Prevalence of Selected Risk Behaviors and Chronic Diseases and Conditions---Steps Communities, United States, 2006--2007

Stella Cory, MD1

Ann Ussery-Hall, MPH2

Shannon Griffin-Blake, PhD1

Alyssa Easton, PhD1

Justin Vigeant3

Lina Balluz, MPH1

William Garvin1

Kurt Greenlund, PhD1

1Division of Adult and Community Health, National Center for Chronic Disease and Prevention

2Ginn Group, Atlanta, Georgia

3Northrop Grumman, Atlanta, Georgia

Corresponding author: Stella Cory, MD, MPH, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, MS K-93, 4770 Buford Hwy, N.E., Atlanta, GA 30341. Telephone: 770-488-4187; Fax: 770-488-8488; E-mail: spk9@cdc.gov.

Abstract

Problem: At least one chronic disease or condition affects 45% of persons and account for seven of the 10 leading causes of death in the United States. Persons who suffer from chronic diseases and conditions, (e.g., obesity, diabetes, and asthma) experience limitations in function, health, activity, and work, affecting the quality of their lives as well as the lives of their family. Preventable health-risk factors (e.g., insufficient physical activity, poor nutrition, and tobacco use and exposure) contribute substantially to the development and severity of certain chronic diseases and conditions.

Reporting Period Covered: 2006--2007

Description of the System: CDC's Healthy Communities Program funds communities to address chronic diseases and related risk factors through policy, systems, and environmental change strategies. As part of the Healthy Communities Program, 40 Steps communities were funded nationwide to address six focus areas: obesity, diabetes, asthma, physical inactivity, poor nutrition, and tobacco use and exposure. During 2006--2007, 38 and 39 of the 40 communities conducted a survey to collect adult health outcome data. The survey instrument was a modified version of the Behavioral Risk Factor Surveillance System (BRFSS) survey, a state-based, random-digit--dialed telephone survey. The survey instrument collected information on chronic diseases and conditions, health risk behaviors, and preventive health practices related to Steps community outcomes from noninstitutionalized community members aged ≥18 years.

Results: Prevalence estimates of chronic diseases and conditions and risk behaviors varied among Steps communities that reported data for 2006 and 2007. The proportion of the population that achieved Healthy People 2010 (HP 2010) objectives also varied among the communities.

In 2006, the estimated prevalence of respondents aged ≥18 years being overweight or obese as calculated from self-reported weight and height ranged from 51.8% to 73.7%. The nationwide 2006 BRFSS median was 62.3%; a total of 20 communities exceeded this median. In 2007, the estimated prevalence being overweight or obese ranged from 50.5% to 77.2%. The nationwide 2007 BRFSS median was 63.0%; a total of 18 communities exceeded this median.

In 2006, the estimated prevalence of diagnosed diabetes (excluding gestational diabetes) ranged from 3.7% to 19.7%. None of the communities achieved the HP 2010 objective of increasing to 91% the proportion of adults with diabetes who have at least an annual clinical foot examination. Six communities reached the HP 2010 objective of increasing to 76% the proportion of adults with diabetes who have an annual dilated eye examination; 20 communities reached the HP 2010 objective of increasing to 65% the proportion of adults who have a glycosylated hemoglobin measurement (A1c) at least once a year.

In 2007, the estimated prevalence of diagnosed diabetes (excluding gestational diabetes) ranged from 4.4% to 17.9%. None of the communities achieved the HP 2010 objective of increasing to 91% the proportion of adults with diabetes who have at least an annual clinical foot examination, eight communities achieved the HP 2010 objective of increasing to 76% the proportion of adults with diabetes who have an annual dilated eye examination, and 16 communities achieved the HP 2010 objective of increasing to 65% the proportion of adults who have an A1c at least once a year.

In 2006, the prevalence of reported asthma ranged from 6.5% to 18.9%. Among those who reported having asthma, the prevalence of having no symptoms of asthma during the preceding 30 days ranged from 11.5% to 29.5% for five communities with sufficient data for estimates.

In 2007, the estimated prevalence of reported asthma ranged from 7.5% to 18.9%. Among those who reported having asthma, the prevalence of having no symptoms of asthma during the preceding 30 days ranged from 10.3% to 36.1% for 12 communities with sufficient data for estimates.

In 2006, the prevalence of respondents who engaged in moderate physical activity for ≥30 minutes at least five times a week or who reported vigorous physical activity for ≥20 minutes at least three times a week ranged from 42.3% to 59.9%. The prevalence of consumption of fruits and vegetables at least five times/day ranged from 11.1% to 30.2%.

In 2007, the prevalence of moderate or vigorous physical activity ranged from 40.6% to 69.8%; 25 communities reached the HP 2010 objective to increase the proportion of adults who engage in physical activity to 50%. The prevalence of consumption of fruits and vegetables ≥5 times/day ranged from 14.6% to 37.6%.

In 2006, the estimated prevalence among respondents aged >18 years who reported having smoked >100 cigarettes in their lifetime and who were current smokers on every day or some days at the time of the survey ranged from 12.5% to 48.0%. Among smokers, the prevalence of having stopped smoking for ≥1 day because of trying to quit smoking during the previous 12 months ranged from 48.4% to 67.9% for 31 communities. No communities reached the HP 2010 target of increasing to 75% smoking cessation attempts by adult smokers.

In 2007, the estimated prevalence of current smokers ranged from 11.2% to 33.7%. Two communities reached the HP 2010 objective to reduce the proportion of adults who smoke. Among smokers, the prevalence of having stopped smoking for ≥1 day because of trying to quit smoking during the preceding 12 months ranged from 50.8% to 69.6% for 26 communities. No communities reached the HP 2010 objective of increasing to 75% smoking cessation attempts by adult smokers.

Interpretation: The findings in this report indicate variations in health risk behaviors, chronic diseases and conditions, and use of preventive health screenings and health services among Steps communities. These findings underscore the continued need to evaluate prevention interventions at the community level and to design and implement policies to promote and encourage healthy behaviors.

Public Health Action: Steps BRFSS data monitored the prevalence of health behaviors, conditions, and use of preventive health services. CDC (at the national level), and Steps staff at state, local, and tribal levels can use BRFSS data to demonstrate accountability to stakeholders; monitor progress in meeting objectives; focus activities on policy, systems and environmental change strategies with the greatest promise of results; identify collaboration opportunities; and identify and disseminate successes and lessons learned.

Introduction

At least one chronic disease or condition affects 45% of persons (1) and account for seven of the 10 leading causes of death in the United States (2). Chronic diseases and conditions (e.g., heart disease, stroke, diabetes, cancer, obesity, and arthritis) account for >75% of the $2 trillion spent annually on medical care in the United States and cost the economy approximately $1 trillion a year in lost productivity (1). Preventable health-risk factors (e.g., insufficient physical activity, poor nutrition, and tobacco use and exposure) substantially contribute to the development and severity of certain chronic diseases and conditions. In 2007, <50% (3) of adults met the recommended levels for physical activity and only 24% (4) reported eating 5 or more servings of fruits and vegetables/day. In addition, an estimated 20.6% (46 million) of U.S. adults were current cigarette smokers (5).

The Steps program was funded through CDC's Healthy Communities Program to use population-based community-level approaches (e.g., policy, systems, and environmental change strategies) that address multiple determinants of health (6). During 2003--2009, the Healthy Communities Program operated two Steps cooperative agreements that funded 40 communities nationwide. In 2003, CDC's Healthy Communities Program funded 12 awardees representing 24 Steps communities; in 2004, the program funded 10 additional awardees representing 16 communities. Key elements of the CDC's Healthy Communities Program include implementing evidence-based strategies; responding to community needs; reaching diverse population groups; working across multiple sectors (e.g., schools, work sites, health care, and the community); creating nontraditional partnerships; (e.g., media, businesses, transportation, public safety, and planning and development departments), and using policy, systems, and environmental change strategies to affect sustainable, community-level change. All of these elements aim to accelerate positive health changes in communities and reduce chronic diseases and conditions.

Steps communities' efforts supported policies and interventions that focused on six priority areas, comprising three health conditions or diseases (i.e., obesity, diabetes, and asthma) and three related risk behaviors (i.e., physical inactivity, poor nutrition, and tobacco use and exposure). Communities were selected as part of a Request for Funding Announcement (RFA) designed to ensure inclusion of populations disproportionately affected by chronic diseases and associated risk factors; inclusion of geographic areas with high age-adjusted rates of chronic disease and associated risk factors; geographic distribution of communities nationwide; and inclusion of communities of varying sizes, including rural, suburban, and urban communities. Steps sites included small cities and rural communities (with sites coordinated at the state level), large cities and urban communities, and tribal communities. As part of the RFA, grantees participated in the Steps Behavioral Risk Factor Surveillance System (BRFSS) to collect data on health conditions and diseases and on related risk factors at the community level and tracked Steps communities' health outcomes and behaviors over time. This report presents data from the second and third years of funding for the Steps communities as they implemented policies and interventions to address Steps priority chronic diseases and conditions.

Methods

The Steps BRFSS survey instrument is a modified version of the BRFSS state-based survey and includes standardized questions related to the three diseases and outcomes (obesity, diabetes, and asthma) and the three related risk factors (physical inactivity, poor nutrition, and tobacco use and exposure). BRFSS uses a disproportionate stratified sample design to select a representative sample of the civilian, noninstitutionalized population aged ≥18 years. To ensure coordinated efforts and efficient use of resources, most Steps communities used BRFSS infrastructure and capacity already in place at the national, state, and local levels to collect data. The survey instrument included standard 2006 and 2007 BRFSS questions (available at http://www.cdc.gov/brfss/) related to the six priority areas. Data collection procedures or processes varied by community because of each community's particular characteristics. For example, certain Steps communities conducted a stand-alone survey whereas others coordinated data collection with the state or local BRFSS. Certain communities adapted their data collection methods to respond to local cultural needs. For the majority of communities, CDC provided technical assistance, data cleaning, weighting, and analysis of surveillance data.

Questionnaire

The 2006 and 2007 Steps BRFSS questionnaire comprised three parts: 1) core questions, 2) optional supplemental modules containing sets of questions on specific topics (e.g., diabetes, health-related quality of life, and arthritis management), and 3) community-specific questions. The questionnaires asked core and optional questions related to risk factors associated with obesity, diabetes, and asthma and the accompanying underlying risk factors of physical inactivity, poor nutrition, and tobacco use and exposure. Questions from the following Core Sections of the 2006 and 2007 BRFSS National Survey were used: Healthy Days, Health Care Access, Diabetes, Asthma, Tobacco Use, Demographics, Fruit and Vegetable Consumption, and Physical Activity. In addition, certain questions from the following optional modules were part of the survey: Diabetes Self Management, Adult Asthma History, and Smoking Cessation. Additional information regarding the national BRFSS standard questions is available at http://www.cdc.gov/brfss/ questionnaires.

Data Collection and Processing

Thirty eight communities collected data in 2006 and 39 communities collected data in 2007* using trained interviewers to administer the survey via computer-assisted telephone interviewing (CATI) system. In 2006, a total of 29 communities submitted their data to CDC for data reliability checks and preparation for analyses, and nine communities conducted analysis at the local level, of which seven sent weighted data to CDC's Healthy Communities Program. Among the tasks included in data reliability checks, CDC validates responses based on expected values for categorical variables. In addition, CDC checks the reliability of the disposition code assigned by the community. However, a record marked as complete might not have enough data according to CDC standards and will need to be reassigned as an incomplete record. For each community, data were collected either monthly or over a fixed period as a point in time.

Data Weighting and Analysis

Upon completion of data collection, communities submitted their data to CDC, which edited and aggregated the data files to create a sample for each community. For this analysis, each sample was weighted to the respondent's probability of selection and to the age- and sex-specific population or age-, sex-, and race-specific population data using current population estimates provided by the community or 2006 and 2007 intercensal estimates provided by Claritas, Inc., a private data vendor that uses census projections to develop yearly population estimates. These sampling weights were then used to calculate community-level prevalence estimates. Detailed weighting and analytic methodologies used for BRFSS have been reported previously (7).

Statistical Analyses

SAS(r) (release 9.1.3) and SUDAAN(r) 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 for selected communities were reported as "not available" if the unweighted sample size for the denominator was <50 or the confidence interval half width was >10. Because those data are not included in this report and certain communities did not measure every indicator, the number of communities represented varies in 2006 (range: 5--38), and in 2007(range: 12--38).

Data Presented

Because of the slightly different methodologies, populations of interest, and primary goal of Steps projects, this report presents yearly data for Steps communities. Given the early stages of Steps, rather than compare with nonintervention communities, Healthy People 2010 (HP 2010) goals were used as a benchmark. HP 2010 objectives were analyzed separately for each year so that communities could continue to track their progress. The tables in this report contain the weighted percentage, sample size, standard error, and CIs. Data for the communities that conducted their own data analysis are reported without standard errors. Standard errors are reported for the five communities that conducted their own data analysis and sent their data to CDC to produce estimates from the weighted data set that they provided. When BRFSS data and HP 2010 objective statements were comparable, nationwide BRFSS median prevalence estimates and HP 2010 targets are presented (10--12). For several questions, comparative HP 2010 goals are not presented because BRFSS data definitions are not comparable to the HP 2010 definitions.

Results

Overweight and Obesity

Prevalence of Overweight and Obesity Among Adults Aged ≥18 Years

Self-reported weight and height were used to calculate body mass index (BMI) (weight[kg]/height [m]). Being overweight or obese was defined as having a BMI of ≥25.0 kg/m2; obesity alone was classified as BMI of ≥30.0 kg/ m2.

In 2006, the estimated prevalence of respondents aged ≥18 years being overweight or obese ranged from 51.8% (95% CI = 46.9--56.8) in Teller, Colorado, to 73.7% (95% CI = 69.4--78.0) in SouthEast Alaska Regional Health Consortium, Alaska (median: 62.6) (Table 1). The nationwide 2006 BRFSS median was 62.3%; 20 communities exceeded this median.

In 2007, the estimated prevalence among respondents aged ≥18 years who had a BMI ≥25.0 kg/m² ranged from 50.5% (95% CI = 45.6--55.4) in Teller County, Colorado, to 77.2% (95% CI = 71.5--83.0) in Inter-Tribal Council, Michigan (median: 63.2%) (Table 2). The 2007 nationwide BRFSS median was 63.0%; 18 communities exceeded this median.

Prevalence of Obesity Among Adults Aged ≥18 Years

In 2006, the estimated prevalence of obesity (BMI ≥30.0 kg/m2) among respondents aged ≥18 years ranged from 14.6% (95% CI = 11.2--18.0) in Teller County, Colorado, to 38.3% (95% CI = 32.3--44.2) in Inter-Tribal Council, Michigan (median: 24.8%) (Table 3). The 2006 nationwide BRFSS median was 25.1%; 17 communities exceeded this median. One community (Teller County, Colorado) achieved the HP 2010 objective† of reducing to 15% the proportion of adults who are obese (objective 19.2).

In 2007, the estimated prevalence of adults who were obese ranged from 16.6% (95% CI = 13.1--20.1) in Teller County, Colorado, to 41.0% (95% CI = 34.0--47.9) in Inter-Tribal Council, Michigan (median: 25.4%) (Table 4). The 2007 nationwide BRFSS median was 26.3%; 17 communities exceeded this median. No communities reached the HP 2010 objective.

Diabetes

Overall Rate of Diabetes Among Adults Aged ≥18 Years

In 2006, the estimated prevalence of respondents aged ≥18 years who reported ever having been told by a doctor that they have diabetes (other than during pregnancy) ranged from 3.7% (95% CI = 2.2--5.1) in Teller, Colorado, to 19.7% (95% CI = 15.1--24.3) in Inter-Tribal Council, Michigan (median: 7.6%) (Table 5). The nationwide 2006 BRFSS median was 7.5%; 19 communities exceeded this median.

In 2007, the estimated prevalence of adults who reported ever having been told by a doctor that they had diabetes (other than during pregnancy) ranged from 4.4% (95% CI = 3.3--5.5) in Minneapolis, Minnesota, to 17.9% (95% CI = 12.5--23.2) in Inter-Tribal Council, Michigan (median: 8.2%) (Table 6). The nationwide 2007 BRFSS median was 8.1%; 19 communities exceeded this median.

Clinical Foot Examination Among Adults Aged ≥18 Years with Diabetes

In 2006, among adults in 27 Steps communities who were ever told by a doctor that they have diabetes (excluding women who were pregnant), the estimated prevalence who reported having a clinical foot examination during the preceding 12 months ranged from 68.2% (95% CI = 61.4--74.9) in San Antonio-Bexar County, Texas, to 89.3% (95% CI = 82.8--95.7) in Willmar, Minnesota (median: 77.4%) (Table 7). The nationwide BRFSS median was 71.6%; 27 communities exceeded this median. No Steps communities achieved the HP 2010 objective of increasing to 91% the proportion of adults with diabetes who have at least an annual clinical foot examination (objective 5-14).

In 2007, among adults with diabetes in 26 communities, the estimated prevalence who reported having a clinical foot examination during the preceding 12 months ranged from 51.1% (95% CI = 41.9--60.4) in Santa Clara County, California, to 83.5% (95% CI = 75.9--91.1) in Minneapolis, Minnesota (median: 77.1%) (Table 8). The nationwide BRFSS median was 73.2%; 19 communities exceeded this median. No communities achieved the HP 2010 objective.

Dilated Eye Examination Among Adults Aged ≥18 Years with Diabetes

In 2006, among adults with diabetes aged ≥18 years in 22 Steps communities, the estimated prevalence who reported having received a dilated eye examination during the preceding 12 months ranged from 63.2% (95% CI = 54.3--72.1) in Cherokee Nation, Oklahoma, to 84.4% (95% CI = 78.7--90.1) in Cleveland, Ohio (median: 72.55%) (Table 9). The nationwide BRFSS median was 70.9%; 11 communities exceeded this median. Six Steps communities achieved the HP 2010 objective of increasing to 76% the proportion of adults with diabetes who have an annual dilated eye examination (objective 5-13).

In 2007, among 26 Steps communities, the estimated prevalence of adults with diabetes who received a dilated eye examination during the preceding 12 months ranged from 60.3% (95% CI = 51.5--69.1) in Cherokee Nation, Oklahoma, to 85.4% (95% CI = 78.5--92.3) in Rochester, Minnesota (median: 72.9%) (Table 10). The nationwide BRFSS median was 71.3%; 16 communities exceeded this median. Eight communities achieved the HP 2010 objective.

Glycosylated Hemoglobin Measurement at Least Once a Year Among Adults Aged ≥18 Years with Diabetes

In 2006, among adults with diabetes aged ≥18 years in 23 Steps communities, the estimated prevalence who reported having received a glycosylated hemoglobin measurement (A1c) at least once a year ranged from 62.5% (95% CI = 53.5--71.4) in Hillsborough, Florida, to 85.1% (95% CI = 76.7--93.5) in Rockland, New York (median: 70.7%) (Table 11). The nationwide BRFSS median was 66.3%; 17 communities exceeded this median. Twenty Steps communities achieved the HP 2010 objective of increasing to 65% the proportion of adults with diabetes who have an A1c at least once a year (objective 5-12).

In 2007, among adults with diabetes in 22 communities, the estimated prevalence who reported having received an A1c at least once a year ranged from 54.5% (95% CI = 46.7--62.2) in San Antonio, Texas, to 90.4% (95% CI = 85.6--95.2) in Boston, Massachusetts (median: 69.9%) (Table 12). The nationwide BRFSS median was 66.3%; 16 communities exceeded this median. Sixteen communities achieved the HP 2010 objective.

Self Blood-Glucose Monitoring Among Adults Aged ≥18 Years with Diabetes

In 2006, among adults with diabetes aged ≥18 years in 19 Steps communities, the estimated prevalence who reported self-blood glucose monitoring at least 2 times daily ranged from 24.8% (95% CI = 17.7--31.9) in St. Petersburg-Pinellas County, Florida, to 51.6% (95% CI = 42.0--61.1) in Broome County, New York (median: 43.5%) (Table 13). The nationwide BRFSS median was 38.8%; 11 communities exceeded this median.

In 2007, among adults with diabetes in 23 communities, the estimated prevalence who reported self-blood glucose monitoring at least 2 times daily ranged from 28.9% (95% CI = 20.9--36.9) in Santa Clara County, California, to 53.3% (95% CI = 43.4--63.1) in Rockland County, New York (median: 41.4%) (Table 14). The nationwide BRFSS median was 38.6%; 16 communities exceeded this median.

Self-Foot Examination Among Adults Aged ≥18 Years with Diabetes

In 2006, among adults aged ≥18 years with diabetes in 21 Steps communities, the estimated prevalence who reported checking their feet at least one time daily for any sore or irritations ranged from 57.5% (95% CI = 47.6--67.5) in Minneapolis, Minnesota, to 88% (95% CI = 81.6--94.5) in Austin-Travis County, Texas (median: 69.3%) (Table 15). The nationwide BRFSS median was 68.8%; 11 communities exceeded this median.

In 2007, among adults with diabetes in 22 communities, the estimated prevalence who reported checking their feet at least once daily for any sores or irritations ranged from 59.2% (95% CI = 49.7--68.8) in Jefferson County, New York, to 80.6% (95% CI = 75.4--85.7) in Cherokee Nation, Oklahoma (median: 68.5%) (Table 16). The nationwide BRFSS median was 69.1%; nine communities exceeded this median.

Asthma

Told by Health Professional that they had Asthma Among Adults Aged ≥18 Years

In 2006, the estimated prevalence among respondents aged ≥18 years who reported being told by a health professional that they have asthma ranged from 6.5% (95% CI = 3.2--9.8) in Santa Cruz County, Arizona, to 18.9% (95% CI = 16.0--21.9) in Philadelphia, Pennsylvania (median: 13.1%) (Table 17). The nationwide 2006 BRFSS median was 13.0%; 19 communities exceeded this median.

In 2007, the estimated prevalence of reported asthma in the Steps communities ranged from 7.5% (CI = 4.7--10.2) in Santa Cruz County, Arizona, to 18.9% (95% CI = 16.1--21.7) in Cleveland, Ohio (Table 18). The nationwide 2007 BRFSS median was 13.0%; 18 communities exceeded this median.

Symptom-Free Days Among Adults Aged ≥18 Years with Asthma

In 2006, among five steps communities, of those adults with asthma who reported having had an episode of asthma or asthma attack during the preceding 12 months, the estimated prevalence with no symptoms of asthma during the preceding 30 days ranged from 11.5% (95% CI = 6.4--16.6) in Cherokee Nation, Oklahoma, to 29.5% (95% CI = 20.8--38.1) in Jefferson County, New York. Among five communities, the median was 25.6% (Table 19). The nationwide BRFSS median was 26.2%; one community exceeded this median.

In 2007, among 12 Steps communities, of those adults with asthma who reported having had an episode of asthma or an asthma attack during the preceding 12 months, the estimated prevalence who reported having no symptoms during the preceding 30 days ranged from 10.3% (95% CI = 4.8--15.7) in Cherokee Nation, Oklahoma, to 36.1% (95% CI = 26.7--45.4) in DeKalb County, Georgia. Among 12 communities, the median was 21.5% (Table 20). The nationwide BRFSS median was 27.1%; two communities exceeded this median.

Physical Activity

Recommended Physical Activity Among Adults Aged ≥18 Years

In 2006, among 22 Steps communities, the estimated prevalence among adults who reported engaging in moderate physical activity for ≥30 minutes at least five times/week or who reported vigorous physical activity for ≥20 minutes at least three times/week ranged from 42.3% (95% CI = 37.5--47.1) in Cherokee Nation, Oklahoma, to 59.9% (95% CI = 55.2--64.7) in SouthEast Alaska Regional Health Consortium, Alaska. Among these 22 communities, the median was 52.4% (Table 21). Seventeen Steps communities achieved the HP 2010 objective of increasing to 50% the proportion of adults engaging in moderate or vigorous physical activity (objective 22-02)

In 2007, the estimated prevalence of adults who reported moderate or vigorous physical activity ranged from 40.6% (95% CI = 36.3--44.8) in Southeast Alabama, to 69.8% (95% CI = 62.4--77.2) in Inter-Tribal Council, Michigan (median: 51.5%) (Table 22). The nationwide 2007 BRFSS median was 49.2%; 26 communities exceeded this median. A total of 25 Steps communities achieved the HP 2010 objective.

Fruits and Vegetables

Fruit and Vegetable Consumption Among Adults Aged ≥18 Years

In 2006, among 22 Steps communities, the percentage of respondents aged ≥18 years who reported eating at least five fruits and vegetables/day ranged from 11.1% (95% CI = 8.0--14.2) in Inter-Tribal Council, Michigan, to 30.2 (95% CI = 27.6--32.8) in St. Paul-Ramsey County, Minnesota (median: 26.4%) (Table 23)§.

In 2007, the estimated prevalence among respondents aged ≥18 years who reported eating fruits and vegetables ≥5 times/day ranged from 14.6% (95% CI = 2.3--16.9) in Cherokee Nation, Oklahoma, to 37.6% (95% CI = 34.3--40.9) in Salinas-Monterey County, California (median: 26.4%) (Table 24). The nationwide 2007 BRFSS median was 24.3%; 25 communities exceeded this median.

Tobacco Use

Cigarette Smoking Among Adults Aged ≥18 Years

In 2006, among 37 Steps communities, the estimated prevalence of respondents aged ≥18 years who reported having smoked 100 cigarettes in their lifetime and were current smokers on every day or certain days ranged from 12.5% (95% CI = 10.4--14.7) in Rochester-Olmstead County, Minnesota, to 48.0% (95% CI = 27.0--69.6) in Colville Confederated Tribes, Washington (median: 19.6%) (Table 25). The nationwide 2006 BRFSS median was 20.1; 18 communities exceeded this median. No Steps community achieved the HP 2010 objective of reducing to 12% the proportion of adults who smoke cigarettes (objective 27-1a).

In 2007, the estimated prevalence of adult current smokers ranged from 11.2% (95% CI = 9.0--13.4) in Rockland County, New York, to 33.7% (95% CI = 30.3--37.0) in Cleveland, Ohio (median: 21.1%) (Table 26). The nationwide 2007 BRFSS median was 19.7%; 21 communities exceeded this median. Two Steps communities achieved the HP 2010 objective.

Tobacco Use Cessation Attempts by Adult Smokers Aged ≥18 Years

In 2006, among adult smokers in 31 Steps communities, the estimated prevalence of who reported having stopped smoking for one day or longer because they were trying to quit smoking during the preceding 12 months ranged from 48.4% (95% CI = 42.2--54.5) in St. Petersburg-Pinellas County, Florida, to 67.9% (95% CI = 59.3--76.5) in Austin-Travis County, Texas (median: 58.4%) (Table 27). No Steps communities achieved the HP 2010 objective of increasing to 75% smoking cessation attempts by adult smokers (objective 27-5).

In 2007, among adult smokers in 26 communities, the estimated prevalence of smokers who reported having stopped smoking for one day or longer during the preceding 12 months because they were trying to quit smoking ranged from 50.8% (95% CI = 43.4--58.2) in Chautauqua County, New York, to 69.6% (95% CI = 62.2--77.1) in Pueblo County, Colorado (median: 55.4%) (Table 28). The nationwide BRFSS median was 57.6%; eight communities exceeded this median. No communities achieved the HP 2010 objective.

Discussion

CDC's Healthy Communities Program responds to community needs and works to affect change at the population level using community-based approaches that include policy, systems, and environmental change. As part of the Healthy Communities Program, Steps communities were funded across the country to demonstrate how local initiatives across sectors (e.g., schools, work sites, health care, and the community) in collaboration with traditional and nontraditional partners (e.g., media, businesses, transportation, public safety, and departments of planning and development) can impact the burden of chronic diseases and conditions (e.g., obesity, diabetes, and asthma), and the underlying risk factors of physical inactivity, poor nutrition, and tobacco use and exposure. For example, approximately 100 work site interventions, advancing policy, systems, and environmental changes were implemented, including implementation of health risk assessments and policies promoting increased access to nutritious foods in vending machines and at meetings. Other strategies used in work sites included development of smoke-free policies and onsite space for exercise. By focusing on joining resources and perspectives of a wide range of sectors and entities dedicated to collaboration for health improvement, the Healthy Communities Program draws on common interests and accelerates progress toward health promotion efforts. Such efforts create measurable improvements in the health of Steps communities through the selection, implementation, and evaluation of interventions promoting policy, systems, and environmental change. For example, the Steps Program in Austin, Texas, partnered with Capital Metro, the Austin transit authority, to implement a worksite wellness program. As a result of worksite wellness program implementation, the Capital Metro has experienced substantial reductions in its health care costs.

The findings in this report indicate variations in the estimated prevalence of chronic diseases and conditions, health-risk behaviors, and use of preventive screening practices across Steps communities. In 2006, six communities achieved the HP 2010 objective of increasing to 76% the proportion of adults with diabetes who have an annual dilated eye examination; eight communities achieved the objective in 2007. In 2006, a total of 20 communities achieved the HP 2010 objective of increasing to 65% the proportion of adults who have an A1c at least once a year; 16 communities achieved the objective in 2007. In 2006, no Steps community achieved the HP 2010 objective of reducing to 12% the proportion of adults who smoke; two communities achieved the objective in 2007. In 2006, a total of 17 communities achieved the HP 2010 objective of increasing to 50% the proportion of adults who engage in moderate physical activity ≥30 minutes/day at least 5 days a week, or vigorous physical activity ≥20 minutes/day at least 3 days a week; 25 communities achieved the objective in 2007. In 2006, one community achieved the HP 2010 objective of reducing to 15% the proportion of adults who are obese; no communities achieved this objective in 2007. No communities achieved the HP 2010 objective of increasing to 75% smoking cessation attempts by adult smokers in 2006 or 2007. In 2007, no communities achieved the HP 2010 objective of increasing to 91% the proportion of adults with diabetes who have at least an annual clinical foot examination.

The direct estimates might be different from those using similar geographic units but based on other small area analysis methods (12). For example, estimates of diabetes and obesity presented here might be slightly different from those using small area analysis methods. Steps communities will need to continue to monitor data and continue to focus on improving health to achieve and maintain these improvements.

Steps communities' use of BRFSS questions for community-specific surveys permits useful collection of data at the local level. Data presented in this report indicate that prevalence rates of important chronic disease indicators vary widely among the communities. This variability might reflect differences in state and local laws and policies, enforcement practices, availability of effective community policies and interventions, prevailing behavioral and social norms, demographic and adult practices, characteristics of the population, and other social determinants of health.

Collection of Steps BRFSS data will provide trend estimates that will enable community-to-community, nationwide, and HP 2010 comparisons. These data also will provide useful information for decision making at the community, district, and state levels and guide local health officials and decision makers in intervention planning and evaluation. CDC staff and other public health and education practitioners can use these data to assess changes in these behaviors over time and assist in evaluating the effectiveness of Steps communities' interventions. An examination of the variations among communities can identify which ones would benefit from additional technical assistance related to effective community policies and interventions. Differences also can alert community representatives to the opportunity to learn from each other by taking advantage of the national Steps network. Communities can use these data to identify, prioritize, and develop community-specific activities to address obesity, diabetes, and asthma by increasing physical activity, encouraging healthy eating, and reducing tobacco use and exposure.

Limitations

The findings in this report are subject to at least five limitations. First, the Steps BRFSS survey is a telephone-based survey, which only queries persons with landline telephone access. Differences might exist in the characteristics of persons who reside in households with telephones compared with those without telephone access or those households that use cell phones only. Therefore, the data might not be generalizable to persons who reside in households without landline telephones. Second, prevalence estimates are self-reported and, for certain behaviors, the reported estimates might be subject to recall and social desirability biases. Third, each Steps community has the option to administer its own data collection method, which might preclude standardization in certain cases. Fourth, the number of interviews ranged from 464 to 2,934. Therefore, estimates for certain communities are based on small sample sizes, and for relatively rare events might yield unstable estimates. Fifth, Steps BRFSS does not collect information from institutionalized persons, thereby excluding persons residing in nursing homes, long-term care, and correctional facilities.

BRFSS offers important benefits for making community-to-community comparisons because of its standardized questionnaire and data collection. BRFSS provides data to guide additional analysis on selected risk factors. The information is invaluable for assisting local health officials in intervention planning and evaluation.

Conclusion

Steps BRFSS data collected in the communities will be used to examine whether the Steps communities made progress on intended health outcomes in the selected intervention areas. BRFSS is a unique surveillance tool that demonstrates its usefulness at gathering comparable state-specific and local area health behavioral data, monitoring health risk behaviors over time, and supporting focused prevention interventions. Steps staff at the national, state, local, and tribal levels will use these data for decision-making, planning, and enhancing technical assistance. CDC's Healthy Communities Program, through Steps and other community funding models, strives toward achieving the established HP 2010 objectives by using BRFSS data to enhance existing program activities, focus efforts on activities with the greatest promise of results, identify opportunities for strategic collaboration, and disseminate lessons learned.

References

1. Partnership to Fight Chronic Disease (PFCD). Almanac of chronic disease, 2008 edition. Available at http://www.fightchronicdisease.org. Accessed January 28, 2010.
2. Heron M, Hoyert D, Murphy S, et al. Deaths: final data for 2006. Natl Vital Stat Rep 2009;57(14). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf. Accessed January 8, 2010.
3. Behavior Risk Factor Surveillance System. Prevalence and trends data, nationwide---2007 physical activity. Available at http://apps.nccd.cdc.gov/brfss/display.asp?cat=&yr=2007&qkey=4418&state=US. Accessed January 8, 2010.
4. Behavior Risk Factor Surveillance System. Prevalence and trends data, nationwide---2007 fruits and vegetables. Available at http://apps.nccd.cdc.gov/brfss/display.asp?cat=&yr=2007&qkey=4415&state=. Accessed January 8, 2010.
5. CDC. Cigarette smoking among adults and trends in smoking cessation---United States, 2008. MMWR 2009; 58:1227--32.
6. CDC Healthy communities program. Available at http://www.cdc.gov/healthycommunitiesprogram. Accessed January 8, 2010.
7. CDC. Behavioral Risk Factor Surveillance System operational and user's guide, version 3.0. Atlanta, GA: US Department of Health and Human Services, CDC; 2004.
8. SAS Institute, Inc. SAS(r) version 8.02 [software and documentation]. Cary, NC: SAS Institute; 2001.
9. Research Triangle Institute. SUDAAN(r), version 9 [software and documentation]. Triangle Park, NC: Research Triangle Institute; 2004.
10. US Department of Health and Human Services. Healthy people 2010: national health promotion and disease prevention objective---full report, with commentary. Washington, DC: US Department of Health and Human Services, US Public Health Service; 2000. Available at http://www.cdc.gov/nchs/about/otgeract/hpdata2010/abouthp.htm. Accessed January 8, 2010.
11. CDC Wonder. The healthy people 2010 database. Available at http://wonder.cdc.gov/data2010. Accessed January 14, 2010.
12. Demeny P, McNicoll G, eds. Encyclopedia of Population. Farmington Hills, MI: Macmillan Reference; 2003:898--901.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.