Health Objectives for the Nation Prevalence of Selected Risk Factors for Chronic Disease by Education Level in Racial/Ethnic Populations -- United States, 1991-1992

One of the three broad national health objectives for the year 2000 is to reduce health disparities within the U.S. population (1). Disparities in risks for chronic diseases are particularly prominent among racial/ethnic minorities (blacks, American Indians/ Alaskan Natives, Asians/Pacific Islanders, and Hispanics). This report summarizes findings from the 1991 and 1992 Behavioral Risk Factor Surveillance System (BRFSS) that characterize the distribution of three major risk factors for chronic disease -- current cigarette smoking, sedentary lifestyle, and overweight -- across racial/ethnic groups and by level of education within the racial/ethnic groups.

Data were analyzed for 180,255 adults who participated in the 1991 or the 1992 BRFSS, a state-based, random-digit-dialed telephone survey that collects self-reported data from a representative sample of civilian, noninstitutionalized persons aged greater than or equal to 18 years. Data from 1991 and 1992 were combined to increase precision of the prevalence estimates for minority populations. In 1991, monthly BRFSS surveys were conducted in the District of Columbia and all states except Kansas, Nevada, and Wyoming, and in 1992 in the District of Columbia and all states except Arkansas and Wyoming. Race/ethnicity and other demographic characteristics were self-reported. Current cigarette smoking was defined as ever having smoked 100 cigarettes and currently smoking regularly. Sedentary lifestyle was defined as reported participation in fewer than three 20-minute sessions of leisure-time physical activity per week; physical activity as part of usual job activities was not included. Self-reported data on height and weight were used to calculate body mass index (BMI) (weight in kilograms divided by height in meters squared). Overweight was defined as BMI greater than or equal to 27.8 for men and greater than or equal to 27.3 for women (1). Years of education were grouped as less than 12 years, 12 years, or greater than 12 years.

For both women and men, the percentage of respondents reporting current cigarette smoking was highest among American Indians/Alaskan Natives and lowest among Asians/Pacific Islanders (Table_1 and Table_2). Among women, a sedentary lifestyle was reported most frequently by blacks (68%) and least frequently by whites (56%). Among men, the prevalence of a sedentary lifestyle was highest for both blacks (63%) and Hispanics (62%) and lowest for American Indians/Alaskan Natives (51%). The prevalence of overweight among women was highest for blacks (38%) and lowest for Asians/Pacific Islanders (10%). Among men, the prevalence of overweight was highest for American Indians/Alaskan Natives (34%) and lowest for Asians/Pacific Islanders (11%). Education levels by sex varied widely across the five racial/ethnic groups.

When results for the racial/ethnic groups were stratified by level of education, the prevalence of risk factors generally varied inversely with level of education within all five population groups Table_3; however, prevalence of cigarette smoking among women was less consistent with this pattern. In addition, when respondents with less than 12 years of education were compared with respondents with greater than 12 years of education, most differences in prevalence estimates were statistically significant. Despite the aggregation of data for the 2-year period, confidence intervals for prevalence estimates among these groups were wide because of the small sample sizes for American Indians/Alaskan Natives (1811) and for Asians/Pacific Islanders (4253). Reported by: Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Although the general inverse association between years of education and important risk factors -- including current cigarette smoking, sedentary lifestyle, and overweight -- has been clearly established (3-5), data characterizing such associations among U.S. racial/ethnic minorities are limited. The BRFSS findings in this report document substantial differences in the prevalence of risk factors among racial/ethnic groups and indicate that using culturally appropriate and culturally based messages in public health programs may be important in decreasing these risk factors in the highest risk groups. For example, a pilot study on effective weight-loss strategies for black women had trained black women as group leaders and used ethnic foods and educational materials reviewed by black advisors to ensure that they were culturally appropriate (6). Further evaluation of culturally appropriate interventions is needed to determine whether they are more effective than interventions that have no cultural adaptations.

The findings in this report are subject to at least two limitations. First, because BRFSS is a telephone survey and 5% of households are without telephones, the findings cannot be generalized to the total respective population groups. In addition, telephone ownership varies substantially across racial/ethnic groups: the Bureau of the Census reported that, by race and ethnicity of the householder, in 1990 telephones were in the homes of 98% of Asians/Pacific Islanders, 96% of whites, 88% of Hispanics, 87% of blacks, and 77% of American Indians/Alaskan Natives (7). Second, prevalence estimates of chronic disease risk factors are based on self-reported data and may be subject to reporting bias.

Because poverty is associated with poor health status and poverty is distributed unequally among racial/ethnic groups, education levels and other socioeconomic factors must be considered when examining racial/ethnic group-specific differences in health status and determining intervention strategies. Within the racial/ethnic groups analyzed in this report, the prevalences of current cigarette smoking, sedentary lifestyle, and overweight generally were highest among those with less than 12 years of education. Although education level is an imperfect proxy measure for socioeconomic status (SES), it is often the only SES marker available from routine surveillance data. Therefore, education level is an important factor in the design of risk-reduction programs to help targeted audiences better understand health messages (8,9). In addition, despite the lower prevalence of telephone ownership among racial/ethnic groups, telephone-based intervention strategies may assist in communicating risk-reduction programs to persons in households with telephones who would not routinely attend risk-reduction programs (10).

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. CDC. Chronic disease in minority populations. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

3. Shea S, Stein AD, Basch CE, et al. Independent associations of educational attainment and ethnicity with behavioral risk factors for cardiovascular disease. Am J Epidemiol 1991;134:567-82.

4. Winkleby MA, Fortmann SP, Barrett DC. Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med 1990;12:1-12.

5. Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, Davis RM. Trends in cigarette smoking in the United States: projections to the year 2000. JAMA 1989;261:61-5.

6. Kanders BS, Ullmann-Joy P, Foreyt JP, et al. The Black American Lifestyle Intervention (BALI): the design of a weight-loss program for working-class African-American women. J Am Diet Assoc 1994;94:310-2.

7. Bureau of the Census. Statistical brief: phoneless in America. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1994; publication no. SB/94-16.

8. Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Rep 1994;109:86-92.

9. Ammerman AS, DeVellis BM, Haines PS, et al. Nutrition education for cardiovascular disease prevention among low income populations- -description and pilot evaluation of a physician-based model. Patient Educ Couns 1992;19:5-18.

10. Lando HA, Hellerstedt WL, Pirie PL, McGovern PG. Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation. Am J Public Health 1992; 82:41-6.

TABLE 1. Weighted prevalences of selected risk factors for women, by race amd ethnicity --- Behavioral Risk Factor
Surveillance System, United States, 1991-1992 *
===========================================================================================================================
                                                                American Indian/         Asian/
                             White               Black           Alaskan Native     Pacific Islander         Hispanic +
                           (n=90,369)          (n=10,465)            (n=989)            (n=2,332)            (n=4,063)
                        ----------------     ---------------     ---------------     ----------------     ---------------
Risk factor              %    (95% CI &)     %      (95% CI)     %      (95% CI)     %       (95% CI)     %      (95% CI)
---------------------------------------------------------------------------------------------------------------------------
Current
  cigarette smoking @   21.6   (+/-0.4)      19.4   (+/-1.1)     28.7   (+/-4.9)      9.7    (+/-2.1)     14.5   (+/-1.5)
Sedentary lifestyle **  56.4   (+/-0.5)      67.7   (+/-1.3)     64.1   (+/-5.2)     64.7    (+/-3.4)     61.9   (+/-2.3)
Overweight ++           21.7   (+/-0.4)      37.7   (+/-1.3)     30.3   (+/-4.9)     10.1    (+/-2.0)     26.5   (+/-2.1)
Education level (yrs)
  <12                   14.8   (+/-0.4)      23.6   (+/-1.2)     25.0   (+/-5.0)      7.3    (+/-1.5)     33.7   (+/-2.3)
   12                   36.3   (+/-0.5)      35.2   (+/-1.3)     36.9   (+/-5.6)     21.9    (+/-3.0)     31.1   (+/-2.2)
  >12                   48.7   (+/-0.5)      40.8   (+/-1.4)     38.0   (+/-5.4)     70.0    (+/-3.3)     34.9   (+/-2.2)
---------------------------------------------------------------------------------------------------------------------------
 * Data were weighted and aggregated. Full descriptions of the weighting procedures and sample sizes for the states are
   given in Appendix F of Chronic Disease in Minority Populations (2).
 + Persons of Hispanic origin may be of any race.
 & Confidence interval.
 @ Reported ever having smoked 100 cigarettes and currently smoking regularly.
** Reported participation in fewer than three 20-minute sessions of leisure-time physical activity per week; physical
   activity as part of usual job activities was not included.
++ Self-reported data on height and weight were used to calculate body mass index (BMI) (weight in kilograms divided by
   height in meters squared). Overweight was defined as BMI >=27.3 for women.
===========================================================================================================================

TABLE 2. Sample size and weighted prevalences of selected risk factors for men aged >=18, by race and ethnicity -- Behavioral
Risk Factor Surveillance System, United States, 1991-1992 *
===========================================================================================================================

                                                               American Indian/            Asian/
                              White               Black        Alaskan Native        Pacific Islander       Hispanic +
                           (n=67,444)           (n=5,913)           (n=822)             (n=1,921)            (n=2,929)
                        ----------------     ---------------     ---------------     ----------------    ---------------
Risk Factor              %    (95% CI &)     %      (95% CI)     %      (95% CI)     %      (95% CI)     %      (95% CI)
---------------------------------------------------------------------------------------------------------------------------
Current
  cigarette smoking @   24.5   (+/-0.5)      27.4   (+/-1.6)     39.9   (+/-5.9)     19.4   (+/-3.1)     22.0   (+/-2.2)
Sedentary lifestyle **  56.2   (+/-0.6)      62.8   (+/-1.7)     50.8   (+/-6.0)     56.6   (+/-3.8)     61.5   (+/-2.7)
Overweight ++           25.8   (+/-0.5)      21.4   (+/-1.6)     33.8   (+/-5.8)     10.8   (+/-2.2)     23.8   (+/-2.3)
Education level (yrs)
  <12                   14.4   (+/-0.4)      23.3   (+/-1.5)     25.1   (+/-5.4)      7.6   (+/-2.2)     33.9   (+/-2.7)
   12                   32.2   (+/-0.5)      36.8   (+/-1.7)     35.1   (+/-5.7)     16.0   (+/-2.7)     28.8   (+/-2.5)
  >12                   53.3   (+/-0.6)      39.7   (+/-1.7)     39.7   (+/-5.8)     75.7   (+/-3.3)     37.1   (+/-2.6)
---------------------------------------------------------------------------------------------------------------------------
 * Data were weighted and aggregated. Full descriptions of the weighting procedures and sample sizes for the states are
   given in Appendix F of Chronic Disease in Minority Populations (2).
 + Persons of Hispanic origin may be of any race.
 & Confidence interval.
 @ Reported ever having smoked 100 cigarettes and currently smoking regularly.
** Reported participation in fewer than three 20-minute sessions of leisure-time physical activity per week; physical
   activity as part of usual job activities was not included.
++ Self-reported data on height and weight were used to calculate body mass index (BMI) (weight in kilograms divided by
   height in meters squared). Overweight was defined as BMI >=27.8 for men.
===========================================================================================================================

TABLE 3. Weighted prevalences of selected risk factors, by race, ethnicity, sex, and education level -- 
Behavioral Risk Factor Surveillance System, United States, 1991-1992 *
==============================================================================================================================
Sex/                                                              American Indian/        Asian/
Risk factor/                  White               Black            Alaskan Native     Pacific Islander       Hispanic +
Education level           ---------------     ----------------    ----------------    ----------------     ---------------
                          %    (95% CI &)     %       (95% CI)     %      (95% CI)     %      (95% CI)     %      (95% CI)
------------------------------------------------------------------------------------------------------------------------------
Women
  Current cigarette
    smoking @
    Education level
      <12                 25.3   (+/-1.1)      19.7   (+/-2.1)     27.0  (+/- 9.7)     17.6  (+/- 8.0)     13.6   (+/-2.4)
       12                 26.0   (+/-0.7)      22.0   (+/-2.1)     28.4  (+/- 8.0)     17.8  (+/- 5.3)     16.2   (+/-2.8)
      >12                 17.2   (+/-0.5)      17.1   (+/-1.6)     30.0  (+/- 8.0)      6.4  (+/- 2.3)     13.3   (+/-2.7)
  Sedentary
    lifestyle **
    Education level
      <12                 72.0   (+/-1.2)      78.2   (+/-2.3)     76.6  (+/- 9.3)     68.5  (+/-10.0)     73.6   (+/-3.6)
       12                 60.3   (+/-0.8)      70.0   (+/-2.2)     70.5  (+/- 8.1)     70.0  (+/- 6.5)     58.2   (+/-4.1)
      >12                 48.8   (+/-0.7)      59.5   (+/-2.1)     49.9  (+/- 8.6)     62.4  (+/- 4.3)     53.4   (+/-3.8)
  Overweight ++
    Education level
      <12                 31.6   (+/-1.2)      50.9   (+/-2.8)     42.9  (+/-11.3)      21.6 (+/- 8.7)     34.7   (+/-4.0)
       12                 23.8   (+/-0.7)      39.3   (+/-2.4)     25.8  (+/- 7.7)      12.1 (+/- 4.1)     25.6   (+/-3.5)
      >12                 17.1   (+/-0.5)      28.9   (+/-1.9)     28.1  (+/- 7.3)       8.3 (+/- 2.4)     19.5   (+/-3.1)

Men
  Current cigarette
    smoking
    Education level
      <12                 34.1   (+/-1.4)      31.2   (+/-3.3)    40.7   (+/-12.4)     34.4  (+/-15.2)     25.4   (+/-4.1)
       12                 30.9   (+/-0.9)      29.7   (+/-2.7)    45.3   (+/-10.2)     27.6  (+/- 8.6)     24.0   (+/-4.2)
      >12                 18.1   (+/-0.6)      23.4   (+/-2.4)    34.9   (+/- 8.8)     16.3  (+/- 3.2)     17.4   (+/-3.1)
  Sedentary lifestyle
    Education level
      <12                 69.4   (+/-1.4)      77.4   (+/-3.0)    58.8   (+/-12.9)     47.0  (+/-14.5)     71.8   (+/-4.6)
       12                 62.2   (+/-1.0)      62.8   (+/-2.9)    53.3   (+/-10.2)     62.6  (+/- 8.8)     61.4   (+/-4.9)
      >12                 49.1   (+/-0.8)      54.1   (+/-2.7)    43.3   (+/- 9.2)     55.9  (+/- 4.4)     51.9   (+/-4.2)
  Overweight
    Education level
      <12                 27.9   (+/-1.4)      28.4   (+/-3.2)    41.2   (+/-13.0)     -- &&             25.6   (+/-4.3)
       12                 27.0   (+/-0.9)      29.5   (+/-2.6)    38.2   (+/- 9.7)     16.5  (+/- 5.4)     26.5   (+/-4.4)
      >12                 23.1   (+/-0.6)      27.7   (+/-2.5)    25.6   (+/- 8.3)      9.6  (+/- 2.5)     20.3   (+/-3.3)
------------------------------------------------------------------------------------------------------------------------------
 * Data were weighted and aggregated. Full descriptions of the weighting procedures and sample sizes for the states are
   given in Appendix F of Chronic Disease in Minority Populations (2).
 + Persons of Hispanic origin may be of any race.
 & Confidence interval.
 @ Reported ever having smoked 100 cigarettes and currently smoking regularly.
** Reported participation in fewer than three 20-minute sessions of leisure-time physical activity per week; physical
   activity as part of usual job activities was not included.
++Self-reported data on height and weight were used to calculate body mass index (BMI) (weight in kilograms divided by
   height in meters squared). Overweight was defined as BMI >=27.8 for men and >=27.3 for women.
&& Estimate is not given because there were fewer than 50 respondents.
==============================================================================================================================

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