Surveillance for Certain Health Behaviors Among States and Selected Local Areas --- United States, 2008

Elizabeth Hughes, DrPH1, Greta Kilmer, MS2,

Yan Li, MPH3, Balarami Valluru, MS3,

Julie Brown4, Gloria Colclough4,

Sonya Geathers, MA4, Henry Roberts, PhD1,

Laurie Elam-Evans, PhD4, Lina Balluz, ScD4

1Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

2RTI International, Research Triangle Park, NC

3Georgia Department of Community Health, Atlanta, GA

4Division of Behavioral Surveillance, Public Health Surveillance Program Office, Office of Surveillance, Epidemiology and Laboratory Services

Corresponding Author: Lina Balluz, ScD, MPH, Division of Behavioral Surveillance, Public Health Surveillance Program Office (PHSPO), Office of Surveillance, Epidemiology and Laboratory Services (OSELS), Centers for Disease Control and Prevention,

2500 Century Parkway, Mailstop E-97, Atlanta, Georgia 30345. Telephone: (404) 498-0496; Fax: (404) 498-0595; E-mail: lballuz@cdc.gov

Abstract

Problem: Chronic diseases (e.g., diabetes, cancer, heart disease, and stroke) are the leading causes of morbidity and mortality in the United States. Data on health risk behaviors that increase the risk for chronic diseases and use of preventive practices are essential for the development, implementation, and evaluation of health promotion programs, policies, and intervention strategies to decrease or prevent the leading causes of morbidity and mortality. Surveillance data from states and territories, selected metropolitan and micropolitan areas, and counties are vital components of these various prevention and intervention strategies.

Reporting Period: January--December 2008

Description of the System: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit--dialed telephone survey of noninstitutionalized adults residing in the United States. BRFSS collects data on health risk behaviors, preventive health services and practices, and access to health care related to the leading causes of death and disability in the United States. This report presents results for 2008 for all 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, 177 metropolitan and micropolitan statistical areas (MMSAs), and 266 counties.

Results: In 2008, the estimated prevalence of high-risk behaviors, chronic diseases and conditions, screening practices, and use of preventive health-care services varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topic. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior as reported by the survey respondent. Adults reporting good or better health: 68% to 89% for states and territories and 69% to 93% for selected MMSAs and counties. Health care insurance coverage: 72% to 96% for states and territories, 61% to 97% for MMSAs, and 61% to 98% for counties. Teeth extractions among persons aged ≥65 years: 10% to 38% for states and territories, 5% to 36% for MMSAs, and 4% to 34% for counties. Adults who had a checkup during the preceding 12 months: 56% to 81% for states and territories, 51% to 85% for MMSAs, and 51% to 89% for counties. Influenza vaccination among persons aged ≥65 years: 31% to 78% for states and territories, 52% to 82% for MMSAs, and 51% to 86% for counties. Pneumococcal vaccination among persons aged ≥65 years: 28% to 73% for states and territories, 46% to 82% for MMSAs, and 41% to 83% for counties. Adults aged ≥50 years who had a sigmoidoscopy/colonoscopy: 38% to 74% for states and territories, 45% to 78% for selected MMSAs, and 45% to 80% for counties. Adults aged ≥50 years who had a blood stool test during the preceding 2 years: 8% to 29% for states and territories, 7% to 51% for MMSAs, and 7% to 40% for counties. Among women aged ≥18 years who had a Papanicolaou test during the preceding 3 years: 67% to 89% for states and territories, 66% to 93% for selected MMSAs, and 66% to 96% for counties. Women aged ≥40 years who had a mammogram during the preceding 2 years: 64% to 85% for states and territories, and 61% to 88% for MMSAs and counties. Men aged ≥40 years who had a Prostate-Specific Antigen (PSA) test during the preceding 2 years: 34% to 66% for states and territories, 39% to 70% for MMSAs, and 37% to 71% for counties. Current cigarette smoking among adults aged ≥18 years: 6% to 27% for states and territories, 5% to 31% for MMSAs, and 5% to 30% for counties. Adults who reported binge drinking during the preceding month: 8% to 23% for states and territories, 3% to 25% for selected MMSAs, and 3% to 26% for counties. Heavy drinking among adults during the preceding month: 3% to 8% for states and territories, <1% to 10% for MMSAs, and 1% to 11% for counties. Adults who reported no leisure-time physical activity: 18% to 47% for states and territories, 12% to 40% for MMSAs, and 10% to 40% for selected counties. Adults who were overweight (BMI ≥25.0 and <30.0): 33% to 40% for states and territories, 31% to 46% for selected MMSAs, and 28% to 50% for counties. Adults aged ≥20 years who were obese (BMI ≥30.0): 20% to 34% for states and territories, 15% to 40% for MMSAs, and 13% to 40% for counties. Asthma among adults: 5% to 11% for states and territories, 4% to 13% for MMSAs, and 4% to 15% for counties. Diabetes among adults: 6% to 12% for states and territories, 3% to 17% for selected MMSAs, and 3% to 14% for counties. Adults aged ≥18 years who had limited activity because of physical, mental, or emotional problems: 10% to 30% for states and territories, 13% to 33% for MMSAs, and 12% to 31% for counties. Adults who required use of special equipment: 4% to 11% for states and territories, 3% to 12% for MMSAs, and 2% to 13% for counties. Angina and coronary heart disease among adults aged ≥45 years: 5% to 19% for states and territories, 6% to 22% for MMSAs, and 4% to 22% for counties. Adults aged ≥45 years with a history of stroke: 3% to 7% for states and territories, 2% to 11% for selected MMSAs, and 1% to 12% for counties.

Interpretation: The findings in this report indicate substantial variation in health-risk behaviors, chronic diseases and conditions, and use of preventive health-care services among U.S. adults at the state and territory, MMSA, and county level. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases and conditions, and the use of preventive health services.

Public Health Action: Healthy People 2010 objectives have been established to monitor health behaviors and the use of preventive health services. Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health behaviors, chronic diseases and conditions, and to evaluate the use of preventive services. In addition, BRFSS data are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality from adverse effects of health-risk behaviors and subsequent chronic conditions.

Introduction

Chronic diseases (e.g., diabetes, heart disease, cancer, stroke, and arthritis) are the leading causes of morbidity and mortality (1) and are among the most common, costly, and preventable health problems in the United States (2). Each year, seven of 10 deaths are the result of chronic diseases (2).

Comprehensive disease surveillance is essential for identifying health issues and disparities, developing prevention programs and strategies, and tracking health indicators of at-risk populations (3). The Behavioral Risk Factor Surveillance System (BRFSS), conducted by state health departments with assistance from CDC, is the largest state-based surveillance system in the United States and the world's largest continuously collected cross-sectional telephone survey (4). Because of its substantial sample size, prevalence estimates also are available for selected metropolitan and micropolitan statistical areas (MMSAs) and their counties. BRFSS collects identifiable, comparable, state-specific data on preventive health practices related to cancer, heart disease, stroke, diabetes, and risk behaviors (e.g., cigarette smoking, poor nutritional habits, and a lack of adequate physical activity) that are linked to chronic diseases, injuries, and preventable infectious diseases that affect the adult U.S. population. Since 1984, BRFSS has been the main source of health information on at-risk behaviors, chronic disease conditions, emerging health issues, and use of preventive health services (4). BRFSS is conducted in all 50 states, the District of Columbia (DC), Puerto Rico, Guam, and the U.S. Virgin Islands.

Healthy People 2010 (HP 2010) sets and monitors national objectives for promoting health and preventing disease. These objectives necessitate collaborations across various entities to guide informed decision-making and measure the impact of prevention activities (5). This report contains comparisons between 2008 BRFSS data and certain HP 2010 objectives.

Methods

BRFSS uses a multistage design based on random-digit--dialing to select a representative sample of the noninstitutionalized civilian population aged ≥18 years. This report includes data from states and territories, selected MMSAs, and counties in the 50 states, DC, Guam, Puerto Rico, and the U.S. Virgin Islands. To produce stable prevalence estimates, statistics for selected MMSAs and counties were not reported if the denominator was <50 or the 95% confidence interval (CI) half-width was >10. In 2008, a total of 177 MMSAs and 266 counties had sufficient sample size (≥500 respondents or ≥19 respondents per final weighting class) to be reported. Weighting classes were based on cross-classification totals of age and sex or age and sex and race. Counties with an estimated population of <10,000 persons were excluded. In 2008, a total of 414,509 interviews were completed. Responses coded as "do not know" or "refused" were excluded from the analyses. Details on methodology, random sampling design and procedures, and reliability and validity of measures used in BRFSS have been described in previous publications (6,7).

Questionnaire

The BRFSS questionnaire includes questions regarding personal behaviors that increase the risk for one or more of the 10 leading causes of mortality in the United States. The questionnaire consists of three components: 1) core questions, 2) optional modules, and 3) state-added questions. Core questions are standardized and are asked of all study respondents in each state and territory. Optional modules are composed of standardized questions that address specific health-related topics relevant to at-risk health behaviors and health-related conditions. Each state and territory has the option to include these modules in the survey. State-added questions consist of questions developed for and used by states and territories to address state-specific health concerns. The 2008 BRFSS core survey incorporated questions that addressed demographics, health status, health care access, health-related quality of life, sleep behavior, exercise, diabetes, oral health, cardiovascular disease prevalence, asthma, disability, tobacco use, alcohol consumption, immunization (adult influenza and pneumococcal vaccination), falls, seatbelt use, drinking and driving, women's health issues, prostate cancer screening, colorectal cancer screening, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), emotional support, and life satisfaction.

In 2008, states and territories selected the following optional modules which addressed health issues and concerns: childhood asthma prevalence (50 states), diabetes (48), prediabetes (34), other tobacco products (14), binge drinking (11), secondhand smoke (10), anxiety and depression (eight), child human papillomavirus (HPV) (eight), visual impairment and access to eye care (eight), adult asthma history (seven), adult HPV (five), influenza---high risk/health-care worker (four), reactions to race (four), general preparedness (two), healthy days---symptoms (two), and veteran health status (two).

This report focuses on 1) health status indicators (health status, health-care coverage, and oral health), 2) preventive practices (routine checkup and influenza and pneumococcal vaccinations for persons aged ≥65 years), 3) cancer prevention (sigmoidoscopy or colonoscopy, blood stool test, Papanicolaou [Pap] test, mammogram, and prostate-specific antigen test [PSA]), 4) health risk behaviors (current cigarette smoking, binge heavy drinking, and no leisure-time physical activity), 5) chronic conditions and disability (overweight and obesity, asthma, diabetes, limited activity, and use of special equipment), and 6) cardiovascular disease (coronary heart disease and stroke). The 2008 BRFSS questionnaire and all other annual surveys are available at http://www.cdc.gov/brfss/questionnaires/english.htm.

Data Collection and Processing

BRFSS data are collected monthly by each state and territory. Trained interviewers use a computer-assisted telephone interviewing system to administer the survey. After interviews are conducted, data are submitted to CDC for editing, processing, weighting, reliability checks, and analyses. In 2008, all states, DC, Guam, Puerto Rico, and the U.S. Virgin Islands participated in BRFSS.

Data Weighting and Statistical Analysis

At the end of the survey year, CDC edits and aggregates the monthly data files to create yearly samples for each state and territory. Each sample is weighted to the respondent's probability of selection and to the age-, sex-, and sometimes race-specific distribution of the population in each state and territory. State level weights are adjusted to produce MMSA- and county-level weights. These sampling weights are used to generate BRFSS state, MMSA, and county-level prevalence estimates. Detailed weighting and analytic methodologies have been documented elsewhere (6,7).

To account for the complex sampling design, CDC used SAS-callable SUDAAN statistical software to execute these analyses (8,9). In 2008, the number of interviews completed ranged from 796 in Guam to 22,532 in Washington (median: 6,468). Response rates* ranged from 35.8% in Maryland to 83.7% in Guam (median: 53.4%), and cooperation rates ranged from 59.3% in California to 87.8% in Kentucky (median: 75.0%)† based on Council of American Survey and Research Organizations guidelines (10).

The Office of Management and Budget has the oversight to define MMSAs (11). BRFSS respondents are assigned to a particular MMSA dependent on their respective Federal Information Processing Standard county code. National prevalence estimates used to monitor progress towards achieving health promotion and disease prevention were produced from aggregated specific state data. Counties within the selected MMSAs for which stable estimates were available also are listed. Counties with an estimated population of <10,000 persons were excluded.

Results

Health Status Indicators

Health Status

Respondents were asked to rate their general health as excellent, very good, good, fair, or poor. Respondents were classified into two groups: those who reported fair or poor health and those who reported good, very good, or excellent health. In 2008, the estimated prevalence of self-reported good or better health among adults aged ≥18 years ranged from 67.8% in Puerto Rico to 89.3% in Utah (median: 85.0%) (Table 1). Among selected MMSAs, the self-reported estimated prevalence of good or better health ranged from 68.5% in El Paso, Texas, to 92.8% in Bozeman, Montana (median: 85.9%) (Table 2). For selected counties, the estimated prevalence of good or better health ranged from 68.5% in El Paso County, Texas, to 93.2% in Douglas County, Colorado (median: 86.2%) (Table 3).

Health-Care Coverage

Health-care coverage was defined as respondents having reported that they had private health insurance (e.g., health maintenance organizations) or government health plans (e.g., Medicare or Medicaid). In 2008, the estimated prevalence of adults who had health-care coverage ranged from 72.4% in the U.S. Virgin Islands to 95.6% in Massachusetts (median: 85.5%) (Table 4). Among MMSAs, the estimated prevalence ranged from 60.5% in El Paso, Texas, to 96.9% in Cambridge-Newton-Framingham, Massachusetts (median: 86.9%) (Table 5). Among selected counties, the estimated prevalence ranged from 60.5% in El Paso County, Texas, to 97.9% in Plymouth County, Massachusetts (median: 87.9%) (Table 6).

Oral Health-Teeth Extraction

Oral health status was assessed by asking adults aged ≥65 years, "How many of your permanent teeth have been removed because of tooth decay or gum disease?" In 2008, the estimated prevalence of adults aged ≥65 years who had all of their natural teeth extracted ranged from 9.6% in Hawaii to 37.8% in West Virginia (median: 18.5%) (Table 7). Among selected MMSAs, the estimated prevalence ranged from 5.2% in Bethesda-Frederick-Gaithersburg, Maryland, to 36.3% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 16.9%) (Table 8). Among selected counties, the estimated prevalence ranged from 4.2% in Montgomery County, Maryland, to 34.2% in Fayette County, Pennsylvania (median: 15.6%) (Table 9).

Preventive Practices

Recent Routine Checkup

A routine checkup is defined as a general physical examination, not an examination for a specific injury, illness, or condition. Respondents were classified as having a recent routine checkup if they reported visiting a doctor for a routine checkup during the preceding 12 months. In 2008, the estimated prevalence of persons aged ≥18 years who had a recent routine checkup ranged from 55.5% in Utah to 80.7% in Delaware (median: 67.4%) (Table 10). Among MMSAs, the prevalence ranged from 50.9% in Provo-Orem, Utah, to 85.0% in Shreveport-Bossier City, Louisiana (median: 67.4%) (Table 11). Among selected counties, the estimated prevalence ranged from 51.4% in Utah County, Utah, to 88.6% in Caddo Parish, Louisiana (median: 68.6%) (Table 12).

Influenza Vaccination

In 2008, the state-specific estimated prevalence among adults aged ≥65 years who had received an influenza vaccination during the preceding 12 months ranged from 30.6% in Puerto Rico to 78.1% in New Hampshire (median: 70.9%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 52.1% in Miami-Fort Lauderdale-Pompano Beach, Florida, to 82.4% in Rochester, New York (median 72.1%) (Table 14). Among selected counties, the estimated prevalence ranged from 51.3% in Kings County, New York, to 85.8% in Westchester County, New York to (median: 72.7%) (Table 15).

Pneumococcal Vaccination

The estimated prevalence of adults aged ≥65 years who ever had a pneumococcal vaccination ranged from 28.4% in Puerto Rico to 73.0% in New Hampshire (median: 66.9%) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 45.6% in Miami-Fort Lauderdale-Miami Beach, Florida, to 81.8% in Bangor, Maine (median: 67.8%) (Table 17). Among selected counties, the estimated prevalence ranged from 40.7% in Hudson County, New Jersey, to 83.2% in Anoka County, Minnesota (median: 69.2%) (Table 18).

Cancer Prevention

Sigmoidoscopy or Colonoscopy

In 2008, the estimated prevalence of adults aged ≥50 years who ever had a sigmoidoscopy or colonoscopy ranged from 38.3% in Guam to 74.3% in Delaware (median: 61.8%) (Table 19). Among selected MMSAs, the estimated prevalence ranged from 44.7% in Norfolk, Nebraska, to 77.9% in Barre, Vermont (median: 64.0%) (Table 20). Among selected counties, the estimated prevalence ranged from 45.0% in Madison County, Nebraska, to 80.1% in Sagadahoc County, Maine (median: 65.0%) (Table 21).

Blood Stool Test

The estimated prevalence of adults aged ≥50 years who had a blood stool test during the preceding 2 years ranged from 7.5% in Puerto Rico to 29.0% in Florida (median 20.9%) (Table 22). Among selected MMSAs, the estimated prevalence ranged from 7.1% in Provo-Orem, Utah, to 50.7% in Tallahassee, Florida (median: 22.1%) (Table 23). Among selected counties, the estimated prevalence ranged from 6.5% in Davis County, Utah, to 39.9% in Santa Clara County, California (median: 21.7%) (Table 24).

Pap Test

In 2008, the estimated prevalence of women aged ≥18 years who had a Pap test during the preceding 3 years ranged from 66.6% in Guam to 88.9% in DC (median: 82.8%) (Table 25). Among selected MMSAs, the estimated prevalence ranged from 65.7% in Provo-Orem, Utah, to 93.2% in Tallahassee, Florida (median: 84.3%) (Table 26). Among selected counties, the estimated prevalence ranged from 65.8% in Utah County, Utah, to 96.1% in DeKalb County, Georgia (median: 85.3%) (Table 27).

Mammogram

In 2008, the state-specific estimated prevalence for women aged ≥40 years who had a mammogram during the preceding 2 years ranged from 63.8% in Guam to 84.9% in Massachusetts (median: 76.0%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 61.1% in Rock Springs, Wyoming, to 88.0% in Barnstable Town, Massachusetts (median: 77.4%) (Table 29). Among selected counties, the estimated prevalence ranged from 61.1% in Sweetwater County, Wyoming, to 88.0% in Barnstable, Massachusetts (median: 78.1%) (Table 30).

PSA Test

The PSA is a blood test that measures the level of prostate-specific antigen, an enzyme only produced by the prostate gland. High levels of PSA in the blood can indicate the development of early-stage cancer. PSA tests can be used as diagnostic tests to determine any change in cell growth from previous tests. In 2008, the estimated prevalence of men aged ≥40 years who had a PSA test during the preceding 2 years ranged from 34.1% in Guam to 65.6% in Puerto Rico (median: 54.8%) (Table 31). Among selected MMSAs, the estimated prevalence ranged from 38.9% in San Francisco-San Mateo-Redwood City, California, to 70.1% in Raleigh-Cary, North Carolina (median: 56.2%) (Table 32). Among selected counties, the estimated prevalence ranged from 37.3% in Dakota County, Nebraska, to 70.6% in Wake County, North Carolina (median: 56.0%) (Table 33).

Health Risk Behaviors

Current Cigarette Smoking

Respondents were classified as current smokers if they reported having smoked at least 100 cigarettes during their lifetime and indicated that they smoked every day or some days at the time of the survey. The estimated prevalence of current cigarette smoking among adults ≥18 years of age in the United States, ranged from 6.4% in the U.S. Virgin Islands to 27.4% in Guam (median: 18.3%) (Table 34). Among selected MMSAs, the estimated prevalence ranged from 4.9% in Provo-Orem, Utah, to 30.9% in Wichita Falls, Texas (median: 18.4%) (Table 35). Among selected counties, the estimated prevalence ranged from 4.7% in Utah County, Utah, to 30.3% in St. Louis City, Missouri (median: 17.7%) (Table 36).

Binge Drinking

Binge drinking was defined as men aged ≥18 years having five or more drinks, and women aged ≥18 years having four or more drinks on at least one occasion during the preceding month. In 2008, the estimated prevalence of binge drinking among adults aged ≥18 years ranged from 8.2% in Utah to 22.8% in Wisconsin (median: 15.5%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 2.9% in Provo Orem, Utah, to 25.1% in Norfolk, Nebraska (median: 15.2%) (Table 38). Among counties, the estimated prevalence ranged from 2.9% in Utah County, Utah, to 25.8% in Pinal County, Arizona (median: 15.4%) (Table 39).

Heavy Drinking

Heavy drinking was defined as men aged ≥18 years having more than two drinks and women aged ≥18 years having more than one drink per day during the preceding month. In 2008, the prevalence of heavy drinking among adults aged ≥18 years ranged from 2.9% in Oklahoma and West Virginia to 8.2% in Nevada (median: 5.1%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 0.6% in Provo Orem, Utah, to 9.8% in Barnstable Town, Massachusetts (median: 5.2%) (Table 41). Among selected counties, the estimated prevalence ranged from 1.4% in Laurens County, South Carolina, to 11.3% in Newport County, Rhode Island (median: 5.3%) (Table 42).

No Leisure-Time Physical Activity

No leisure-time physical activity was defined by the respondent's indication of no participation in exercise (e.g., running, calisthenics, golf, gardening, or walking for exercise) other than their regular job during the preceding month. In 2008, the estimated prevalence of physical inactivity among adults aged ≥18 years ranged from 18.1% in Minnesota to 47.3% in Puerto Rico (median: 24.8%) (Table 43). Among MMSAs, the estimated prevalence ranged from 12.3% in Boulder, Colorado, to 40.1% in Wichita Falls, Texas (median: 24.0%) (Table 44). Among selected counties, the estimated prevalence ranged from 9.8% in Douglas County, Colorado, to 40.3% in Hinds County, Mississippi (median: 23.0%) (Table 45).

Chronic Conditions and Disabilities

Overweight and Obesity

Self-reported weight and height were used to calculate body mass index (BMI) (weight [kg]/height [m2]). Respondents were categorized as being overweight if they had a BMI ≥25.0 and <30.0. In 2008, the estimated prevalence of being overweight among persons aged ≥18 years ranged from 32.8% in DC to 39.6% in North Dakota (median: 36.6%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 31.2% in Shreveport-Bossier City, Louisiana, to 45.7% in Montgomery, Alabama (median: 36.4%) (Table 47). Among selected counties, the estimated prevalence ranged from 28.0% in New York County, New York, to 49.7% in Bristol County, Rhode Island (median: 36.7%) (Table 48).

Respondents were classified as obese if their BMI was ≥30.0. Obesity analyses were restricted to adults aged ≥20 years to permit comparison with HP 2010 objectives. In 2008, the estimated prevalence of obesity ranged from 19.9% in Colorado to 34.0% in Mississippi (median: 27.3%) (Table 49). Among selected MMSAs, the estimated prevalence ranged from 15.3% in Boulder, Colorado, to 39.9% in Orangeburg, South Carolina (median: 27.0%) (Table 50). Among selected counties, the estimated prevalence ranged from 12.9% in Summit County, Utah, to 39.9% in Orangeburg County, South Carolina (median: 26.0%) (Table 51).

Current Asthma

Respondents were defined as currently having asthma if they reported having ever been told by a doctor, nurse, or other health-care professional that they had asthma and still had it during the survey. In 2008, the estimated prevalence of current asthma among adults aged ≥18 years ranged from 4.5% in the U.S. Virgin Islands and Guam to 10.6% in Rhode Island (median: 8.8%) (Table 52). Among selected MMSAs, the estimated prevalence ranged from 3.6% in Fargo, North Dakota-Minnesota, to 13.2% in Rochester, New York (median: 8.8%) (Table 53). Among selected counties, the estimated prevalence ranged from 3.8% in Westchester County, New York and Wake County, North Carolina, to 14.9% in Monroe County, New York (median: 8.7%) (Table 54).

Diabetes

Respondents were classified as having diabetes if they reported ever being told by a doctor that they have diabetes. For this report, gestational diabetes, prediabetes, or borderline diabetes in adults were not included in the estimates. In 2008, the estimated prevalence of diabetes ranged from 5.9% in Minnesota to 12.4% in Puerto Rico (median: 8.3%) (Table 55). Among selected MMSAs, the estimated prevalence ranged from 2.8% in Bozeman, Montana, to 16.7% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 8.0%) (Table 56). Among selected counties, the estimated prevalence ranged from 2.7% in Summit County, Utah, to 13.8% in Jefferson County, Alabama, and Jefferson Parish, Louisiana (median: 7.8%) (Table 57).

Limited Activity

Estimated prevalence for respondents who reported limitation of activity in any way because of physical, mental, or emotional problems ranged from 9.8% in the U.S. Virgin Islands to 29.5% in West Virginia (median: 20.4%) (Table 58). Among selected MMSAs, the estimated prevalence ranged from 12.8% in Norfolk, Nebraska, to 32.6% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 20.2%) (Table 59). Among selected counties, the estimated prevalence ranged from 11.7% in Summit County, Utah, to 30.7% in Kitsap County, Washington (median: 20.0%) (Table 60).

Use of Special Equipment

Respondents were asked if they required use of equipment (e.g., cane, wheelchair, special bed, or special telephone) because of health problems. The estimated prevalence of persons requiring use of special equipment ranged from 4.0% in the U.S. Virgin Islands to 10.9% in West Virginia (median: 7.2%) (Table 61). Among selected MMSAs, the estimated prevalence ranged from 2.9% in San Jose-Sunnyvale-Santa Clara, California, to 12.3% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 7.0%) (Table 62). Among selected counties, the estimated prevalence ranged from 2.4% in Douglas County, Colorado, to 13.1% in Wyandotte County, Kansas (median: 6.9%) (Table 63).

Cardiovascular Diseases

Coronary Heart Disease

Respondents were classified as having coronary heart disease (CHD) if they had ever been told by a doctor that they had CHD, including heart attack or angina. CHD analyses were restricted to adults aged ≥45 years. The estimated prevalence among adults ranged from 5.1% in the U.S. Virgin Islands to 19.4% in West Virginia (median: 11.3%) (Table 64). Among MMSAs, the estimated prevalence ranged from 5.6% in Boulder, Colorado and Fort Collins-Loveland, Colorado, to 21.9% in Wichita Falls, Texas (median: 11.0%) (Table 65). Among selected counties, the estimated prevalence ranged from 4.3% in Douglas County, Colorado, to 21.6% in Kanawha County, West Virginia (median: 10.9%) (Table 66).

Stroke

Respondents were classified as having a history of stroke if they reported having ever been told by a doctor that they had a stroke. Stroke analyses were restricted to adults aged ≥45 years. In 2008, the estimated prevalence of stroke among adults ranged from 3.2% in Vermont to 7.1% in West Virginia (median: 4.5%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 1.5% in Bozeman, Montana, to 10.5% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 4.1%) (Table 68). Among selected counties, the estimated prevalence ranged from 1.4% in DeKalb County, Georgia, to 11.5% in Wichita County, Texas (median: 4.1%) (Table 69).

Discussion

The findings in this report indicate that substantial variations exist in the estimated prevalence of health-risk behaviors, chronic diseases, and use of preventive health screening practices among U.S. adults at the state and territory, MMSA, and county level. State-specific BRFSS estimates are a major tool used by policymakers, public health officials, community stakeholders, and activists to identify local health burdens and needs and to assist in planning, directing, implementing, and monitoring the effectiveness of intervention and prevention strategies.

These variations might reflect differences in demographic and socioeconomic composition of the study populations; availability of, access to, and use of health-care services; state laws or local ordinances; use of preventive health screenings; and the subsequent reimbursement of preventive services by insurance providers. Prevalence estimates are derived from direct estimates for states and territories, MMSAs, and counties. The estimates for smaller geographic units (i.e., MMSA and county) might vary from estimates in other reports where different methods were used (e.g., Bayesian statistical methods) to produce local area estimates.

Health Status Indicators

Health Status

Self-reported health status is a multidimensional construct that incorporates health behaviors, physical manifestations of health conditions, activity limitations, and psychological indicators (12). Poor self-assessed health is associated with increased risk for mortality, even after controlling for other more objective measures of health status (13). For this report, self-assessed health status was reported for good or better health. In 2008, the proportion of adults who reported good or better health varied across states and territories, MMSAs, and counties. These variations suggest differences in the underlying aspects of the measure, which might reflect differences in the etiology and severity of specific diseases and illnesses, disparities in access to adequate medical care, or access to treatment for underlying medical conditions.

Health-Care Coverage

During the preceding 25 years, health services research has identified having no health insurance as a risk indicator for decreased overall health status, exacerbation of chronic disease indicators, and access to health care (14,15). The HP 2010 objective for health insurance coverage is 100% (objective no. 1-1). In 2008, no state and territory, MMSA, or county achieved the 100% health insurance coverage goal (Table 70).

Oral Health

Loss of natural teeth impacts self-esteem, chewing ability, difficulty with relaxation, pain and distress, socialization, and other measures of quality of life (16). Extraction of all natural teeth represents an endpoint influenced by the incidence of dental caries or periodontal disease earlier in life (17). Socioeconomic disparities play a substantial role in periodontal disease and teeth extraction (18). The HP 2010 objective is to reduce to <22% the proportion of adults aged ≥65 years who have lost or had all of their natural teeth extracted (objective no. 21-4). In 2008, 79% of states and territories, 84% of MMSAs, and 87% of counties achieved the HP 2010 target (Table 70).

Preventive Practices

Routine Checkup

Routine health screenings can minimize outcomes related to illness and disability and reduce health-care costs. Early detection of chronic diseases (e.g., diabetes, heart disease, and cancer) can substantially lower the risk for complications and provide opportunities for intervention of at-risk lifestyle behaviors before conditions exacerbate (19).

Pneumococcal and Influenza Vaccination

Pneumonia and influenza are leading causes of morbidity and mortality among persons aged ≥65 years (20) and the fifth-leading causes of death among the elderly in the United States (21). Influenza and pneumococcal vaccination can effectively reduce the negative health effects from these diseases (21--23). During 1986--2006, there has been a steady increase in self-reported influenza and pneumococcal vaccination among persons aged ≥65 years (24). The HP 2010 objectives are to increase to 90% the proportion of adults aged ≥65 years who are vaccinated for influenza and pneumococcal disease (objectives no. 14-29a and14-29b). In 2008, no state and territory, MMSA, or county achieved the objective for influenza vaccination or pneumococcal vaccination (Table 70).

Cancer Prevention

Colorectal Cancer Screening

Cancer is the second-leading cause of death in the United States. Colorectal cancer, one of the most commonly diagnosed cancers, is the second-leading cause of cancer mortality. In 2006§, a total of 139,127 persons were diagnosed with colorectal cancer resulting in 53,196 deaths (25). Colorectal cancer usually begins from polyps present in the rectum or colon. Although it affects both men and women and all racial/ethnic groups, the risk for colorectal cancer is greater for persons aged ≥50 years. The sigmoidoscopy, colonoscopy, and fecal occult blood tests are the recommended screening tests for early detection of precancerous polyps and prevention of colorectal cancer (18). The HP 2010 objective is to increase the proportion of adults aged ≥50 years who have ever received a colorectal cancer screening examination (objective 3-12). The HP 2010 objective for adults aged ≥50 is to increase to 33% the proportion that received a blood stool test during the preceding 2 years (objective no. 3-12a). Although no state and territory achieved this goal in 2008, approximately 4% of MMSAs and counties achieved the target. The target for ever having a sigmoidoscopy/colonoscopy is 50% (objective no. 3-12b). In 2008, 94% of states and territories, 98% of MMSAs, and 94% of counties achieved the target objective.

Cervical Cancer Screening

Cervical cancer was once the leading cause of cancer deaths among women in the United States (25). In 2006§, a total of 11,982 women were told they had cervical cancer and 3,976 women died of the disease (26). The numbers of cases and deaths from cervical cancer have declined substantially during the past 40 years (27,28), largely because of early detection by the Pap test, which detects precancerous or abnormal cells in the cervix (29). Cervical cancer most often occurs in women aged ≥30 years, and racial/ethnic disparities exists in the incidence of cervical cancer among women in the United States. The Pap test is highly recommended for women aged ≥18 years (30). The HP 2010 objective is to increase to 90% the proportion women aged ≥18 years who received a Pap test during the preceding 3 years (objective no. 3-11b). In 2008, no state and territory achieved the target goal. However, 5% of MMSAs and 9% of counties achieved the objective.

Breast Cancer Screening

Among women, breast cancer is the second-leading cause of cancer deaths in the United States (31). However, breast cancer does affect men. In 2006§, a total of 191,410 women and 1,854 men were diagnosed with breast cancer, and 40,820 women and 389 men died from the disease (25). Three established methods for conducting a breast cancer screening are mammogram, clinical breast examination, and breast self-examination (32). The mammogram, a radiograph of the breast, is considered the best method to detect early breast cancer. Regular mammogram screenings can lower risk for mortality from breast cancer disease (32,33). The HP 2010 objective is to increase to 70% the proportion of women aged ≥40 years who had received a mammogram during the preceding 2 years (objective no. 3-13). In 2008, approximately 83% of states and territories, 89% of MMSAs, and 90% of counties met the HP 2010 target for mammogram screening.

Prostate Cancer Screening

Prostate cancer, one of the most commonly diagnosed cancers in the United States (34), is the second-leading cause of cancer deaths among men (35). In 2006§, a total of 203,415 new cases of prostate cancer were diagnosed and 28,372 men died from the disease (25). Among racial/ethnic groups, black men experienced a higher rate of prostate cancer compared with white men (218 versus 135 per 100,000 men, respectively) (25,36). Two common tests for prostate cancer are the digital rectal examination (DRE) and PSA tests (37). PSA is a substance produced by cells from the prostate gland and released into the blood. The PSA test measures the level of PSA in the bloodstream (36). Higher PSA levels are associated with inflammation of the prostate gland or the presence of cancer (37). On the basis of the results of the PSA test and other factors (e.g., age, race/ethnicity, and family history), the physician can determine if further tests are warranted (37,38).

A report by USPSTF indicated that the PSA test lacks precision for detecting clinical determinants of prostate cancer among men aged <75 years (38). In addition, the task force suggested that evidence is insufficient to assess the potential benefits of testing compared with potential complications resulting from diagnostic testing by biopsy (38).

Health Risk Behaviors

Cigarette Smoking

Cigarette smoking is the single most preventable cause of morbidity and mortality in the United States (39). It causes approximately 443,000, or one in five, deaths each year (40). In 2009, approximately 20.9% of persons aged ≥18 years were current smokers. Of these, approximately 78.1% smoked every day and 21.9% smoked some days (41).

Lung cancer is a major health outcome attributable to cigarette smoking and varies among smokers, sex, and racial/ethnic populations (42). Among men who smoke cigarettes, the risk for developing lung cancer is approximately two-to-three times greater than nonsmokers (43). Cigarette smoking increases the length of time a person develops a disability by approximately 2 years (43). For every person who dies from a smoking-related disease, ≥20 persons suffer with at least one major illness related to cigarette smoking (44,45). In addition, an estimated 49,000 tobacco-related deaths and >$10 billion in annual health care expenditures result from exposure of secondhand smoke (44,45).

Although the overall rate of current cigarette smokers has declined (39), smoking rates continue to be high among states and territories, MMSAs, and counties. The HP 2010 objective is to reduce to 12% the proportion of adults aged ≥18 years who smoke cigarettes (objective no. 27-1a). In 2008, 6% of states and territories, 7% of MMSAs, and 11% of counties achieved this objective.

Binge and Heavy Drinking

Excessive alcohol consumption, which includes binge and heavy drinking, has been linked to injuries and deaths from fires, falls, motor-vehicle crashes, domestic violence, rape, child abuse, and drowning (46--48). Continued excessive drinking can result in chronic diseases (e.g., high blood pressure, heart arrhythmias, stroke, liver cirrhosis, pancreatitis, and cancer) (49--51). The HP 2010 objective is to reduce to ≤13.4% the proportion of adults aged ≥18 years who engage in binge drinking during the preceding month (objective no. 26-11c). In 2008, approximately 30% of states and territories, 26% of MMSAs, and 28% of counties achieved the HP 2010 goal.

No Leisure-Time Physical Activity

Inactivity has been a precursor to several chronic disease outcomes (e.g., diabetes, heart disease, arthritis management, and certain forms of cancer) (52). Adults who do not participate in any leisure-time physical activity are at greater risk for developing chronic diseases and experiencing limitation of activities because of disability compared with those who participate in certain type of leisure-time physical activity (53). The HP 2010 objective is to reduce to ≤20% the proportion of adults aged ≥18 years who engage in no physical activity (objective no. 22-1). In 2008, approximately 13% of states and territories, 14% of MMSAs, and 26% of counties achieved this HP 2010 target.

Overweight and Obesity

Effects of overweight and obesity in the United States continue to be a major health priority (54). Overweight and obesity increase the risk for various chronic diseases (e.g., diabetes, heart disease, hypertension, stroke, gall bladder disease, and arthritis-related disabilities), and certain cancers (e.g., colon, breast, esophagus, endometrial, and kidney) (55). Obesity and type 2 diabetes coexist in specific geographic patterns on the basis of socioeconomic status, community and environmental factors, and genetic risk factors among similar ethnic groups. This comorbid relation between obesity and type 2 diabetes demonstrates the complexity of chronic disease indicators and the need to develop comprehensive intervention strategies to address both components (56,57). In addition, a direct association between a high BMI (BMI ≥35 kg/m2) and years of life loss (YLL) exists (58). The HP 2010 objective is to reduce to <15% the proportion of adults aged ≥20 years who are obese (BMI ≥30.0) (objective no. 19-2). In 2008, the HP 2010 target was achieved by only one county (Summit County, Utah).

Chronic Conditions

Asthma Prevalence

Asthma is a chronic inflammatory disorder characterized by excessive sensitivity of the lungs that results in airway obstruction, respiratory symptoms, edema, and limitation of airflow (59). Environmental factors (e.g., airborne allergens and respiratory infections) and certain socioeconomic factors have an impact on the severity of asthma and its associated costs. In 2008, approximately 23.3 million persons in the United States indicated they had current asthma (60). In addition, asthma disproportionately affects minorities, the poor, and inner-city populations (61). Because asthma is an episodic disease, the cost for treatment is driven by emergency department visits, hospital admissions, and chronic comorbid conditions (e.g., acute seasonal rhinitis and sinusitis) (59). Effects of asthma include limitation of activities, increased hospital admissions and emergency department visits, and loss of workdays (61). In 2008, BRFSS data indicated variability among states and territories, MMSAs, and counties.

Diabetes Prevalence

Diabetes is a group of diseases characterized by increased levels of blood glucose resulting from defects in insulin production by the pancreas or because cells in the muscles, liver, and fat do not use insulin efficiently (62,63). Diabetes is a highly prevalent and debilitating disease that increases the risk for other serious health conditions (e.g., heart disease, stroke, kidney disease, blindness, and lower-extremity amputations) (64). Control and monitoring of high glucose levels and participation in certain types of physical activity can prevent, delay, or decrease the negative health outcomes from diabetes (64).

Disability

Approximately 50 million adults experience a certain type of disability in the United States (65). Disabilities (e.g., physical limitations because of arthritis or other chronic conditions, vision loss, hearing loss, and intellectual or mental disability) can negatively impact determinants of quality of life (e.g., ability to perform basic activities of daily living, maintain employment, and socialization) (66,67). Disability is closely linked to increased medical expenditures and poses a substantial concern for future health-care financing (68). Disability-related costs for medical care and loss of productivity is approximately $300 billion annually in the United States (68). Although rates of severe disability have been declining among older populations during the preceding two decades, young and work-age populations have experienced an increase in disability rates (69). The need to use special equipment (e.g., special telephone, cane, or wheelchair) also is an indicator of overall health status (69). Disability studies indicate an association between the number of assistive devices used and perceived decreased life experience and dependence (70,71).

Cardiovascular Diseases

Coronary Heart Disease

Heart disease continues to be the leading cause of mortality in the United States (72). Cardiovascular disease refers to several diseases and conditions affecting the heart and blood vessels (73). CHD, including angina and myocardial infarction, is the most prevalent cardiovascular disease (70). CHD is a widely studied and complex disease with modifiable risk factors (e.g., high blood pressure, high cholesterol, inactivity, obesity, and smoking) (74). Because a substantial proportion of the population has more than one CHD risk factor, and research has identified racial/ethnic and socioeconomic disparities associated with CHD, it is imperative to focus intervention strategies on identifying persons with multiple risk factors and addressing health disparities (75).

Stroke

Stroke is the third-leading cause of death in the United States (76). When nonfatal, stroke is a leading cause of permanent disability and economic loss because of physical impairment (74). In 2006, one in 17 deaths was caused by stroke (76). Approximately 795,000 persons suffer a stroke each year (75,76). Risk factors associated with stroke are high blood pressure, diabetes, heart disease, atrial fibrillation, high blood cholesterol levels, physical inactivity, alcohol and tobacco use, and obesity (77). The incidence of stroke varies by age and race/ethnicity, and the risk for stroke increases with age; however, stroke can occur at any age. Blacks have nearly twice the risk for having a stroke compared with whites, and both blacks and Hispanics are more likely to die following a stroke than whites (75,76). Health-care services, medications, and loss of work because of stroke costs approximately $68.9 billion per year (78,79).

Limitations

The findings in this report are subject to at least five limitations. First, BRFSS is a telephone-based survey that does not collect information from persons in institutions, nursing homes, long-term-care facilities, and correctional institutions, and results are not generalizable to these populations. Because of changes in telecommunications use by the general public, response rates for landline-only households have decreased. In 2009, BRFSS began collecting data on use of multimode communications modalities (e.g., cell phone only households, cell phone and landline households, and mail surveys). However, these data are not available for all states and territories and are not included in this report. Second, BRFSS is conducted in several languages other than English (i.e., Spanish, Chinese [Mandarin], and Portuguese), but does not provide data on persons who speak other languages and some geographical dialects of Spanish and Chinese. In particular, BRFSS is limited in reaching persons aged 18--24 years, males, and persons of various racial/ethnic categories other than non-Hispanic whites. Fourth, BRFSS does not collect data on persons residing in institutional settings (e.g., nursing homes and correctional facilities). Finally, data is self-reported and subject to recall bias.

Despite these limitations, BRFSS is a cost-effective, timely, and flexible survey that provides reliable and valid estimates of health-risk behaviors, chronic diseases, and conditions and use of preventive services at the national, state, and local levels. BRFSS data have been demonstrated to provide reliable and valid estimates when compared with national household surveys (80) and often are the only timely source of data available to states and communities to assess local health conditions and to accurately track progress of health promotion programs and strategies.

Conclusion

The results in this report indicate the need for high-quality health promotion and disease prevention programs and development of beneficial policies. Results from BRFSS are used to identify emerging health problems, to support health-related legislative efforts, to develop and evaluate public health policies and programs, and to monitor progress toward achieving HP 2010 objectives. BRFSS data are used at the federal, state, and local level to monitor progress and support efforts to prevent the leading causes of morbidity and mortality in the United States.

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2008 Behavioral Risk Factor Surveillance System State and Territory Project Coordinators

Alabama, Jesse Pevear, III, MSPH; Alaska, Rebecca Wells, MS; Arizona, Brian Bender; Arkansas, LaTonya Bynum; California, Marti Induni, PhD; Colorado, Rickey Tolliver, MPH; Connecticut, Diane Aye, PhD; Delaware, Fred Breukelman; District of Columbia, Tracy Garner; Florida, Melissa Murray, MS; Georgia, Leah Bryan, MPH; Guam, William Brandshagen; Hawaii, Florentina Reyes-Salvail. MS; Idaho, Teresa Abbott; Illinois, Bruce Steiner, MS; Indiana, Linda Stemnock; Iowa, Donald Shepherd, PhD; Kansas, Farooq Ghouri, MBBS; Kentucky, Tracey Sparks; Louisiana, Todd Griffin, MSPH; Maine, Kip Neale; Maryland, Helio Lopez, MS, Massachusetts, Bruce Cohen, PhD; Michigan, Ann Rafferty, PhD; Minnesota, Nagi Salem, PhD; Mississippi, Ron McAnally; Missouri, Janet Wilson, MEd; Montana, Susan Cummings; Nebraska, Larry Andelt, PhD; Nevada, Alicia Hansen, MS; New Hampshire, Susan Knight, MSPH; New Jersey, Kenneth O'Dowd, PhD; New Mexico, Wayne Honey, PhD; New York, Colleen Baker; North Carolina, Harry Herrick, MSPH; North Dakota, Melissa Parsons; Ohio, Patricia Coss; Oklahoma, Derek Pate, MPH; Oregon, Renee Boyd; Pennsylvania, Robert Dewar, MPA; Puerto Rico, Ruby Serrano-Rodriguez, DrPH; Rhode Island, Jana Hesser, PhD; South Carolina, Kristen Helms, MSPH; South Dakota, Mark Gildemaster; Tennessee, David Ridings; Texas, Michelle Cook, MPH; Utah, Jennifer Wrathall, MPH; Vermont, Rodney McCormick, PhD; Virgin Islands, Sharon Williams, MS; Virginia, Susan Spain; Washington, Katrina Wynkoop Simmons, PhD; West Virginia, Fred King; Wisconsin, Anne Ziege, PhD; Wyoming, Menlo Futa, MA.

2008 Behavioral Risk Factor Surveillance System Staff

Lina Balluz, ScD; William (Bill) Bartoli, MSc; Annie Bragg; Julie Brown; Pranesh Chowdhury, MPH; Gloria Colclough; Satvinger (Pearly) Dhingra, MPH; Amy Fan, MD; Earl Ford, MD; Suzianne Garner, MPA; William Garvin; David Gilbertz, MSc; Tod Hebenton; Jody Hill; Shaohua (Sean) Hu, MD; Elizabeth Hughes, DrPH; Greta Kilmer, MS; Kenneth Laliberte, MPA; Chaoyang Li, MD; Yan Li, MD; Wilmon Murphy; Catherine (Katie) Okoro, MS; William Pearson, PhD; Mohamed Qayad, PhD; Xiaoting Qin, PhD; Henry Roberts, PhD; James Ribble; Ajay Sharma; Tara Strine, MPH; Machell Town, MS; Balarami Valluru, MS; Justin Vigeant; Judith Wellen, MHS; Xiao-Jun (John )Wen, MD; Guixiang Zhao, MD; Yuna Zhong, MD; Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

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