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State Variations of Chronic Disease Risk Factors in Older Americans

Stacey L. Tannenbaum, PhD, RD, LDN; Diana Kachan, BS; Cristina A. Fernandez, MSEd; Laura A. McClure, MSPH; William G. LeBlanc, PhD; Kristopher L. Arheart, EdD; David J. Lee, PhD

Suggested citation for this article: Tannenbaum SL, Kachan D, Fernandez CA, McClure LA, LeBlanc WG, Arheart KL, et al. State Variations of Chronic Disease Risk Factors in Older Americans. Prev Chronic Dis 2012;9:120143. DOI: http://dx.doi.org/10.5888/pcd9.120143.

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Abstract

The objective of this study was to examine and compare 3 key health behaviors associated with chronic disease (ie, risky drinking, smoking, and sedentary lifestyle). We used data from the National Health Interview Survey from 1997 through 2010 to calculate the prevalence of these behaviors among older Americans and rank each state, and we analyzed overall trends in prevalence for each behavior over the 14 years. Older adults residing in Arkansas and Montana had the worst chronic disease risk profile compared with other states. These findings indicate the need for improved or increased targeted interventions in these states.

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Objective

Risky drinking, smoking, and sedentary lifestyle are key health behaviors associated with chronic disease and increased illness and death in older adults (1). Excessive drinking is associated with cancers of the liver, head and neck, colorectum, pancreas, and breast, as well as cardiovascular disease and diabetes (2). Smoking is associated with cancer and poor cardiovascular outcomes (1). Cardiovascular disease and cancer risk are increased by sedentary behavior (1). The objective of this study was to examine the prevalence and trends of these 3 health behaviors among older Americans and rank them at the state level to determine the best allocation of public health resources.

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Methods

Data were obtained from the National Health Interview Survey (NHIS), an annual, cross-sectional, multistage probability household survey of the noninstitutionalized civilian US population, from 1997 through 2010. Eligibility criteria were adults aged 65 or older (N = 79,973; representing 34,632,575 people). NHIS questions regarding the 3 variables are available online (3). Smoker was defined as “current smoker” (4). Risky drinking was defined as current drinkers having 10 or more drinks per week in men and 7 or more drinks per week in women, or having 5 or more drinks on 1 occasion, 1 or more times per year for men and women (4). Physical activity level was defined as compliance with the Healthy People 2010 goal of moderate physical activity for at least 30 minutes per day on 5 or more days per week or vigorous physical activity for at least 20 minutes per day on 3 or more days per week (5).

NHIS data were pooled and analyses were conducted using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina), adjusting for sample weights and design effects (3). We calculated prevalence, standard errors (SEs), and 95% confidence intervals (CIs) and ranked states according to the prevalence of each risk factor indicator. We analyzed trends by using weighted linear regression of prevalence on year. Weight was generated with the inverse of the variance of prevalence. Some states were missing values because they did not meet the criteria for stable estimate analysis in all study years (6).

Because state-level data are not released to the public, all analyses were performed remotely at the National Center for Health Statistics Research Data Center. The study was approved by the University of Miami’s institutional review board.

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Results

The prevalence of smoking among US adults aged 65 years or older was 9.6% (Table 1). States with the highest smoking prevalence were Nevada (17.9%) and Kentucky (15.0%). States with the lowest rates of smoking were Utah (5.4%) and South Dakota (6.2%). Overall, 22% of older Americans reported risky drinking patterns; Arizona and New Hampshire had the highest prevalence, both at 29.0%, and the lowest prevalences were found in Kansas (14.4%) and Oklahoma (16.4%) (Table 2). Twenty-two percent of older Americans reported meeting physical activity recommendations; the highest prevalence was reported in Colorado (30.8%), Hawaii (34.8%), and Maine (40.1%), and the lowest prevalence was reported in Louisiana (13.4%), Mississippi (13.4%), and South Dakota (14.6%) (Table 3). Older Americans residing in Arkansas and Montana were in the top 10 worst rankings for all 3 behaviors.

A downward trend in smoking was observed during the 14 years for California (slope, −0.32; SE, 0.09; P = .004) and South Carolina (slope, −0.54; SE, 0.21; P = .046), and an increased trend for risky drinking was observed in Massachusetts (slope, 1.07; SE, 0.39; P = .026). In North Carolina (slope, 0.82; SE, 0.25; P = .007) and Texas (slope, 0.57; SE, 0.16; P = .004), an upward trend in exercise compliance was observed. Trend analysis was not conducted for 7 states and the District of Columbia due to insufficient sample sizes.

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Discussion

The average age of Americans is expected to increase substantially in the coming years (7). Modifying key health behaviors and creating cost-effective interventions may contribute to decreasing illness and death in this growing population demographic (8).

Lifestyle changes that occur with aging can affect chronic disease risk. Older adults who exercise regularly have a reduced mortality risk (9), but those who drink alcohol excessively are more prone to oxidative stress, which further increases the incidence of chronic disease (10). A twofold higher mortality rate was shown for older male smokers than nonsmokers (11). Risky drinking with aging has been positively associated with vigorous physical activity and negatively associated with current smoking, possibly reflecting better health among adults who engage in risky drinking as they age (12). Nevertheless, excessive alcohol consumption is associated with risk of falls (1) and adverse medication interactions in older Americans (10).

Limitations of this study included an inability to use estimates from all states due to small sample sizes or unstable estimates in some states (ie, a relative SE of ≥30%). We were unable to conduct complete trend analyses for all states given sample size limitations. The strength of this study was the access to a large set of sample data at the state level for prevalence comparisons in older Americans.

Public health resources should focus on specific interventions to affect behaviors in states with residents at high risk for developing chronic disease. These resources can include a purposeful combination of the following: 1) increasing tobacco excise taxes, proven to be the most effective means to decrease smoking (1), 2) using online and telephone substance abuse treatment facility locators and media campaigns to disseminate information on alcohol abuse (1), and 3) enhancing access to recreational and physical activity facilities in communities specific to older Americans, pursuant to the Healthy People 2010 guidelines (5). Emphasis on geographic aggregation of risk factors should be considered so that integrated and tailored prevention activities can be developed and customized to each state’s profile and funds be made appropriately available. States with the highest prevalence of 2 or 3 risky behaviors should review resource allocation to promote health more effectively.

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Acknowledgments

This study was fully funded by Bankhead-Coley Cancer Research Program grant no. 1BG06-341963.

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Author Information

Corresponding Author: Stacey L. Tannenbaum, PhD, RD, LDN, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, 1120 NW 14th St, 10th Fl, Miami, FL 33136. Telephone: 305-243-0330. E-mail: STannenbaum@med.miami.edu.

Author Affiliations: Diana Kachan, Cristina A. Fernandez, Laura A. McClure, William G. LeBlanc, Kristopher L. Arheart, David J. Lee, University of Miami Miller School of Medicine, Miami, Florida.

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References

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Tables

Return to your place in the textTable 1. State-Specific Prevalence of Smokinga for Older US Adults: Pooled Data From the 1997–2010 National Health Interview Survey
StateNPrevalence, % (95% CI)SERankb
All79,9739.6 (9.3–9.8)0.1 NA
Alabama1,5369.4 (8.1–10.8)0.723
Alaskac735.3 (2.6–10.5)1.91
Arizona1,42910.2 (7.8–13.1)1.332
Arkansas96513.4 (10.3–17.3)1.846
California8,3557.6 (6.9–8.3)0.48
Colorado92710.2 (8.5–12.3)1.032
Connecticut1,0377.5 (6.2–9.1)0.86
District of Columbiac2059.1 (4.6–17.3)3.120
Delaware21811.8 (7.5–17.9)2.644
Florida6,1588.2 (7.2–9.3)0.512
Georgia1,86310.0 (8.5–11.6)0.829
Hawaiic4787.2 (3.6–13.8)2.55
Idaho30910.7 (8.8–13.0)1.135
Illinois3,3519.2 (8.1–10.4)0.621
Indiana1,69713.4 (11.8–15.1)0.946
Iowa8728.3 (6.9–9.9)0.813
Kansas79411.2 (9.0–13.7)1.242
Kentucky1,15115.0 (12.7–17.6)1.350
Louisiana1,18911.0 (9.4–12.7)0.940
Maine45810.0 (6.8–14.5)2.029
Maryland1,25511.5 (9.2–14.2)1.343
Massachusetts1,8479.9 (8.0–12.1)1.027
Michigan2,7779.9 (8.8–11.1)0.627
Minnesota1,2398.8 (7.4–10.3)0.817
Mississippi8309.2 (6.7–12.4)1.421
Missouri1,77110.9 (9.1–13.0)1.038
Montana30613.9 (10.2–18.9)2.249
Nebraska6137.5 (5.6–10.0)1.16
Nevada47417.9 (14.1–22.5)2.151
New Hampshirec32211.1 (5.8–20.2)3.541
New Jersey2,4678.9 (7.8–10.3)0.618
New Mexico76712.2 (8.8–16.7)2.045
New York5,4608.6 (7.8–9.5)0.416
North Carolina2,3039.0 (7.9–10.2)0.619
North Dakota2638.1 (5.9–11.0)1.311
Ohio3,34310.2 (8.9–11.7)0.732
Oklahoma1,03310.9 (8.9–13.2)1.138
Oregon9967.7 (6.3–9.5)0.89
Pennsylvania3,7659.7 (8.6–10.8)0.526
Rhode Islandc2617.0 (3.7–13.0)2.34
South Carolina1,2259.6 (8.7–10.6)0.524
South Dakota2936.2 (3.7–10.2)1.63
Tennessee1,51710.8 (8.6–13.5)1.236
Texas5,19610.8 (9.9–11.8)0.536
Utah5225.4 (3.4–8.4)1.32
Vermont1497.7 (4.9–11.7)1.79
Virginia1,99410.0 (8.6–11.7)0.829
Washington1,4419.6 (7.7–11.9)1.124
West Virginia5798.4 (6.5–10.9)1.114
Wisconsin1,7378.5 (7.1–10.1)0.815
Wyoming16313.7 (9.9–18.6)2.248

Abbreviations: CI, confidence interval; SE, standard error; NA, not applicable.
a Defined as current smoker.
b States with the same ranking indicate identical prevalence estimates; in these instances, the subsequent state skips a number in ranking and continues.
c Prevalence estimate considered statistically unreliable with a relative SE of 30% or more or sample size of fewer than 50 (6).

 

Return to your place in the textTable 2. State-Specific Prevalence of Risky Drinkinga for Older US Adults: Pooled Data From the 1997–2010 National Health Interview Survey
StateNPrevalence, % (95% CI)SERankb
All31,43222.0 (21.4–22.6)0.3NA
Alabama32419.8 (14.8–25.9)2.818
Alaskac<5029.9 (11.8–57.6)12.451
Arizona67729.0 (25.3–32.9)1.949
Arkansas19726.1 (19.3–34.4)3.942
California3,70223.8 (21.9–25.9)1.035
Colorado45321.4 (17.5–25.8)2.126
Connecticut53417.4 (14.5–20.7)1.66
District of Columbiac8120.6 (10.0–37.4)7.022
Delaware11016.9 (12.0–23.4)2.95
Florida2,94724.1 (22.3–25.9)0.938
Georgia49718.5 (14.7–23.0)2.19
Hawaii14527.2 (18.0–38.8)5.345
Idaho11423.0 (13.6–36.1)5.832
Illinois1,36222.6 (19.6–26.0)1.630
Indiana51723.9 (18.7–30.1)2.937
Iowa40322.6 (18.1–27.9)2.530
Kansas26614.4 (9.5–21.3)3.02
Kentucky24118.8 (12.4–27.5)3.813
Louisiana33925.3 (18.9–33.0)3.641
Maine22027.3 (21.7–33.7)3.047
Maryland52720.8 (17.0–25.2)2.124
Massachusetts91723.3 (19.1–28.2)2.334
Michigan1,20922.1 (19.5–24.9)1.428
Minnesota65821.2 (18.3–24.3)1.525
Mississippi16318.5 (12.9–26.0)3.39
Missouri63416.7 (13.2–20.9)2.04
Montana18027.2 (19.1–37.3)4.745
Nebraska26618.6 (15.6–21.9)1.612
Nevada23920.2 (15.2–26.2)2.819
New Hampshire16729.0 (20.7–39.0)4.749
New Jersey1,14418.8 (16.3–21.5)1.313
New Mexico27923.8 (19.5–28.8)2.435
New York2,34120.7 (19.1–22.5)0.923
North Carolina53122.5 (17.5–28.3)2.829
North Dakotac11513.9 (6.2–28.2)5.41
Ohio1,15419.3 (16.8–22.1)1.315
Oklahoma25716.4 (11.7–22.5)2.83
Oregon49126.9 (21.6–32.9)2.944
Pennsylvania1,68218.5 (16.0–21.3)1.49
Rhode Island13124.9 (17.4–34.4)4.440
South Carolina33221.8 (18.1–25.9)2.027
South Dakota10618.2 (11.6–27.5)4.08
Tennessee37419.5 (14.6–25.7)2.816
Texas1,59826.2 (23.6–28.9)1.443
Utah13220.4 (13.7–29.3)4.021
Vermont8620.3 (18.5–22.2)0.920
Virginia66424.6 (20.9–28.7)2.039
Washington72223.0 (19.0–27.5)2.232
West Virginia11319.7 (14.1–27.0)3.317
Wisconsin98817.8 (16.1–19.7)0.97
Wyoming7028.0 (18.8–39.5)5.348

Abbreviations: CI, confidence interval; SE, standard error; NA, not applicable.
a Defined as 10 or more drinks per week in men and 7 or more drinks per week in women, or 5 or more drinks on 1 occasion 1 or more times per year for both men and women.
b States with the same ranking indicate identical prevalence estimates; in these instances, the subsequent state skips a number in ranking and continues.
c Prevalence estimate considered statistically unreliable with a relative SE of 30% or more or sample size of fewer than 50 (6).

 

Return to your place in the textTable 3. State-Specific Prevalence of Meeting Physical Activity Recommendationsa for Older US Adults: Pooled Data From the 1997–2010 National Health Interview Survey
StateNPrevalence, % (95% CI)SERankb
All74,47022.0 (21.6–22.5)0.2 NA
Alabama1,42719.9 (17.1–22.9)1.532
Alaska6220.9 (14.6–29.0)3.729
Arizona1,34027.0 (24.8–29.3)1.18
Arkansas90815.1 (10.4–21.4)2.847
California7,83926.9 (25.4–28.3)0.711
Colorado87630.8 (26.7–35.3)2.23
Connecticut96626.3 (22.0–31.2)2.414
District of Columbia19124.0 (17.5–40.4)4.619
Delaware20627.5 (16.2–34.1)5.97
Florida5,81426.6 (24.2–29.1)1.212
Georgia1,74316.3 (14.3–18.5)1.145
Hawaii45734.8 (27.5–42.9)4.02
Idaho29022.7 (18.6–27.5)2.324
Illinois3,10321.4 (19.6–23.4)1.028
Indiana1,58515.1 (12.8–17.6)1.247
Iowa82025.1 (22.5–28.0)1.415
Kansas74923.5 (19.2–28.4)2.321
Kentucky1,06215.5 (13.1–18.4)1.446
Louisiana1,12013.4 (10.0–17.7)2.050
Maine43640.1 (33.0–47.6)3.71
Maryland1,17622.8 (20.0–25.7)1.523
Massachusetts1,72722.3 (19.2–25.7)1.626
Michigan2,53522.9 (20.6–25.5)1.322
Minnesota1,15327.6 (25.2–30.1)1.36
Mississippi76313.4 (8.8–19.8)2.850
Missouri1,64819.6 (17.2–22.3)1.335
Montana28417.7 (14.2–21.8)2.043
Nebraska57820.5 (14.5–28.2)3.530
Nevada44922.6 (18.1–27.9)2.525
New Hampshire30527.0 (19.7–35.7)4.18
New Jersey2,29318.2 (15.9–20.7)1.238
New Mexico72323.7 (19.3–28.8)2.420
New York4,97019.7 (18.3–21.2)0.734
North Carolina2,20418.7 (16.3–21.3)1.337
North Dakota24619.5 (14.8–25.1)2.636
Ohio3,05117.7 (16.0–19.5)0.943
Oklahoma93718.2 (13.8–23.5)2.538
Oregon87026.4 (22.1–31.3)2.313
Pennsylvania3,43319.9 (18.0–21.5)0.832
Rhode Island24621.6 (16.2–28.2)3.027
South Carolina1,16317.8 (14.5–21.6)1.842
South Dakota27914.6 (9.6–21.7)3.049
Tennessee1,42018.1 (16.0–20.4)1.140
Texas4,91620.3 (18.7–21.9)0.831
Utah49628.5 (23.2–34.4)2.95
Vermont13427.0 (17.7–38.9)5.58
Virginia1,84924.2 (22.0–26.6)1.218
Washington1,33829.8 (26.7–33.0)1.64
West Virginia51917.9 (14.0–22.5)2.241
Wisconsin1,61725.0 (23.0–27.1)1.016
Wyoming15424.9 (16.8–35.3)4.717

Abbreviations: CI, confidence interval; SE, standard error; NA, not applicable.
a Moderate physical activity for at least 30 minutes per day on 5 or more days per week or vigorous physical activity for at least 20 minutes per day on 3 or more days per week.
b States with the same ranking indicate identical prevalence estimates; in these instances, the subsequent state skips a number in ranking and continues.

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