.55, 2.80) compared to none was associated with a higher likelihood of COPD among women only. Conclusion ACEs are related to COPD, especially among women. These findings underscore the need for further research that examines sex-specific differences and the possible mechanisms linking ACEs and COPD. This work adds to a growing body of research suggesting that ACEs may contribute to health problems later in life and suggesting a need for program and policy solutions.

The Association between Psychological Distress and Self-Reported Sleep Duration in a Population-Based Sample of Women and Men

Mental health and sleep are intricately linked. This study characterized associations of psychological distress with short (≤6 hours) and long (≥9 hours) sleep duration among adults aged ≥18 years. 2013 Behavioral Risk Factor Surveillance System data (n = 36,859) from Colorado, Minnesota, Nevada, Tennessee, and Washington included the Kessler 6 (K6) scale, which has been psychometrically validated for measuring severe psychological distress (SPD); three specifications were evaluated. Overall, 4.0% of adults reported SPD, 33.9% reported short sleep, and 7.8% reported long sleep. After adjustment, adults with SPD had 1.58 (95% CI: 1.45, 1.72) and 1.39 (95% CI: 1.08, 1.79) times higher probability of reporting short and long sleep duration, respectively. Using an ordinal measure showed a dose-response association with prevalence ratios of 1.00, 1.16, 1.38, 1.67, and 2.11 for short sleep duration. Each additional point added to the K6 scale was associated with 1.08 (95% CI: 1.07, 1.10) and 1.02 (95% CI: 1.00, 1.03) times higher probability of reporting short and long sleep duration, respectively. Some results were statistically different by gender. Any psychological distress, not only SPD, was associated with a higher probability of short sleep duration but not long sleep duration. These findings highlight the need for interventions.

Clinical InvestigationGeographic Variations in Heart Failure Hospitalizations Among Medicare Beneficiaries in the Tennessee Catchment Area

Introduction:Although differences in heart failure (HF) hospitalization rates by race and sex are well documented, little is known about geographic variations in hospitalizations for HF, the most common discharge diagnosis for Medicare beneficiaries. Methods:Using exploratory spatial data analysis techniques, the authors examined hospitalization rates for HF as the first-listed discharge diagnosis among Medicare beneficiaries in a 10-state Tennessee catchment area, based on the resident states reported by Tennessee hospitals from 2000 to 2004. Results:The age-adjusted HF hospitalization rate (per 1000) among Medicare beneficiaries was 23.3 [95% confidence interval (CI), 23.3–23.4] for the Tennessee catchment area, 21.4 (95% CI, 21.4–21.5) outside the catchment area and 21.9 (95% CI, 21.9–22.0) for the overall United States. The age-adjusted HF hospitalization rates were also significantly higher in the catchment area than outside the catchment area and overall, among men, women and whites, whereas rates among the blacks were higher outside the catchment area. Beneficiaries in the catchment area also had higher age-specific HF hospitalization rates. Among states in the catchment area, the highest mean county-level rates were in Mississippi (30.6 ± 7.6) and Kentucky (29.2 ± 11.5), and the lowest were in North Carolina (21.7 ± 5.7) and Virginia (21.8 ± 6.6). Conclusions:Knowledge of these geographic differences in HF hospitalization rates can be useful in identifying needs of healthcare providers, allocating resources, developing comprehensive HF outreach programs and formulating policies to reduce these differences.