Surveillance of Certain Health Behaviors and Conditions Among States and Selected Local Areas --- Behavioral Risk Factor Surveillance System, United States, 2007

Please note: An erratum has been published for this article. To view the erratum, please click here.

Prepared by

Pranesh Chowdhury MBBS, MPH, Lina Balluz, ScD, MPH, Machell Town, MS, Farah M Chowdhury, MBBS, MPH, William Bartoli, William Garvin, Haci Akcin, MS, Kurt J. Greenlund, PhD, Wayne Giles, MD

Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Lina Balluz, ScD , MPH, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, MS K-66, 4770 Buford Hwy, N.E., Atlanta, GA 30341. Telephone: 770-488-2466; Fax: 770-488-8150; E-mail: lballuz@cdc.gov.

Abstract

Problem: Chronic diseases (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors (e.g., smoking, physical inactivity, poor diet, and excessive drinking) and using preventive health-care services (e.g., cancer, hypertension, and cholesterol screenings) can reduce morbidity and mortality from chronic diseases. Monitoring health-risk behaviors, chronic health conditions, and preventive care practices is essential to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels.

Reporting Period Covered: January 2007--December 2007

Description of the System: The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based, on-going, random--digit-dialed household telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors and use of preventative health services related to the leading causes of death and disability in the United States. This report presents results for 2007 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin Islands, 184 metropolitan and micropolitan statistical areas (MMSAs), and 298 counties.

Results: In 2007, prevalence estimates of risk behaviors, chronic conditions, and the use of preventive 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 subject. Adults who reported fair or poor health: 11% to 32% for states and territories and 6% to 31% for MMSAs and counties. Adults with health-care coverage: 71% to 94% for states and territories and 51% to 97% for MMSAs and counties. Annual influenza vaccination among adults aged ≥65 years: 32% to 80% for states and territories, 48% to 83% for MMSAs, and 44% to 88% for counties. Pneumococcal vaccination among adults aged ≥65 years: 26% to 74% for states and territories, 44% to 83% for MMSAs, and 39% to 87% for counties. Adults who had their cholesterol checked within the preceding 5 years: 66% to 85% for states and territories and 58% to 90% for MMSAs and counties. Adults who consumed at least 5 servings of fruits and vegetables per day: 14% to 33% for states and territories, 16% to 34% for MMSAs and 14% to 37% for counties. Adults who reported no leisure-time physical activity: 17% to 44% for states and territories and 9% to 38% for MMSAs and counties. Adults who engaged in moderate or vigorous physical activity: 31% to 61% for states and territories and 36% to 67% for MMSAs and counties. Adults who engaged in only vigorous physical activity: 19% to 40% for states and territories and 15% to 45% for MMSAs and counties. Cigarette smoking among adults: 9% to 31% for states and territories, 7% to 34% for MMSAs, and 7% to 30% for counties. Binge drinking among adults: 3% to 8% for states and territories. Adults classified as overweight: 33% to 40% for states and territories and 26% to 47% for MMSAs and counties. Adults aged ≥20 years who were obese: 20% to 34% for states and territories and 14% to 38% for MMSAs and counties. Adults who were told of a diabetes diagnosis: 5% to 13% for states and territories and 2% to 17% for MMSAs and counties. Adults with high blood pressure diagnosis: 21% to 35% for states and territories and 16% to 38% for MMSAs and counties. Adults who had high blood cholesterol: 28% to 43% for states and territories, 29% to 49% for MMSAs, and 26% to 51% for counties. Adults with a history of coronary heart disease: 2% to 14% for states and territories, MMSAs, and counties. Adults who were told of a stroke diagnosis: 1% to 7% for states and territories, MMSAs, and counties. Adults who were diagnosed with arthritis: 14% to 36% for states and territories and 16% to 40% for MMSAs and counties. Adults who had asthma: 5% to 10% for states and territories and 3% to 13% for MMSAs and counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10% to 26% for states and territories. Adults who required special equipment because of health problems: 3% to 10% for states and territories and 3% to 14% for MMSAs and counties.

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

Public Health Actions: Healthy People 2010 (HP 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.

Introduction

Chronic diseases (e.g., heart disease, cancer, stroke and diabetes) are the leading causes of death (1) and disability in the United States (2). Engaging in healthy behaviors (e.g., reducing smoking, being more physically active, and eating a nutritious diet) and using preventive services (e.g., screening for blood pressure, blood cholesterol and cancer and receiving recommended vaccinations) can reduce morbidity and premature mortality from chronic diseases (3). The estimated prevalence of health behavior risk factors, chronic conditions, and use of preventive care services varies substantially across the United States. Ongoing surveillance is essential to identify groups at highest risk and to design and implement appropriate public health programs and policies.

BRFSS is a state-based, ongoing telephone survey of adults aged ≥18 years conducted by the state health departments with assistance from CDC. It is the largest continuously conducted telephone survey in the world with more than 350,000 adult interviews completed each year. Since 1984, BRFSS has been the main source for states on health-risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease and injury. BRFSS data are used to set health goals and to monitor progress and success of public health programs and policies at the national and state levels. Since 2002, the large sample size in BRFSS facilitated calculation of prevalence estimates for selected metropolitan and micropolitan statistical areas (MMSAs), metropolitan divisions, and selected counties. This report provides comparable prevalence estimates for selected risk behaviors, preventive services, and chronic conditions by states and territories, and MMSAs and counties.

HP 2010 sets forth a national agenda to prevent or delay diseases, decrease morbidity and mortality, and to improve healthy-related quality of life for all Americans (4). HP 2010 includes specific objectives to be achieved by 2010 for various modifiable risk factors and preventive services. These objectives can be used to monitor and develop health promotion and disease prevention programs at the state and local levels. This report contains comparisons between 2007 BRFSS data and certain HP 2010 objectives.

Methods

In 2007, BRFSS was conducted in all 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. BRFSS uses a multistage sampling design based on random-digit-dialing methods to select a representative sample from the noninstitutionalized adult population aged ≥18 years in each state and territory. Details on methodology, random sampling procedures, design, and reliability and validity of measures used in BRFSS have been described in previous publications (5,6).

Questionnaire

The standard BRFSS questionnaire consists of three parts: 1) core questions, 2) optional supplemental modules, which are sets of questions on specific topics (e.g., diabetes, healthy-related quality of life, arthritis management); and 3) state-added questions. All 50 states, the District of Columbia, and three territories ask the same core questions. Optional modules and state-added questions are included at their discretion. State-added questions address state-specific health-care concerns. The core questions address demographics, health status, number of healthy days, health-related quality of life, health-care access, exercise or leisure time physical activity, prevalence of diabetes, high blood pressure, cardiovascular diseases, cholesterol awareness, asthma, immunization including flu and pneumonia vaccination among older adults, hepatitis vaccination, tobacco/cigarette use, alcohol consumption, disabilities, arthritis burden, fruit and vegetable consumption, moderate and vigorous physical activity, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), emotional support and life satisfaction, and gastrointestinal disease.

In 2007, the following optional modules were selected: diabetes (40 states), random child selection (33 states), childhood asthma prevalence (33 states), mental illness and stigma (26 states), cardiovascular health (20 states), actions to control high blood pressure (19 states), arthritis management (19 states), heart attack and stroke (13 states), women's health (nine states), adult asthma history (eight states), colorectal cancer screening (five states), visual impairment and access to eye care (five states), sexual violence (five states), general preparedness (three states), intimate partner violence (three states), prostate cancer screening (three states), symptoms of healthy days (one state), and reaction to race (one state).

This report focuses on 1) health status indicators (e.g., self-reported fair or poor health and health-care coverage), 2) preventive health-care practices (e.g., influenza and pneumococcal vaccinations for persons aged ≥65 years and cholesterol checking in the preceding 5 years), 3) health-risk behaviors (e.g., no or minimal daily fruit or vegetable consumption, no or minimal physical activity participation or leisure time, current cigarette smoking, and binge and heavy drinking), 4) chronic health conditions (e.g., obesity, diabetes, high blood pressure, high cholesterol, history of coronary heart disease including heart attack and angina, and history of stroke), and 5) other chronic conditions (e.g., arthritis, current asthma, activity limitation because of physical, mental, or emotional health problems, and use of special equipment [e.g., a cane, wheelchair, special bed, or special telephone] because of health problems). The 2007 and all other BRFSS questioners can be obtained from: http://www.cdc.gov/brfss/questionnaires/english.htm.

Data Collection and Processing

Trained interviewers administer the BRFSS questionnaire using a computer-assisted telephone interviewing system. Data are collected monthly by each state and territory. After the monthly interviewing cycle concludes, data are submitted to CDC for reliability checks and analyses preparation.

Data Weighting

At the end of the survey year, CDC edits and aggregates the monthly data files to create a yearly sample for each state. Each sample is weighted to the respondent's probability of selection and to the age- and sex-specific population or age-, sex-, and race-specific population using the 2007 census projections reported by the census bureau for each state. State-level weights are adjusted to produce MMSA- and county-level weights. These sampling weights are used to calculate BRFSS state and territory-, MMSA-, and county-level prevalence estimates. MMSAs used in this report were defined by the Office of Management and Budget in December 2006. Respondents were assigned to a particular MMSA based on their Federal Information Processing Standard (FIPS) county code. Aggregated data from states were used to produce national prevalence estimates. Detailed weighting and analytic methodologies have been documented elsewhere (5,7).

Statistical Analyses

SAS(r) and SUDAAN(r) (release 9.0.1; Research Triangle Institute, Research Triangle Park, North Carolina) were used in the analyses to account for the complex sampling design and to calculate prevalence estimates, standard errors, and 95% confidence intervals (CIs) (8,9). Statistics were not reported if the unweighted sample size for the denominator was <50 or the CI half width was >10. Only MMSAs with ≥500 respondents and ≥19 respondents in all the final weighting classes and counties within selected MMSAs were included. Within each MMSA or county, weighting classes were based on age and sex cross-classification totals or age, sex, and race cross-classification totals. Responses coded as "do not know" or "refused" were excluded from the analyses.

Results

This report presents results for 2007 from the 54 states and territories, 184 MMSAs, and 298 counties with an adequate sample size to produce stable prevalence estimates. In 2007, a total of 430,912 interviews were completed and ranged from 657 in Guam, to 39,549 in Florida (median: 6,564). This report presents prevalence of health status, access to health care, use of preventive health-care services, health behaviors, and selected chronic conditions.

According to the Council of American Survey and Research Organizations (CASRO) guidelines, the 2007 BRFSS CASRO cooperation rate (the proportion of all respondents interviewed of all eligible units in which a respondent was selected and actually contacted) ranged from 49.6% in New Jersey, to 84.6% in Minnesota (median: 72.1%) (7).

Health 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 2007, among adults aged ≥18 years, the estimated prevalence of self-reported fair or poor health ranged from 10.9% in Utah to 32.2% in Puerto Rico (median: 15.2%) (Table 1). Among 184 MMSAs, the estimated prevalence of self-reported fair or poor health among respondents ranged from 7.2% in Lincoln, Nebraska, to 31.2% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 15.0%) (Table 2). Among 298 counties, the estimated prevalence of self-reported fair or poor health among respondents ranged from 5.7% in Davis County, Utah, to 30.6% in Webb County, Texas (median: 14.3%) (Table 3).

Health-Care Coverage

Health-care coverage was defined as respondents having reported that they had private health insurance, prepaid plans (e.g., health maintenance organizations) or government health plans (e.g., Medicare or Medicaid). In 2007, among adults aged ≥18 years, the estimated prevalence of health-care coverage ranged from 71.3% in the U.S. Virgin Islands to 94.0% in Hawaii (median: 85.6%) (Table 4). Among 184 MMSAs, the estimated prevalence ranged from 51.2% in McAllen-Edinburg-Mission, Texas, to 95.4% in Cambridge-Newton-Framingham, Massachusetts (median: 85.5%) (Table 5). Among selected counties, the estimated prevalence ranged from 51.2% in Hidalgo County, Texas, to 96.8% in Norfolk County, Massachusetts (median: 86.3%) (Table 6).

Preventive Practices

Influenza Vaccination

In 2007, among adults aged ≥65 years, the estimated prevalence of influenza vaccination during the preceding 12 months ranged from 32.2% in Puerto Rico to 80.0% in Rhode Island (median: 71.9%) (Table 7). Among selected MMSAs, the estimated prevalence ranged from 48.3% in Miami-Fort Lauderdale-Miami Beach, Florida, to 83.4% in Cambridge-Newton-Framingham, Massachusetts (median: 72.6%) (Table 8). Among selected counties, the estimated prevalence ranged from 43.8% in Miami-Dade County, Florida, to 88.2% in Orange County, North Carolina (median: 73.4%) (Table 9).

Pneumococcal Vaccination

In 2007, among adults aged ≥65 years, the estimated prevalence of pneumococcal vaccination ranged from 26.1% in Puerto Rico to 74.0% in Oregon (median: 67.2%) (Table 10). Among selected MMSAs, the estimated prevalence ranged from 43.7% in Miami-Fort Lauderdale-Miami Beach, Florida, to 82.8% in Bangor, Maine (median: 68.0%) (Table 11). Among selected counties, the estimated prevalence ranged from 38.6% in Miami-Dade County, Florida, to 86.7% in Douglas County, Colorado (median: 69.0%) (Table 12).

Blood Cholesterol Checked During Preceding 5 Years

In 2007, among adults aged ≥18 years, the estimated prevalence of having blood cholesterol checked during the preceding 5 years ranged from 65.9% in Utah to 85.0% in the District of Columbia (median: 74.9%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 57.6% in El Paso, Texas, to 89.8% in Barnstable Town, Massachusetts (median: 76.5%) (Table 14). Among selected counties, the estimated prevalence ranged from 57.6% in El Paso County, Texas, to 89.9% in Norfolk County, Massachusetts, and 89.9% in Gaston County, North Carolina (median: 78.1%) (Table 15).

Nutrition

In 2007, among adults aged ≥18 years, the estimated prevalence of consuming at least 5 servings of fruits or vegetables per day ranged from 13.7% in Puerto Rico to 32.5% in the District of Columbia (median: 24.3%) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 16.2% in Huntington-Ashland, West Virginia-Kentucky-Ohio, to 34.0% in Kapaa, Hawaii (median: 24.6%) (Table 17). Among selected counties, the estimated prevalence ranged from 13.7% in Wyandotte County, Kansas, to 37.4% in Arlington County, Virginia (median: 24.7%) (Table 18).

Physical Activity

Leisure-time physical activity was defined as participating in exercise (e.g., running, calisthenics, golf, gardening, or brisk walking) other than as part of the respondent's regular work during the preceding month. In 2007, among adults aged ≥18 years, the estimated prevalence of no leisure-time physical activity by state and territory ranged from 16.7% in Minnesota to 43.7% in Puerto Rico (median: 23.0%) (Table 19). Among the selected MMSAs, the estimated prevalence ranged from 8.8% in Boulder, Colorado, to 37.5% in Clewiston, Florida (median: 22.4%) (Table 20). Among counties, the estimated prevalence ranged from 8.6% in Douglas County, Colorado, to 37.5% in Hendry County, Florida (median: 22.3%) (Table 21).

Moderate or vigorous physical activity was defined as participating in moderate exercise (e.g., brisk walking, bicycling, vacuuming, gardening, or anything else that causes a small increase in breathing and heart rate on at least 5 days per week for at least 30 minutes each day) or vigorous exercise (e.g., running, aerobics, heavy yard work, or anything else that causes a large increase in breathing and heart rate on 3 or more days per week for at least 20 minutes each day) other than the respondent's regular work in a usual week. In 2007, among adults by state and territory, the estimated prevalence of moderate or vigorous physical activity ranged from 30.9% in Puerto Rico, to 60.8% in Alaska (median: 49.2%) (Table 22). Among the selected MMSAs, the estimated prevalence ranged from 37.3% in Chattanooga, Tennessee-Georgia, to 67.1% in Boulder, Colorado (median: 50.3%) (Table 23). Among counties, the estimated prevalence of moderate physical activity ranged from 35.9% in Hamilton County, Tennessee, to 67.1% in Boulder County, Colorado (median: 50.0%) (Table 24).

Vigorous physical activity was defined as participating in exercise (e.g., running, aerobics, heavy yard work, or anything else that causes a large increase in breathing and heart rate on 3 or more days per week for at least 20 minutes each day) other than the respondent's regular work in a usual week. In 2007, among adults by state and territory, the estimated prevalence of vigorous physical activity ranged from 18.5% in Tennessee, to 39.5% in Alaska (median: 28.1%) (Table 25). Among the selected MMSAs, the estimated prevalence ranged from 15.4% in Charleston, West Virginia, to 44.1% in Provo-Orem, Utah (median: 28.1%) (Table 26). Among counties, the estimated prevalence of vigorous physical activity ranged from 15.0% in Sullivan County, Tennessee, to 44.5% in Utah County, Utah (median: 28.4%) (Table 27).

Health Risk Behaviors

Current Cigarette Smoking

Respondents were categorized as current smokers if they reported having smoked at least 100 cigarettes during their lifetime and indicated that they smoked every day or occasionally at the time of the survey. In 2007, among adults aged ≥18 years, the estimated prevalence of current smokers ranged from 8.7% in the U.S. Virgin Islands to 31.0% in Guam (median: 19.7%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 6.5% in Provo-Orem, Utah, to 34.4% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 19.7%) (Table 29). Among selected counties, the estimated prevalence ranged from 6.5% in Utah County, Utah, to 29.7% in Pasco County, Florida (median: 19.0%) (Table 30).

Alcohol Consumption

Binge Drinking

Binge drinking was defined as adult males having five or more drinks, and adult females having four or more drinks on at least one occasion during the last 30 days. In 2007, among adults aged ≥18 years, the estimated prevalence of binge drinking ranged from 8.2% in Kentucky to 23.4% in Wisconsin (median: 15.7%) (Table 31). Among selected MMSAs, the estimated prevalence of binge drinking ranged from 4.3% in Provo-Orem, Utah, to 21.4% in Milwaukee-Waukesha-West Allis, Wisconsin (median: 15.7%) (Table 32). Among selected counties, the estimated prevalence ranged from 4.3% in Utah County, Utah, to 25.6% in Arlington County, Virginia (median: 15.6%) (Table 33).

Heavy Drinking

Heavy drinking was defined as adult males having more than two drinks, and adult females having more than one drink per day during the last 30 days. In 2007, among adults aged ≥18 years, the estimated prevalence of heavy drinking ranged from 2.5% in Utah to 7.7% in Hawaii (median: 5.2%) (Table 34). Among selected MMSAs, the estimated prevalence of heavy drinking ranged from 2.1% in Idaho Falls, Idaho and Wauchula, Florida, to 11.0% in Key West-Marathon, Florida (median: 5.3%) (Table 35). Among selected counties, the estimated prevalence ranged from 1.2% in Davis County, Utah, to 11.6% in St. Johns County, Florida (median: 5.5%) (Table 36).

Chronic Health Conditions

Overweight

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 of ≥25.0 and <30.0. In 2007, among adults aged ≥18 years, the estimated prevalence of overweight ranged from 33.1% in the District of Columbia to 40.4% in Kentucky (median: 36.7%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 29.2% in Okeechobee, Florida, to 47.2% in Yuma, Arizona (median: 36.9%) (Table 38). Among selected counties, the estimated prevalence ranged from 26.3% in Montgomery County, Alabama, to 47.3% in Sarpy County, Nebraska (median: 36.7%) (Table 39).

Obesity

Respondents were categorized as obese if their BMI was ≥30.0. Obesity analyses were restricted to adults aged ≥20 years to permit comparison with HP 2010. In 2007, among adults aged ≥20 years, the estimated prevalence of obesity ranged from 19.9% in Colorado to 33.5% in Mississippi (median: 26.8%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 14.8% in West Palm Beach-Boca Raton-Boynton Beach, Florida, to 37.6% in McAllen-Edinburg-Mission, Texas (median: 26.6%) (Table 41). Among selected counties, the estimated prevalence ranged from 13.8% in New York County, New York, to 37.6% in Hidalgo County, Texas (median: 26.0%) (Table 42).

Diabetes

The prevalence of diagnosed diabetes was assessed by asking respondents, "Have you ever been told by a doctor that you have diabetes?" Those who reported "yes" were considered to have diabetes. Specific types of diabetes (e.g., Type 1 or Type 2) were not assessed. Adults reporting gestational, borderline, or pre-diabetes were not considered diabetic for these analyses. In 2007, among adults aged ≥18 years, the estimated prevalence of diagnosed diabetes ranged from 5.3% in Colorado to 12.5% in Puerto Rico (median: 8.1%) (Table 43). Among selected MMSAs, the estimated prevalence ranged from 2.2% in Boulder, Colorado, to 16.5% in Laredo, Texas (median: 8.4%) (Table 44). Among selected counties, the estimated prevalence ranged from 1.8% in Douglas County, Colorado, to 16.5% in Webb County, Texas (median: 8.1%) (Table 45).

High Blood Pressure

Prevalence of high blood pressure (HBP) was assessed by asking respondents aged ≥20 years, "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?" Adults who reported pre-hypertension or borderline high blood pressure, and females who reported high blood pressure during pregnancy, were not considered hypertensive for these analyses. In 2007, among adults, the estimated prevalence of HBP ranged from 20.9% in Utah to 35.1% in Mississippi (median: 28.3%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 16.5% in Boulder, Colorado, to 38.1% in Seaford, Delaware (median: 27.8%) (Table 47). Among selected counties, the estimated prevalence ranged from 15.9% in Douglas County, Colorado, to 38.1% in Sussex County, Delaware (median: 27.4%) (Table 48).

High Blood Cholesterol

Respondents aged ≥20 years were categorized as having high blood cholesterol if they ever had their blood cholesterol checked and were told by a doctor, nurse, or other health-care professional that their blood cholesterol was high. In 2007, among adults aged ≥18 years, the estimated prevalence of high blood cholesterol ranged from 27.9% in Guam to 43.2% in West Virginia (median: 37.8%) (Table 49). Among selected MMSAs, the estimated prevalence of high blood cholesterol ranged from 29.1% in Gainesville, Florida, to 48.5% in Seaford, Delaware (median: 37.6%) (Table 50). Among selected counties, the estimated prevalence ranged from 26.1% in Davidson County, Tennessee, to 50.7% in Gloucester County, New Jersey (median: 37.4%) (Table 51).

Coronary Heart Disease

Respondents aged ≥18 years were categorized as having coronary heart disease (CHD) if they reported having ever been told by a doctor, nurse, or other health professionals that they had CHD, angina, or a heart attack. In 2007, among adults aged ≥18 years, the estimated prevalence of CHD ranged from 2.8% in the U.S. Virgin Islands, to 10.7% in West Virginia (median: 6.4%) (Table 52). Among selected MMSAs, the estimated prevalence ranged from 2.7% in Boulder, Colorado, to 13.5% in Homosassa Springs, Florida (median: 6.3%) (Table 53). Among selected counties, the estimated prevalence ranged from 2.0% in Arlington County, Virginia, to 13.5% in Citrus County, Florida (median: 6.0%) (Table 54).

Stroke

Respondents aged ≥18 years were categorized as having a history of stroke if they reported having ever been told by a doctor, nurse, or other health professionals that they had a stroke. In 2007, among adults aged ≥18 years, the estimated prevalence of stroke ranged from 1.1% in the U.S. Virgin Islands to 3.7% in Missouri (median: 2.6%) (Table 55). Among selected MMSAs, the estimated prevalence of stroke ranged from 0.7% in Nogales, Arizona, to 6.5% in Mobile, Alabama (median: 2.5%) (Table 56). Among selected counties, the estimated prevalence ranged from 0.7% in Santa Cruz County, Arizona, to 6.5% in Mobile County, Alabama (median: 2.4%) (Table 57).

Arthritis

Respondents aged ≥18 years were categorized as having arthritis if they reported having ever been told by a doctor that they have some form of arthritis. Arthritis diagnoses included rheumatism, polymyalgia rheumatica; osteoarthritis (not osteoporosis); tendonitis, bursitis, bunion, tennis elbow; carpal tunnel syndrome, tarsal tunnel syndrome; joint infection, Reiter's syndrome; ankylosing spondylitis; spondylosis; rotator cuff syndrome; connective tissue disease; scleroderma; polymyositis, Raynaud's syndrome or vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener's granulomatosis, polyarteritis nodosa). In 2007, among adults aged ≥18 years, the estimated prevalence of arthritis ranged from 13.7% in Guam to 35.5% in West Virginia (median: 27.5%) (Table 58). Among selected MMSAs, the estimated prevalence of arthritis ranged from 16.3% in Laredo, Texas, to 40.3% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 27.1%) (Table 59). Among selected counties, the estimated prevalence ranged from 16.3% in Webb County, Texas, to 40.1% in Fayette County, Pennsylvania (median: 26.1%) (Table 60).

Current Asthma

Respondents aged ≥18 years were categorized 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 2007, among adults aged ≥18 years, the estimated prevalence of current asthma ranged from 5.4% in the U.S. Virgin Islands to 10.3% in Maine (median: 8.3%) (Table 61). Among selected MMSAs, the estimated prevalence of current asthma ranged from 3.6% in Brownsville-Harlingen, Texas, and 3.6% in Cape Coral-Fort Myers, Florida, to 13.2% in Bangor, Maine (median: 8.1%) (Table 62). Among selected counties, the estimated prevalence ranged from 3.4% in Nassau County, New York, to 13.2% in Penobscot County, Maine, and 13.2% in Westchester County, New York (median: 8.0%) (Table 63).

Disability or Health Impairment

Activity Limitation

Respondents aged ≥18 years were categorized as having activity limitation if they reported any limitation of activities because of physical, mental, or emotional problems. In 2007, among adults aged ≥18 years, the estimated prevalence of limitations in activities because of physical, mental, or emotional problems ranged from 10.3% in the U.S. Virgin Islands to 25.9% in West Virginia (median: 18.8%) (Table 64). Among selected MMSAs, the estimated prevalence ranged from 13.0% in Nogales, Arizona, to 32.3% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 18.7%) (Table 65). Among selected counties, the estimated prevalence ranged from 9.4% in DuPage County, Illinois, to 31.4% in Mobile County, Alabama (median: 18.3%) (Table 66).

Special Equipment Requirement

Respondents aged ≥18 years were categorized as using special equipment because of a health problem if they used a cane, wheelchair, special bed, or special telephone occasionally or in certain circumstances. In 2007, among adults aged ≥18 years, the estimated prevalence who reported requiring special equipment because of a health problem ranged from 3.1% in the U.S. Virgin Islands to 9.5% in Alabama (median: 7.1%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 3.0% in Fargo, North Dakota-Minnesota, to 14.4% in Mobile, Alabama (median: 6.4%) (Table 68). Among selected counties, the estimated prevalence ranged from 2.7% in Alexandria City, Virginia, to 14.4% in Mobile County, Alabama (median: 6.4%) (Table 69).

Discussion

The findings in this report indicate wide variations in the estimated prevalence of health-risk behaviors, chronic diseases, and use of preventative health practices and services among U.S. adults at the state and territory, MMSA, and county levels. These variations might reflect differences in the demographic factors of respondents, including age, race, and sex distribution of the population; socioeconomic conditions including education level attained, income level and employment status; state laws and local ordinances; availability and access to health-care services; use of preventive health-care services; and patterns of reimbursement for preventive services. The results provided in this report were estimated on the basis of survey results and might differ from those derived by other methods.

The HP 2010 objectives established goals for certain health behaviors to be attained by 2010 (4). The data presented in this report can be compared with the goals of HP 2010 (Table 70). Some findings indicate that certain HP 2010 goals have not been attained. For example, in 2007, no state and territory, MMSA, or county achieved the HP 2010 goals for health-care coverage, vaccination against influenza or pneumococcal disease, high blood pressure, or high blood cholesterol.

Health Indicators

Although measured by a single question, self-reported health status encompasses physical health, mental health, and functional capacity of persons (10). It is a proxy indicator for perceived burden of acute and chronic health conditions (11). Large variations in fair or poor health at the state and local level suggest differences in the underlying burden of chronic diseases, health-care coverage, and health behaviors among states and territories, MMSAs, and counties.

The HP 2010 objective for health-care coverage is 100% (4). Lack of health-care coverage might have an adverse impact on health because it is associated with access to and use of preventive health-care services that include blood pressure, cholesterol, and cancer screenings (e.g., mammography, and Pap test) (12). In 2007, no state and territory, MMSA, or county achieved the HP 2010 objective of 100% health-care coverage.

Preventive Practices

The risks for complications, hospitalizations, and deaths from influenza and pneumonia are highest among persons aged ≥65 years (13,14). Influenza and pneumonia vaccination among older adults (aged ≥65) is a key public health strategy in the United States (15). The HP 2010 target for adults aged ≥65 who had annual influenza vaccination is 90% and the HP 2010 target for adults aged ≥65 who had annual vaccination against pneumococcal disease is 90% (4). In 2007, no state and territory or county met the HP 2010 target of 90% (4). The reasons for inadequate coverage include lack of knowledge, misconceptions about vaccines and vaccine-associated illness, and lack of recommendations by physicians (16,17). The strategies offered by the Task Force on Community Preventive Services to improve immunization among adults can be employed at the state and local levels (18).

Health-Risk Behaviors

Substituting fruits and vegetables for higher-calorie foods can help maintain healthy weight and reduce the risk for chronic diseases and certain cancers (19,20). The Dietary Guidelines for Americans, released in January 2005 (20), changed fruit and vegetable recommendations for all Americans from 5 to 9 servings per day to 5 to 13 servings per day. BRFSS still uses 5 servings as a measure of fruit or vegetable daily consumption. In 2007, the prevalence of 5 servings of fruit and vegetable daily consumption ranged from 14% to 33%, indicating a need to increase public awareness of the overall benefits of fruits and vegetables. In addition, sustained and effective public health efforts are needed to promote the importance of to eating more fruits and vegetables (21).

One of the HP 2010 goals is to increase prevalence of moderate physical activity to 50% and vigorous physical activity to 30% (4). Despite the proven benefit of physical activity (22), prevalence of moderate and vigorous physical activity is still low. In 2007, approximately 50% of states and territories, MMSAs, and counties had not met the HP 2010 goal for physical activity. Recommended strategies to increase physical activity include communitywide campaigns, signage to encourage stair use near elevators and escalators, individually adapted health-behavior change programs, school physical education, social support interventions in community settings, and the creation of or enhanced access to places for physical activity combined with informational outreach activities (23). According to the 2008 Physical Activity Guidelines for Americans, in addition to conducting muscle strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms), adults should do at least 2 hours and 30 minutes of moderate aerobic exercise (i.e., brisk walking) every week or 1 hour and 15 minutes of vigorous aerobic exercise (i.e., jogging or running) every week (24).

Cigarette smoking is the single most preventable cause of morbidity and mortality in the United States (25). Smoking causes many types of cancer, cardiovascular and pulmonary diseases (25). Health consequences of secondhand smoke include pediatric respiratory problems, cardiovascular disease, and lung cancer in adults (26). Only two states, five MMSAs, and 22 counties met the HP 2010 target for smoking (12%) (4). These results indicate a need for continued implementation of comprehensive tobacco-control programs at the state and local levels (27).

Excessive alcohol consumption is a leading preventable cause of death in the United States (28). Binge and heavy drinking can lead to risky sexual activity, unintentional injuries, falls, violence, and suicide (29,30). The HP 2010 target is to reduce binge drinking to 13.4% (4). Only 15 states met the national target for binge drinking. The estimated prevalence for heavy drinking ranged from 1.2% in Davis County, Utah, to 11.6% in St. Johns County, Florida. It is necessary to initiate and strengthen population-based prevention efforts to reduce binge and heavy drinking.

Chronic Health Conditions

Chronic health conditions are also the targets of national health goals (4). Overweight and obesity continues to be a critical public health problem (31,32). In 2007, the estimated prevalence of overweight among states and territories ranged from 33% to 40% and obesity (aged ≥20) ranged from 20% to 34%. The HP 2010 target is to reduce the proportion of adults (aged ≥20) who are obese to 15%. No state or territory, only three MMSAs, and four counties met the HP 2010 target of obesity. Moreover, the estimated prevalence of obesity for counties during 2007 (14% to 38%) did not change substantially from 2006 (10% to 37%) and 2005 (15% to 33%). Extensive public health programs that target healthy life styles are necessary to control overweight and obesity at the state and local levels (33).

Persons with diabetes are more likely to develop cardiovascular disease, high blood pressure, high cholesterol, and complications during pregnancy (34). These diseases and conditions can be prevented by controlling blood glucose through healthy eating, physical activity, medication and receiving proper preventive services (34). The estimated prevalence of diabetes among persons aged ≥18 ranged from 5% to 13% among states and territories.

Heart disease and stroke are the first and third leading causes of death, respectively, in the United States (35). High blood pressure and high blood cholesterol are important modifiable risk factors for cardiovascular disease (36). High blood pressure and high cholesterol are relatively easy to monitor and should be maintained at an optimal level (37,38). In 2007, no state and territory, MMSA, or county met the HP 2010 target for reducing the proportion of adults with high blood pressure (14%) and the proportion of adults with high blood cholesterol (17%). The findings in this report indicate a need for more public health efforts to reduce high blood pressure and high blood cholesterol. Population-level approaches to prevent or control high blood pressure include engaging in moderate physical activity; maintaining normal body weight; limiting consumption of alcohol; reducing intake of sodium; maintaining adequate intake of potassium; and consuming a diet rich in fruits, vegetables, and low-fat dairy products (39). Strategies suggested by National High Blood Pressure Education Program (38) and National Cholesterol Education Program (37) can be applied at the state and local levels to help reduce high blood pressure and high blood cholesterol.

Asthma is a major cause of morbidity in the United States (40). However, most asthma symptoms can be prevented with appropriate medication, medical care, and self-management. Guidelines to control asthma are provided by the National Asthma Education and Prevention Program (41). In 2007, the estimated current asthma prevalence among persons aged ≥18 years ranged from 3.4% in Nassau County, New York to 13.2% in Penobscot County, Maine and Westchester County, New York.

Arthritis continued to be the most common cause of disability (42) in the United States. In 2007, the estimated prevalence for arthritis ranged from 5% to 10% for states and territories, and from 3% to 13% for MMSAs and counties. Strategies to reduce the burden of arthritis among persons include being more physically active, controlling weight, and learning self-management techniques (e.g., those developed by Arthritis Foundation Self-Help Program or Chronic Disease Self-Management Program) (43).

Disability or Health Impairment

Disabilities or health impairment caused by limitation in activities because of physical, mental, or emotional problems severely affect quality of life (44). Persons with disability are less likely to use preventive health services, to have lower health-care costs, to participate in health behaviors (e.g., physical activity, smoking), and are more likely to have higher rates of chronic conditions (e.g., diabetes, obesity, hypertension) compared with persons without disability (45). In 2007, the estimated prevalence of special equipment usage (e.g., a cane, wheelchair, special bed or special telephone) because of any health problem ranged from 3% to 10% for states and territories and from 3% to 14% for MMSAs and counties. As the population ages and the prevalence of disabilities increases, it is essential to continue disability surveillance in the United States.

Limitations

The findings in this report are subject to at least four limitations. First, changes in telecommunication use (e.g., increases in the number of cell-phone only households and telephone number portability) continue to decrease the response rate to BRFSS. CDC has conducted research to evaluate 1) multiple mode data collection including address-based sampling frames and mail surveys, 2) online translations to reach households that speak a language other than English and Spanish, and 3) advance letters distribution. In 2008, BRFSS conducted a cell phone pilot study in 21 states to assess how BRFSS could access persons who had cell phones but no landline, and to produce samples that better represent the population. In 2009, all states plan to incorporate cell phone-only household surveys along with landline surveys.

Second, BRFSS does not collect information from persons in institutions, nursing homes, long-term--care facilities, and correctional institutions. Third, BRFSS data are self-reported and are subject to recall bias and social desirability effects. Finally, estimates for some health indicators could not be obtained for all MMSAs and counties, and as a result these MMSAs and counties were not ranked on these health indicators. Despite these limitations, BRFSS is cost-effective and a timely survey that provides reliable and valid estimates (6,46) of health-risk behaviors, chronic diseases, and conditions and use of preventive services for states and local jurisdictions. BRFSS data are often the only data source of information available to communities to assess local health conditions and to evaluate effectiveness of interventions.

Conclusion

The results in this report indicate a need to continue to monitor health-risk behaviors, chronic conditions and use preventive health services at state and local levels. 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.

References

1. Kung HC, Hoyert DL, Xu J, et al. Deaths: final data for 2005. Natl Vital Stat Rep 2008; 56.
2. CDC. The burden of chronic diseases and their risk factors--National and State perspectives. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Feb. 2004. Available at: http://www.cdc.gov/nccdphp/burdenbook2004/pdf/burden_book2004.pdf Accessed June 22, 2009.
3. Nelson DE, Bland S, Powell-Griner E, et al. State trends in health risk factors and receipt of clinical preventive services among U.S. adults during the 1990s. JAMA 2002;287:2659--67.
4. US Department of Health and Human Services. Healthy People 2010: understanding and improving health. 2nd ed. Washington, DC. 2000.
5. CDC. Behavioral Risk Factor Surveillance System operational and user's guide, Version 3.0. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at ftp://ftp.cdc.gov/pub/Data/Brfss/userguide.pdf. Accessed June 22, 2009.
6. Nelson DE, Holtzman D, Bolen J, et al. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Social and Preventive Medicine 2001;46:S03-S42.
7. CDC. Behavioral Risk Factor Surveillance System summary data quality report, version March 9, 2008. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at: ftp://ftp.cdc.gov/pub/Data/Brfss/2007SummaryDataQualityReport.pdf. Accessed June 22, 2009.
8. SAS Institute, Inc. SAS(r) version 9.1 [software and documentation]. Cary, NY: SAS Institute, 2004.
9. Research Triangle Institute. SUDAAN (r) version 9 [software and documentation]. Triangle Park, NC: Research Triangle Institute: 2005.
10. Simon JG, De Boer JB, Joung IM, et al. How is your health in general? A qualitative study on self-assessed health. Eur J Public Health 2005;15:200--8.
11. CDC. Measuring healthy days. Atlanta, GA. November 2000.
12. CDC. Health insurance coverage and receipts of preventive health services---United States, 1993. MMWR 1995;44:219--25.
13. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179--86.
14. Simonsen L, Fukuda K, Schonberger LB, Cox NJ. The impact of Influenza epidemics on hospitalizations. J Infect Dis 2000;181:831--7.
15. CDC. Influenza and pneumococcal vaccination coverage among persons aged >65 years---United States, 2004-2005. MMWR 2006;55:1065--8.
16. CDC. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations---United States, 1996. MMWR 1999;48:886--90.
17. CDC. Vaccination levels among Hispanics and Non-Hispanic whites aged ≥65 years---Los Angeles County, California, 1996. MMWR 1997;46:1165--8.
18. Task force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18:S92--S96.
19. CDC. Fruits and vegetables benefits. Division of Nutrition and Physical Activity and Obesity. Available at: http://www.fruitsandveggiesmatter.gov/benefits/index.html#. Accessed June 22, 2009.
20. US Department of Health and Human Services. Dietary guidelines for Americans 2005. US Department of Agriculture. Available at: http://www.health.gov/dietaryguidelines/dga2005/document/pdf/DGA2005.pdf. Accessed June 22, 2009.
21. Blanck HM, Galuska DA, Gillespie C, et al. Fruit and vegetable consumption among adults---United States, 2005. MMWR 2007;56;213-7.
22. US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta (GA): US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion; 1996.
23. CDC. Increasing physical activity: a report on recommendation of the Task Force on Community Preventive Services. MMWR 2001;50 (No. RR-18).
24. CDC. How much physical activity do adults need. Available at: http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html. Accessed August 17, 2009.
25. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: 2004.
26. Moritsugu, KP. The 2006 report of the Surgeon General: the health consequences of involuntary exposure to tobacco smoke. Am J Prev Med 2007;32:542--3.
27. CDC. Best practices for comprehensive tobacco control programs---August 1999. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: 1999.
28. Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA 2004;291:1238--45.
29. Marczinski CA, Stewart WC, Fillmore MT. Increased sensitivity to the disinhibiting effects of alcohol in binge drinkers. Psychol Addict Behav 2007;21:346--54.
30. Mukamal KJ, Kawachi I, Miller M, et al. Drinking frequency and quantity and risk of suicide among men. Soc Psychiatry Psychiatr Epidemiol 2007;42:153--60.
31. Flegal KM, Carrol M, Ogden CL, et al. Prevalence and trends in obesity among U.S. adults, 1999--2000. JAMA 2002; 288:1723--7.
32. Kilmer G, Roberts H, Hughes E, et al. Surveillance of certain health behaviors and conditions among states and selected local areas---Behavioral Risk Factor Surveillance System (BRFSS), 2006. Surveillance Summaries, August 15, 2008, MMWR 2008;57 (No. SS-7).
33. National Heart, Lung, and Blood Institute. Clinical guidelines on identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: National Institutes of Health, National; Heart, Lung, and Blood Institute, 1998; NIH Publication No. 98-4083.
34. CDC. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: US Department of Health and Human Services, CDC, 2008. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed on June 22
35. CDC. The burden of chronic diseases and their risk factors: national and state perspectives, 2004. Atlanta GA: US Department of Health and Human Services, 2004.
36. CDC. Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke---United States, 2003. MMWR 2005;54:113--7.
37. American Heart Association. Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 106:3143, 2002. Available at http://circ.ahajournals.org/cgi/reprint/106/25/3143.pdf.
38. Aram V, Chobanian AV, Bakris GL, et al. National High Blood Pressure Education Program. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension 2003;42:1206--52. Available at http://hyper.ahajournals.org/cgi/content/full/42/6/1206
39. Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882--8.
40. Moorman JE, Rudd RA, Johnson CA, et al. National surveillance for asthma---United States, 1980-2004. Surveillance Summaries, October 19, 2007, MMWR 2007;56 (No. SS-8)
41. Department of Health and Human Services. National Institute of US Health. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. 2007. NIH Publication No. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed June 22, 2009.
42. CDC. Arthritis meeting the challenges. At a glance 2009. National Center for Chronic Disease Prevention and Health Promotion. Available at: http://www.cdc.gov/NCCDPHP/publications/aag/pdf/arthritis.pdf. Accessed June 22, 2009.
43. CDC. Healthy People with Disabilities. Atlanta, GA: National Center on Birth Defects and Developmental Disabilities; 2002. Available at: http://www.cdc.gov/ncbddd/factsheets/DH_hp2010.pdf. Accessed June 22, 2009.
44. Okoro CA, Strine TW, Balluz L, et al. Serious psychological distress among adults with and without disabilities. Int J Public Health. 2009;54 :52--60.
45. CDC. Prevalence and most common causes of disability among adults---United States, 2005. MMWR 2009;58:421--6.
46. Nelson DE, Powell-Griner E, Town M, et al. A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System (BRFSS). Am J Public Health 2003;93:1335--41.