Surveillance of Certain Health Behaviors and Conditions Among States and Selected Local Areas --- Behavioral Risk Factor Surveillance System, United States, 2009

Chaoyang Li, MD, PhD

Lina S. Balluz, ScD

Catherine A. Okoro, MS

Tara W. Strine, PhD

Jin-Mann S. Lin, PhD

Machell Town, MS

William Garvin

Wilmon Murphy

William Bartoli

Balarami Valluru, MS

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

Corresponding author: Lina Balluz, ScD, Division of Behavioral Surveillance, Public Health Surveillance Programs Office, Office of Surveillance, Epidemiology, and Laboratory Sciences, CDC. 1600 Clifton Road, N.E., MS E-97, Atlanta, GA 30333. Telephone: 404-498-0496; Fax: 404-498-0585; E-mail: lballuz@cdc.gov.

Abstract

Problem: Chronic diseases and conditions (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors and conditions (e.g., smoking, physical inactivity, poor diet, excessive drinking, and obesity) and using preventive health-care services (e.g., physical examination, vaccination, screening for high blood pressure and high cholesterol, consumption of fruits and vegetables, and participation in regular leisure-time physical activity) can reduce morbidity and mortality from chronic diseases.

Reporting Period: January 2009--December 2009.

Description of the System: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based random-digit--dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors and conditions, chronic diseases and conditions, access to health care, and use of preventative health services and practices related to the leading causes of death and disabilities in the United States. This report presents results for 2009 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 180 metropolitan and micropolitan statistical areas (MMSAs), and 283 selected counties.

Results: In 2009, the estimated prevalence of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairments and disabilities varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topics. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior, as reported by the survey respondent. Adults who reported having fair or poor health: 10.1%--30.9% for states and territories, 7.9%--25.8% for MMSAs, and 4.5%--26.1% for counties. Adults with health-care coverage: 71.4%--94.7% for states and territories, 52.7%--96.3% for MMSAs, and 52.7%--97.6% for counties. Annual routine physical checkup among adults aged ≥18 years: 55.8%--79.3% for states and territories, 51.8%--80.7% for MMSAs, and 49.2%--83.5% for counties. Annual influenza vaccination among adults aged ≥65 years: 26.8%--76.8% for states and territories, 55.4%--81.4% for MMSAs, and 50.5%--83.5% for counties. Pneumococcal vaccination among adults aged ≥65 years: 19.1%--73.9% for states and territories, 52.9%--81.3% for MMSAs, and 41.9%--82.0% for counties. Adults who had their cholesterol checked within the preceding 5 years: 67.5%--85.3% for states and territories, 58.2%--88.8% for MMSAs, and 58.2%--92.4% for counties. Adults who consumed at least five servings of fruits and vegetables per day: 14.6%--31.5% for states and territories, 12.6%--33.0% for MMSAs, and 13.4%--34.9% for counties. Adults who engaged in moderate or vigorous physical activity: 28.0%--60.7% for states and territories, 34.6%--64.9% for MMSAs, and 33.6%--67.3% for counties. Adults who engaged in only vigorous physical activity: 13.7%--40.1% for states and territories, 13.8%--43.3% for MMSAs, and 14.2%--50.0% for counties. Current cigarette smoking among adults: 6.4%--25.6% for states and territories, 5.7%--29.0% for MMSAs, and 5.6%--29.8% for counties. Binge drinking among adults: 6.8%--23.9% for states and territories, 3.5%--23.2% for MMSAs, and 3.4%--26.3% for counties. Heavy drinking among adults: 1.9%--8.1% for states and territories, 1.0%--11.1% for MMSAs, and 0.9%--11.1% for counties. Adults who reported no leisure-time physical activity: 15.8%--45.6% for states and territories, 13.3%--40.2% for MMSAs, and 10.5%--40.2% for counties. Adults aged ≥18 years who were overweight: 31.6%--38.7% for states and territories, 28.7%--44.1% for MMSAs, and 25.6%--46.7% for counties. Adults aged ≥20 years who were obese: 19.7%--36.0% for states and territories, 15.4%--43.6% for MMSAs, and 13.8%--45.7% for counties. Adults aged ≥18 years who did not get enough rest or sleep: 34.3%--52.6% for states and territories, 28.2%--54.8% for MMSAs, and 24.5%--55.6% for counties. Adults who had received a high blood pressure diagnosis: 22.1%--38.5% for states and territories, 18.8%--43.9% for MMSAs, and 17.2%--43.6% for counties. Adults who had a high blood cholesterol diagnosis: 24.9%--42.2% for states and territories, 27.5%--47.8% for MMSAs, and 26.7%--51.4% for counties. Adults who had received a diagnosis of coronary heart disease: 2.5%--10.3% for states and territories, 2.6%--11.6% for MMSAs, and 1.6%--12.3% for counties. Adults who had received a stroke diagnosis: 1.4%--3.9% for states and territories, 0.8%--5.9% for MMSAs, and 0.8%--6.6% for counties. Adults who had received a diabetes diagnosis: 5.8%--12.9% for states and territories, 2.8%--15.4% for MMSAs, and 2.8%--14.7% for counties. Adults who had received a cancer diagnosis: 3.0%--12.6% for states and territories, 5.8%--15.1% for MMSAs, and 3.9%--16.2% for counties. Adults who had asthma: 4.4%--11.1% for states and territories, and 3.2%--15.3% for MMSAs, and 3.2%--15.7% for counties. Adults who had arthritis: 10.7%--35.6% for states and territories, 16.2%--36.0% for MMSAs, and 12.6%--39.4% for counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10.2%--27.1% for states and territories, 13.1%--33.7% for MMSAs, and 10.4%--36.1% for counties. Adults who required special equipment because of health problems: 3.6%--10.2% for states and territories, 3.4%--11.5% for MMSAs, and 1.7%--13.0% for counties.

Interpretation: The findings in this report indicate substantial variations in self-rated general health status, health-care coverage, use of preventive health-care services, health risk behaviors and health conditions, cardiovascular conditions, other chronic diseases, and health impairments and disabilities among U.S. adults at the state and territory, MMSA, and county levels. The findings show that Healthy People 2010 objectives had not been met in many areas by 2009, which underscores the continued need for surveillance of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairment and disability.

Public Health Action: Data on health risk behaviors, chronic health conditions, preventive care practices, and chronic diseases are used to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels.. The overarching goals of Healthy People 2010 are to increase quality and years of healthy life and to eliminate health disparities. Local and state health departments and federal agencies should continue to use BRFSS data to identify populations at high risk for certain health risk behaviors and conditions, cardiovascular conditions, and other chronic diseases and to evaluate the use of preventive health-care services. In addition, BRFSS data can be 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 and conditions (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of morbidity and mortality in the United States (1,2). Engaging in healthy behaviors (e.g., reducing smoking, being more physically active, and eating a healthy and nutritious diet) and using preventive health-care services (e.g., screening for blood pressure, blood cholesterol, and cancer; and receiving recommended vaccinations) can reduce morbidity and premature mortality from chronic disease (3). The estimated prevalence of health behavior risk factors, chronic diseases and conditions, and use of preventive care services varies substantially across the United States (4,5).

Ongoing surveillance is essential to identify populations at the highest risk and to design and implement appropriate public health programs and policies.

Healthy People 2010 (HP 2010) set national objectives to prevent or delay diseases, decrease morbidity and mortality, and improve health-related quality of life for all U.S. residents (6). HP 2010 includes specific objectives that were to be achieved by 2010 for various modifiable risk factors and preventive health-care 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 2009 BRFSS data and certain HP 2010 objectives.

Methods

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing random-digit--dialed state-based telephone survey of noninstitutionalized adults aged ≥18 years that has been conducted since 1984 by state and territorial health departments with assistance from CDC. BRFSS is the largest continuously conducted telephone survey in the world with >400,000 adult interviews completed each year. 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 previously (2,7).

Since 2007, BRFSS has been conducted in all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands. BRFSS is the main source of data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease and injury in the United States. 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 has facilitated calculation of prevalence estimates for selected metropolitan and micropolitan statistical areas (MMSAs), metropolitan divisions, and certain counties. This report provides comparable prevalence estimates for selected risk behaviors, preventive health-care services, and chronic conditions by states and territories, MMSAs, and counties.

Questionnaire

The standard BRFSS questionnaire consists of three parts: 1) core questions, 2) optional supplemental modules, which are sets of questions on specific topics; and 3) state-added questions. All 54 jurisdictions ask the same core questions. Optional modules and jurisdiction-added questions are included at the jurisdiction's discretion to address specific health-care concerns. The core questions address demographics, general health status, number of healthy days, health-related quality of life, health-care access, exercise or leisure-time physical activity, prevalence of cardiovascular diseases, high blood pressure, cholesterol awareness, diabetes, cancer, arthritis, asthma, disabilities, immunization including flu and pneumonia vaccination among older adults, tobacco/cigarette use, alcohol consumption, fruit and vegetable consumption, moderate and vigorous physical activity, sleep habits, caregiver status, being tested for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and emotional support and life satisfaction.

In 2009, the following optional modules were included in BRFSS: prediabetes (35 states), diabetes (38 states), visual impairment (three states), inadequate sleep (six states), cardiovascular health (14 states), actions to control high blood pressure (19 states), heart attack and stroke (19 states), women's health (four states), prostate cancer screening (two states), colorectal cancer screening (two states), cancer survivorship (four states), adult asthma history (two states), arthritis management (eight states), tetanus diphtheria (five states), adult human papilloma virus (two states), shingles vaccination (five states), general preparedness (one state), reaction to race (two states), mental illness and stigma (eight states), carbon monoxide detectors and gas-powered generators (one state), social context (eight states), adverse childhood experience (two states), random child selection (35 states), childhood asthma prevalence (31 states), childhood immunization (nine states), child human papilloma virus vaccination (five states), and tetanus diphtheria vaccination (adolescents) (five states). Details about the contents for the modules can be found in the 2009 BRFSS questionnaire.

To address the most significant and common public health issues closely related to the HP 2010 objectives and sustain consistency with previous reports, this report focuses on 1) health status indicators (self-rated fair or poor health and health-care coverage), 2) preventive health-care practices (recent routine physical checkup, influenza and pneumococcal vaccinations for persons aged ≥65 years, blood cholesterol checking in the preceding 5 years, consumption of at least five servings of vegetables and fruits per day, and participation in moderate or vigorous leisure-time physical activity), 3) health risk behaviors and health conditions (current cigarette smoking, binge and heavy drinking, no leisure-time physical activity participation, overweight, obesity, and insufficient rest or sleep), 4) cardiovascular conditions (high blood pressure, high cholesterol, coronary heart disease including heart attack, angina, and stroke), 5) other chronic diseases (diabetes, cancer, current asthma, and arthritis), and 6) health impairments and disabilities (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 2009 and all other BRFSS questionnaires are available at http://www.cdc.gov/brfss/questionnaires/pdf-ques/2009brfss.pdf.

Data Collection, Processing, and Cooperation Rate

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 editing, processing, weighting, reliability checks, and analysis. According to the guidelines of the Council of American Survey and Research Organizations (CASRO), the 2009 BRFSS cooperation rate (defined as the proportion of all respondents interviewed of all eligible units in which a respondent was selected and actually contacted) ranged from 55.0% in California to 88.0% in Kentucky (median: 75.0%), and the 2009 BRFSS response rate ranged from 37.9% in Oregon to 66.9% in Nebraska (median: 52.5%) (8).

Data Weighting and Statistical Analysis

At the end of the survey year, CDC edits and aggregates the monthly data files to create a yearly sample for each state and territory. Each sample is weighted to the respondent's probability of selection and the age- and sex-specific population or the age-, sex-, and race/ethnicity-specific population by using the 2009 postcensus projections for each state. MMSA- and county-level weights are produced beginning with the design weights for a given geographic area. These sampling weights are used to calculate BRFSS prevalence estimates at the state, territory, MMSA, and county levels. MMSAs used in this report were defined by the Office of Management and Budget in December 2008. Respondents were assigned to a particular MMSA on the basis of their American National Standards Institute (ANSI) county code. Aggregated data from states were used to produce nationwide prevalence estimates. Detailed weighting and analytic methodologies have been documented previously (2,8).

SAS and SUDAAN (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) (9,10). Statistics were not reported if the unweighted sample size for the denominator was <50 or the CI half width was >10. MMSAs were included only if they had ≥500 respondents and ≥19 respondents in all the final weighting classes and counties. 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 2009 from the 54 states and territories, 180 MMSAs, and 283 counties participating in BRFSS that had adequate sample sizes to produce stable prevalence estimates. In 2009, a total of 432,607 interviews were completed and ranged from 1,266 in Guam to20,294 in Washington (median: 6,736). In each section below, "estimated overall prevalence" refers to the state/territorial level; MMSA and county levels are specified separately. This report presents prevalence of general health status, access to health care, use of preventive health-care services, health risk behaviors and health conditions, cardiovascular conditions, other selected chronic diseases, and health impairments and disabilities.

Health Status Indicators

Health Status

Respondents were asked to rate their general health as excellent, very good, good, fair, or poor. Respondents were classified into two groups: those who rated their health as being fair or poor and those who rated it as good, very good, or excellent. In 2009, among adults aged ≥18 years, the estimated overall prevalence of self-rated fair or poor health ranged from 10.1% in Minnesota to 30.9% in Puerto Rico (median: 14.6%) (Table 1). Among selected MMSAs, the estimated prevalence of self-rated fair or poor health among respondents ranged from 7.9% in Fort Collins--Loveland, Colorado to 25.8% in Charleston, West Virginia (median: 14.1%) (Table 2). Among selected counties, the estimated prevalence of self-rated fair or poor health among respondents ranged from 4.5% in Douglas County, Colorado, to 26.1% in Fayette County, Pennsylvania (median: 13.6%) (Table 3).

Health-Care Coverage

Health-care coverage was defined as having any kind of health-care coverage, including health insurance, prepaid plans (e.g., health maintenance organizations), or government plans (e.g., Medicare or Medicaid). In 2009, among adults aged ≥18 years, the estimated overall prevalence of adults who had health-care coverage ranged from 71.4% in the U.S. Virgin Islands to 94.7% in Massachusetts (median: 85.3%) (Table 4). Among selected MMSAs, the estimated prevalence ranged from 52.7% in McAllen--Edinburg--Mission, Texas, to 96.3% in Cambridge--Newton--Framingham, Massachusetts (median: 86.3%) (Table 5). Among selected counties, the estimated prevalence ranged from 52.7% in Hidalgo County, Texas to 97.6% in Norfolk County, Massachusetts (median: 87.5%) (Table 6).

Preventive Practices

Recent Routine Physical Checkup

A routine physical checkup is defined as a general physical examination, not an examination for a specific injury, illness, or condition. Respondents were classified as having a recent routine physical checkup if they reported visiting a doctor for a routine physical checkup during the preceding 12 months. In 2009, the estimated prevalence of adults aged ≥18 years who had a recent routine physical checkup ranged from 55.8% in Oklahoma to 79.3% in Delaware (median: 68.3%) (Table 7). Among selected MMSAs, the estimated proportion ranged from 51.8% in Provo--Orem, Utah, to 80.7% in Seaford, Delaware (median: 68.2%) (Table 8). Among selected counties, the estimated proportion ranged from 49.2% in Madison County, Nebraska to 83.5% in Union County, New Jersey (median: 69.1%) (Table 9).

Influenza Vaccination

In 2009, the estimated overall prevalence of influenza vaccination during the preceding 12 months among adults aged ≥65 years ranged from 26.8% in Puerto Rico to 76.8% in Minnesota (median: 69.8%) (Table 10). Among selected MMSAs, the estimated prevalence ranged from 55.4% in Idaho Falls, Idaho, to 81.4% in Durham, North Carolina (median: 70.3%) (Table 11). Among selected counties, the estimated prevalence ranged from 50.5% in Hudson County, New Jersey, to 83.5% in Monroe County, New York (median: 71.3%) (Table 12).

Pneumococcal Vaccination

In 2009, the estimated overall prevalence of pneumococcal vaccination among adults aged ≥65 years ranged from 19.1% in Guam to 73.9% in Colorado (median: 68.1%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 52.9% in Idaho Falls, Idaho, to 81.3% in Casper, Wyoming (median: 69.5%) (Table 14). Among selected counties, the estimated prevalence ranged from 41.9% in Hudson County, New Jersey, to 82.0% in Stone County, Mississippi (median: 69.9%) (Table 15).

Blood Cholesterol Checked During Preceding 5 Years

In 2009, the estimated overall prevalence among adults aged ≥18 years of having blood cholesterol checked during the preceding 5 years ranged from 67.5% in Utah to 85.3% in the District of Columbia (median: 77.0%) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 58.2% in McAllen--Edinburg--Mission, Texas, to 88.8% in Miami--Fort Lauderdale--Pompano Beach, Florida (median: 78.2%) (Table 17). Among selected counties, the estimated prevalence ranged from 58.2% in Hidalgo County, Texas, to 92.4% in Westchester County, New York (median: 79.0%) (Table 18).

Nutrition

In 2009, the estimated overall prevalence among adults aged ≥18 years of consuming at least five servings of fruits or vegetables per day ranged from 14.6% in Oklahoma to 31.5% in the District of Columbia (median: 23.5%) (Table 19). Among selected MMSAs, the estimated prevalence ranged from 12.6% in Sioux Falls, South Dakota, to 33.0% in Concord, New Hampshire (median: 23.8%) (Table 20). Among selected counties, the estimated prevalence ranged from 13.4% in Minnehaha County, South Dakota, to 34.9% in Travis County, Texas (median: 24.0%) (Table 21).

Physical Activity

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 days per week for at least 20 minutes each day) other than the respondent's regular work in a usual week. In 2009, the estimated overall prevalence of moderate or vigorous physical activity among adults aged ≥18 years ranged from 28.0% in Puerto Rico to 60.7% in Alaska (median: 50.7%) (Table 22). Among selected MMSAs, the estimated prevalence ranged from 34.6% in Charleston, West Virginia, to 64.9% in Barre, Vermont (median: 50.7%) (Table 23). Among selected counties, the estimated prevalence ranged from 33.6% in Harrison County, Mississippi, to 67.3% in Summit County, Utah (median: 50.9%) (Table 24).

In 2009, the estimated overall prevalence of vigorous physical activity among adults aged ≥18 years ranged from 13.7% in Puerto Rico to 40.1% in Alaska (median: 29.3%) (Table 25). Among selected MMSAs, the estimated prevalence ranged from 13.8% in Charleston, West Virginia, to 43.3% in Bozeman, Montana (median: 29.7%) (Table 26). Among selected counties, the estimated prevalence of vigorous physical activity ranged from 14.2% in Sullivan County, Tennessee, to 50.0% in Summit County, Utah (median: 29.5%) (Table 27).

Health Risk Behaviors and Conditions

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 2009, the estimated overall prevalence of current smokers among adults aged ≥18 years ranged from 6.4% in the U.S. Virgin Islands to 25.6% in both Kentucky and West Virginia (median: 17.9%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 5.7% in Provo--Orem, Utah, to 29.0% in Myrtle Beach--North Myrtle Beach--Conway, South Carolina (median: 17.4%) (Table 29). Among selected counties, the estimated prevalence ranged from 5.6% in Utah County, Utah, to 29.8% in Vanderburgh County, Indiana (median: 16.9%) (Table 30).

Binge Drinking

Binge drinking was defined as adult men having five or more drinks and adult women having four or more drinks on at least one occasion during the last 30 days. In 2009, the estimated overall prevalence of binge drinking among adults aged ≥18 years ranged from 6.8% in Tennessee to 23.9% in Wisconsin (median: 15.5%) (Table 31). Among selected MMSAs, the estimated prevalence of binge drinking ranged from 3.5% in Provo--Orem, Utah, to 23.2% in Butte--Silver Bow, Montana (median: 15.5%) (Table 32). Among selected counties, the estimated prevalence ranged from 3.4% in Utah County Utah, to 26.3% in Macomb County, Michigan (median: 15.5%) (Table 33).

Heavy Drinking

Heavy drinking was defined as adult men having more than two drinks and adult women having more than one drink per day during the last 30 days. In 2009, the estimated overall prevalence of heavy drinking among adults aged ≥18 years ranged from 1.9% in Tennessee to 8.1% in Vermont (median: 5.1%) (Table 34). Among selected MMSAs, the estimated prevalence of heavy drinking ranged from 1.0% in Provo--Orem, Utah, to 11.1% in Kapaa, Hawaii (median: 5.1%) (Table 35). Among selected counties, the estimated prevalence ranged from 0.9% in Utah County, Utah, to 11.1% in Kauai County, Hawaii (median: 5.1%) (Table 36).

No Leisure-Time Physical Activity

No leisure-time physical activity was defined by the respondent's indication of no participation in exercise (e.g., running, calisthenics, golf, gardening, or walking for exercise) other than their regular job during the preceding month. In 2009, the estimated overall prevalence of no leisure-time physical activity among adults aged ≥18 years ranged from 15.8% in Minnesota to 45.6% in Puerto Rico (median: 24.2%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 13.3% in Provo--Orem, Utah, to 40.2% in McAllen--Edinburg--Mission, Texas (median: 23.4%) (Table 38). Among selected counties, the estimated prevalence ranged from 10.5% in Douglas County, Colorado, to 40.2% in Hidalgo County, Texas (median: 22.6%) (Table 39).

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 their BMI was ≥25.0 kg/m2 but <30.0 kg/m2. In 2009, the estimated overall prevalence of overweight among adults aged ≥18 years ranged from 31.6% in the District of Columbia to 38.7% in Iowa (median: 36.2%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 28.7% in both Chattanooga, Tennessee--Georgia and Lake Charles, Louisiana, to 44.1% in Hilton Head Island--Beaufort, South Carolina (median: 36.7%) (Table 41). Among selected counties, the estimated prevalence ranged from 25.6% in Orange County, North Carolina, to 46.7% in Henderson County, North Carolina (median: 36.7%) (Table 42).

Obesity

Respondents were categorized as being obese if their BMI was ≥30.0 kg/m2. Obesity analyses were restricted to adults aged ≥20 years to permit comparison with the HP 2010 objective (objective no. 19.2) (6). In 2009, the estimated overall prevalence of obesity among adults aged ≥20 years ranged from 19.7% in Colorado to 36.0% in Mississippi (median: 28.0%) (Table 43). Among selected MMSAs, the estimated prevalence ranged from 15.4% in Bozeman, Montana, to 43.6% in Houma--Bayou Cane--Thibodaux, Louisiana (median: 27.9%) (Table 44). Among selected counties, the estimated prevalence ranged from 13.8% in Douglas County, Colorado, to 45.7% in Terrebonne Parish, Louisiana (median: 27.3%) (Table 45).

Insufficient Rest or Sleep

Insufficient rest or sleep was defined by the respondent's indication of not getting enough rest or sleep for at least 14 days during the preceding month. In 2009, the estimated overall prevalence of insufficient rest or sleep among adults aged ≥18 years ranged from 34.3% in Virgin Islands to 52.6% in West Virginia (median: 39.3%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 28.2% in Dallas--Plano--Irving, Texas, to 54.8% in Huntington--Ashland, West Virginia--Kentucky--Ohio (median: 39.5%) (Table 47). Among selected counties, the estimated prevalence ranged from 24.5% in Douglas County, Washington, to 55.6% in Cumberland County, North Carolina (median: 39.3%) (Table 48).

Cardiovascular Conditions

High Blood Pressure

Prevalence of high blood pressure was assessed by asking respondents aged ≥20 years if they had ever been told by a doctor, nurse, or other health professional that they had high blood pressure. Adults who reported having prehypertension or borderline high blood pressure and women who reported having high blood pressure during pregnancy were not considered hypertensive for these analyses. In 2009, the estimated overall prevalence of high blood pressure ranged from 22.1% in Minnesota to 38.5% in Mississippi (median: 29.6%) (Table 49). Among selected MMSAs, the estimated prevalence ranged from 18.8% in Greeley, Colorado to 43.9% in Alexandria, Louisiana (median: 29.4%) (Table 50). Among selected counties, the estimated prevalence ranged from 17.2% in Riley County, Kansas, to 43.6% in Rapides Parish, Louisiana (median: 29.1%) (Table 51).

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 2009, the estimated overall prevalence of high blood cholesterol ranged from 24.9% in Guam to 42.2% in South Carolina (median: 38.1%) (Table 52). Among selected MMSAs, the estimated prevalence of high blood cholesterol ranged from 27.5% in Gallup, New Mexico, to 47.8% in Gulfport--Biloxi, Mississippi (median: 38.2%) (Table 53). Among selected counties, the estimated prevalence ranged from 26.7% in Hampshire County, Massachusetts, to 51.4% in Hancock County, Mississippi (median: 37.7%) (Table 54).

Coronary Heart Disease

Respondents aged ≥18 years were categorized as having coronary heart disease if they reported having ever been told by a doctor, nurse, or other health professional that they had coronary heart disease, angina, or a heart attack. In 2009, the estimated overall prevalence of coronary heart disease ranged from 2.5% in the U.S. Virgin Islands to 10.3% in West Virginia (median: 5.9%) (Table 55). Among selected MMSAs, the estimated prevalence ranged from 2.6% in Provo--Orem, Utah, to 11.6% in Huntington--Ashland, West Virginia--Kentucky--Ohio (median: 6.3%) (Table 56). Among selected counties, the estimated prevalence ranged from 1.6% in Summit County, Utah, to 12.3% in Westmoreland County, Pennsylvania (median: 5.5%) (Table 57).

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 professional that they had a stroke. In 2009, among adults aged ≥18 years, the estimated overall prevalence of stroke ranged from 1.4% in Colorado to 3.9% in both Alabama and Oklahoma (median: 2.4%) (Table 58). Among selected MMSAs, the estimated prevalence of stroke ranged from 0.8% in Heber, Utah, to 5.9% in Gulfport--Biloxi, Mississippi (median: 2.3%) (Table 59). Among selected counties, the estimated prevalence ranged from 0.8% in both Adams County, Colorado, and Wasatch County, Utah, to 6.6% in Harrison County, Mississippi (median: 2.3%) (Table 60).

Chronic Illness and Disabilities

Diabetes

The prevalence of diagnosed diabetes was assessed by asking respondents if they had ever been told by a doctor that they had diabetes. Those who answered in the affirmative were considered to have diabetes. Specific types of diabetes (e.g., Type 1 or Type 2) were not assessed. Adults reporting gestational, borderline, or prediabetes were not considered to have diabetes for these analyses. In 2009, the estimated overall prevalence of diagnosed diabetes among adults aged ≥18 years ranged from 5.8% in Alaska to 12.9% in Puerto Rico (median: 8.4%) (Table 61). Among selected MMSAs, the estimated prevalence ranged from 2.8% in Bozeman, Montana, to 15.4% in Kingsport--Bristol--Bristol, Tennessee--Virginia (median: 8.2%) (Table 62). Among selected counties, the estimated prevalence ranged from 2.8% in Gallatin County, Montana, to 14.7% in Sullivan County, Tennessee (median: 8.3%) (Table 63).

Cancer

The prevalence of cancer was assessed by asking respondents if they had ever been told by a doctor, nurse, or other health professional that they had cancer. Those who answered in the affirmative were considered to have had cancer. Specific sites and types of cancer also were assessed but are not reported in this summary because of limited space. In 2009, the estimated overall prevalence of cancer among adults aged ≥18 years ranged from 3.0% in Guam to 12.6% in Oregon (median: 9.9%) (Table 64). Among selected MMSAs, the estimated prevalence ranged from 5.8% in Gallup, New Mexico, to 15.1% in Asheville, North Carolina (median: 9.7%) (Table 65). Among selected counties, the estimated prevalence ranged from 3.9% in Clayton County, Georgia, to 16.2% in Buncombe County, North Carolina (median: 9.6%) (Table 66).

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 2009, the estimated overall prevalence of current asthma ranged from 4.4% in the U.S. Virgin Islands to 11.1% in Oregon (median: 8.8%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 3.2% in McAllen--Edinburg--Mission, Texas, to 15.3% in Rochester, New York (median: 8.5%) (Table 68). Among selected counties, the estimated prevalence ranged from 3.2% in Hidalgo County, Texas, to 15.7% in Monroe County, New York (median: 8.2%) (Table 69).

Arthritis

Respondents aged ≥18 years were categorized as having arthritis if they reported having ever been told by a doctor that they had some form of arthritis. Arthritis diagnoses included rheumatism and polymyalgia rheumatica; osteoarthritis (not osteoporosis); tendonitis, bursitis, bunion, and tennis elbow; carpal tunnel syndrome and tarsal tunnel syndrome; joint infection and Reiter's syndrome; ankylosing spondylitis; spondylosis; rotator cuff syndrome; connective tissue disease; scleroderma; and polymyositis, Raynaud's syndrome, or vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener's granulomatosis, and polyarteritis nodosa). In 2009, the estimated overall prevalence of arthritis ranged from 10.7% in Guam to 35.6% in Kentucky (median: 25.9%) (Table 70). Among selected MMSAs, the estimated prevalence of arthritis ranged from 16.2% in Gallup, New Mexico; Lawrence, Kansas; and Provo--Orem, Utah, to 36.0% in Butte--Silver Bow, Montana (median: 25.8%) (Table 71). Among selected counties, the estimated prevalence ranged from 12.6% in Cobb County, Georgia, to 39.4% in Harrison County, Mississippi (median: 25.5%) (Table 72).

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 2009, the estimated overall prevalence of limitations in activities because of physical, mental, or emotional problems ranged from 10.2% in the U.S. Virgin Islands to 27.1% in West Virginia (median: 18.7%) (Table 73). Among selected MMSAs, the estimated prevalence ranged from 13.1% in Santa Ana--Anaheim--Irvine, California, to 33.7% in Gulfport--Biloxi, Mississippi (median: 18.6%) (Table 74). Among selected counties, the estimated prevalence ranged from 10.4% in Sarpy County, Nebraska, to 36.1% in Harrison County, Mississippi (median: 18.5%) (Table 75).

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 2009, the estimated overall prevalence who persons who reported requiring special equipment because of a health problem ranged from 3.6% in the U.S. Virgin Islands to 10.2% in both Alabama and West Virginia (median: 7.0%) (Table 76). Among selected MMSAs, the estimated prevalence ranged from 3.4% in Heber, Utah, to 11.5% in both Gulfport--Biloxi, Mississippi and Huntington--Ashland, West Virginia--Kentucky--Ohio (median: 6.9%) (Table 77). Among selected counties, the estimated prevalence ranged from 1.7% in Summit County, Utah to 13.0% in both Baltimore City, Maryland, and George County, Mississippi (median: 6.7%) (Table 78).

Comparisons between the selected HP 2010 objectives and estimated prevalence ranges by states/territories, MMSAs, and counties in 2009 BRFSS have been provided (Table 79).The results indicated that certain HP 2010 goals have not been achieved in some states, territories, and local areas.

Discussion

The findings in this report indicate that substantial variations exist in the estimated prevalence of health status, health-care coverage, use of preventative health practices and services, health risk behaviors and conditions, cardiovascular conditions, other chronic diseases, and health impairments and disabilities 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 health-care services.

HP 2010 established targets for certain health indicators and health behaviors to be attained by 2010 (6). The findings provided in this report indicate that as of 2009, certain HP 2010 goals had not been attained. For example, in 2009, no state and territory, MMSA, or county achieved the HP 2010 objectives for health-care coverage, vaccination against influenza, high blood pressure, or high blood cholesterol.

Health Status Indicators

Health Status

Self-rated general health status encompasses physical health, mental health, and functional capacity of persons (11) and is a proxy indicator for perceived burden of acute and chronic health conditions (12). Substantial 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.

Health-Care Coverage

The HP 2010 objective for health-care coverage is 100% (6). 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) (13). In 2009, 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 (14,15). Influenza and pneumonia vaccination among older adults (aged ≥65 years) is a key public health strategy in the United States (16). The HP 2010 target for adults aged ≥65 years who had annual influenza vaccination is 90% (objective no. 14.29a), and the HP 2010 target for adults aged ≥65 years who had annual vaccination against pneumococcal disease is 90% (objective no. 14.29b) (6). In 2009, no state and territory or county met the HP 2010 target of 90% (6). The reasons for inadequate coverage include lack of knowledge, misconceptions about vaccines and vaccine-associated illness, and lack of recommendations by physicians (17,18). 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 (19).

Health Risk Behaviors and Conditions

Consumption of Fruits and Vegetables

Consuming adequate fruits and vegetables can help maintain healthy weight and reduce the risk for cardiovascular conditions and certain cancers (20,21). The 2005 Dietary Guidelines for Americans (20) recommended that U.S. residents consume five to 13 servings of fruits and vegetables per day. BRFSS uses five servings as a measure of fruit or vegetable daily consumption. In 2009, the prevalence of daily consumption of five or more servings of fruit or vegetables ranged from 14.6% to 31.5% across states and territories, indicating a need to increase public awareness of the overall benefits of consuming fruits and vegetables. In addition, sustained and effective public health efforts are needed to promote the importance of eating more fruits and vegetables (22).

Physical Activity

HP 2010 goals are to increase prevalence of moderate physical activity to 50% (objective no. 22.2) and vigorous physical activity to 30% (objective no. 22.3) (6). Despite the proven benefit of physical activity (23), prevalence of moderate and vigorous physical activity is still low. In 2009, approximately half of states and territories, MMSAs, and counties had not met the HP 2010 goal for moderate or vigorous 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 (24). According to the 2008 Physical Activity Guidelines for Americans, in addition to conducting muscle strengthening activities on ≥2 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 (25).

Cigarette Smoking

Cigarette smoking remains the most preventable cause of morbidity, disability, and mortality in the United States (26). Smoking causes many types of cancer, cardiovascular, and pulmonary diseases (27). Health consequences of breathing secondhand smoke include pediatric respiratory problems, cardiovascular disease, and lung cancer in adults (28). Only three states and territories, 15 MMSAs, and 36 counties met the HP 2010 target for smoking (12%) (6). In addition to recent legislation (i.e., Family Smoking Prevention and Tobacco Control Act [Public Law 111-31]) at the national level, these results indicate a need for continued implementation of comprehensive tobacco-control programs at the state and local levels. Such programs have been described previously (29).

Binge Drinking

Excessive alcohol consumption is a leading preventable cause of death in the United States (30,31). Binge and heavy drinking can lead to risky sexual activity, unintentional injuries and accidents, falls, violence, and suicide (32,33). The HP 2010 target is to reduce binge drinking to 13.4% (objective no. 26.11) (6). Only 17 states and territories, 50 MMSAs, and 75 counties met the national target for binge drinking. Compared with other adverse health behaviors (e.g., smoking), binge drinking has not been subjected to intense prevention efforts (34). The differences in binge drinking among states, MMSAs, and counties might reflect cultural factors and differences in state and local laws that affect the price, availability, and marketing of alcoholic beverages (35,36). Population-based prevention efforts to reduce binge drinking should be initiated and strengthened (37).

No Leisure-Time Physical Activity

The HP 2010 objective is to reduce the proportion of adults who engage in no leisure-time physical activity to 20% (objective no. 22-1) (6). In 2009, only eight states, 46 MMSAs, and 93 counties met the national target for no leisure-time physical activity. Continued efforts are needed to promote leisure-time physical activity in the general population and in population subgroups. Science-based recommendations have been published for several populations, including children and adolescents aged 6--17 years, adults aged 18--64 years, adults aged ≥65 years, and persons with disabilities (25). A toolkit has been developed to assist organizations in promoting physical activity in their communities (25).

Overweight and Obesity

The prevalence of overweight and obesity continues to be a critical public health problem (4,5,38,39). The HP 2010 target is to reduce the proportion of adults aged ≥20 years who are obese to <15% (objective no. 19-2). In 2009, the estimated prevalence of overweight among states and territories ranged from 31.6%--38.7%, and the prevalence of obesity among adults aged ≥20 years ranged from 19.7% to 36.0% across states and territories. No state or territory, no MMSA, and only four counties (i.e., Douglas County, Colorado [13.8%]; San Francisco County, California [14.0%]; New York County, New York [14.0%]; and Summit County, Utah [14.8%]) met the HP 2010 target for obesity. However, the estimated prevalence of obesity for counties during 2009 (13.8%--45.7%) did not increase substantially from 2008 (12.9%--39.9%) (4) and 2007 (13.8%--37.6%) (5). These results are similar to those of the National Health and Nutrition Examination Survey (38,39), suggesting that the increasing trend in obesity prevalence might have slowed. Nevertheless, because prevalence of overweight and obesity continues to be high, extensive public health programs that target healthy life styles remain necessary to control overweight and obesity at the state and local levels (40).

Insufficient Rest or Sleep

A recent study indicated that, compared with persons reporting no days of insufficient rest or sleep, those reporting 14--29 days and those reporting ≥30 days of insufficient rest or sleep had approximately 33% and 67% increased likelihood of having any cardiovascular diseases (including coronary heart disease and stroke), 15% and 31% increased likelihood of having diabetes, and 36% and 51% increased likelihood of having obesity, respectively (41). In 2009, nearly one third to half of adults across states and territories or MMSAs, and one fourth to half of adults across counties reported insufficient rest or sleep for ≥14 days during the preceding month, suggesting a potential health issue among U.S. adults. Future studies might be needed to access the predictors or correlations of insufficient rest or sleep. Furthermore, because health risk behaviors and conditions tend to cluster together (42) and are associated with impairment of health-related quality of life and self-rated health (42,43), greater efforts might be needed to develop and implement interventions that address multiple health risk factors and conditions.

Cardiovascular Conditions

Heart Disease and Stroke

Heart disease and stroke are the first and third leading causes of death, respectively, in the United States (1). No substantial change occurred in the prevalence of coronary heart disease in 2009 (2.5%--10.3%) compared with that reported in 2007 (2.8%--10.7%) (5). Meanwhile, the prevalence of stroke in 2009 (1.4%--3.9%) was similar to that in 2007 (1.1%--3.7%) (5). High blood pressure and high blood cholesterol are important modifiable risk factors for cardiovascular disease (44). High blood pressure and high cholesterol are relatively easy to monitor and should be maintained at an optimal level (45,46). In 2009, according to the HP 2010 objectives, no state or territory, MMSA, or county met the target for reducing the proportion of adults with high blood pressure (14%; objective no. 12.9) or the target for reducing the proportion of adults with high blood cholesterol (17%; objective no. 12.14). These findings indicate a need for more public health efforts to reduce high blood pressure and high blood cholesterol. 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 (47). Strategies suggested by the National High Blood Pressure Education Program (46) and the National Cholesterol Education Program (45) can be applied at the state and local levels to help reduce high blood pressure and high blood cholesterol.

Chronic Diseases

Diabetes

Approximately 25.6 million (11.3%) adults aged ≥20 years were estimated to have diabetes in 2010 (48). The estimated prevalence of diabetes among persons aged ≥18 years ranged from 5.8% to 12.9% among states and territories. Persons with diabetes are more likely to have cardiovascular disease, high blood pressure, high cholesterol, complications during pregnancy, and mental disorders (48--50). These diseases and conditions can be prevented by controlling blood glucose through healthy eating, physical activity, medication, and receipt of proper preventive health-care services (48). Moreover, clustering of multiple healthy lifestyle habits might improve health-related quality of life among persons with diabetes (51).

Cancer

Cancer is the second leading causes of death in the United States (52). Because of early detection and medical advances in clinical treatment, persons are living many years after receiving a cancer diagnosis. Approximately 11.7 million Americans were living with cancer in 2007 (53). In 2009, approximately 9.9% of U.S. adults had cancer (range: 3.0%--12.6%). Since cancer survivors core questions were included in the BRFSS for the first time in 2009, these prevalence estimates can be used as baseline rates for monitoring prevalence trends in future surveys.

Asthma

Asthma, a chronic inflammatory disorder of airways, is a major cause of morbidity related to the limitation of activities, increased hospital admissions and emergency department visits, and loss of workdays in the United States (54,55). The majority of 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 (55). During 2001--2003, approximately 20 million persons in the United States had asthma annually (54). In 2009, the estimated median current asthma prevalence among persons aged ≥18 years was 8.8%, which is similar to the prevalence estimates in 2008 (8.8%) (4) and 2007 (8.3%) (5).

Arthritis

In 2009, arthritis continued to be the most common cause of disabilities in the United States with approximately 25% of U.S. adults affected (56). 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 the Arthritis Foundation Self-Help Program or the Chronic Disease Self-Management Program) (56).

Disabilities

Activity Limitations and Use of Assistive Technology

Limitation in activities because of physical, mental, or emotional problems or disabilities severely affect quality of life (57). In 2009, approximately 18.7% of U.S. adults in states and territories had activity limitations (range: 10.2%--27.1%), which is similar to the prevalence estimates in 2008 (20.4%; range: 9.8%--29.5%) (4) and 2007 (18.8%; range: 10.3%--25.9%) (5). Persons with disabilities are less likely to use preventive health services and to participate in healthy behaviors (e.g., physical activity and nonsmoking) and are more likely to have higher rates of chronic conditions (e.g., depression, diabetes, obesity, and hypertension) compared with persons without disabilities (58). Moreover, disability is closely related to excessive medical expenditures and loss of productivity. The estimated disability-related costs are approximately $300 billion annually in the United States (59). Rates of severe disability have been declining among older populations; however, during the preceding 2 decades, the prevalence of disability has been rising among young and working-age populations, particularly among those with obesity and comorbidities (60).

In 2009, the estimated prevalence of special equipment usage (e.g., a cane, wheelchair, special bed or special telephone) because of any health problem was 7.0% (range: 3.6%--10.2%). For persons with disabilities, access to assistive technology can assist with functioning, independence, maintaining physical and mental health, and participation in community life (e.g., work, school, social functions) (61,62). As the population ages and the prevalence of disabilities increases, it is essential to continue disability surveillance in the United States, to increase the quality of years lived among those with disabilities, and to increase access to needed assistive devices and technologies.

Limitations

The findings in this report are subject to at least five limitations. First, BRFSS is a household telephone survey that excludes persons in institutions, nursing homes, long-term-care facilities, and correctional institutions; therefore, results might not be generalizable to these populations. Second, increases in the number of cell-phone--only households and telephone number portability might lead to decreases in the response rate in BRFSS land-line based surveys (63). In 2009, BRFSS began collecting data on use of multimode communications modalities (e.g., cell-phone--only households only, and both cell phone and landline households). However, these data are not available for all states and territories and are not included in this report. Third, BRFSS is conducted in several languages other than English (i.e., Spanish, Chinese [Mandarin], and Portuguese) but does not provide data on persons who speak other languages. Fourth, estimates for some health status indicators could not be obtained for all MMSAs and counties, and consequently these MMSAs and counties were not ranked on these health status indicators. Finally, BRFSS data are self-reported and are subject to recall bias and social desirability effects.

Despite these limitations, BRFSS is a cost-effective, timely, and flexible survey that provides reliable and valid estimates of health risk behaviors and conditions, use of preventive health-care services, cardiovascular conditions, other chronic diseases, and health impairments and disabilities at the national, state, and local levels (64,65). BRFSS data have been demonstrated to provide reliable and valid estimates when compared with national household surveys (7,66) and often are the only timely sources of data available to states and communities to assess local health conditions and to accurately track progress of health promotion programs and strategies.

Conclusion

Because many of the Healthy People 2010 objectives were not achieved in some states, territories, and local areas, continuing to monitor the trends and geographic disparities in health risk behaviors and health conditions, use of preventive health services, chronic diseases, and health impairment and disabilities at state and local levels is warranted. BRFSS data can be used to identify states and local areas that may need additional resources, support, and/or to refocus their efforts on population groups most in need. In addition, the BRFSS survey facilitates effective program evaluation, and can be used to evaluate and improve public health interventions and demonstrate accountability to stakeholders. Moreover, 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 and HP 2020 objectives.

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2009 Behavioral Risk Factor Surveillance System State/Territory Project Coordinators

Alabama: Jesse Pevear III, MSPH; Alaska: Rebecca Wells, MS; Arizona: Brian Bender Judy Bass; Arkansas: LaTonya Bynum; California: Arti Parikh-Patel; Colorado: Kieu Vu; Connecticut, Diane Aye, PhD; Delaware: Fred Breukelman; District of Columbia: Tracy Garner; Florida: Melissa Murray, MS; Georgia: Leah Bryan MPH, Suprana Bagchi; Guam: William Brandshagen, Gil Suguitan; Hawaii: Florentina Reyes-Salvail, MS; Idaho: Teresa Abbott; Illinois: Bruce Steiner, MS; Indiana: Linda Stemnock; Iowa: Donald Shepherd, PhD; Kansas: Farooq Ghouri, MBBS, Ghazala Perveen; Kentucky: Tracey Sparks Sarojini Kanotra; Louisiana: Todd Griffin, MSPH; Maine: Kip Neale; Maryland: Helio Lopez, MS; Massachusetts: Helen Hawk; Michigan: Chris Fussman; Minnesota: Nagi Salem, PhD; Mississippi: Ron McAnally; Missouri: Janet Wilson, MEd; Montana: Joanne Oreskovich; Nebraska: Larry Andelt, PhD; Nevada: Alicia Hansen, MS; New Hampshire: Susan Knight, MSPH; New Jersey: Kenneth O'Dowd, PhD; New Mexico: Vivian Heye; New York: Colleen Baker; North Carolina: Harry Herrick, MSPH, James Cassell; North Dakota: Melissa Parsons; Ohio: Patricia Coss; Oklahoma: Derek Pate, MPH; Oregon: Renee Boyd; Pennsylvania: Robert Dewar, MPA, Alden Small; Puerto Rico: Ruby Serrano-Rodriguez, DrPH; Rhode Island: Jana Hesser, PhD, Donald Perry; South Carolina: Ryan Lewis; South Dakota: Mark Gildemaster; Tennessee: David Ridings; Texas: Michelle Cook, MPH; Utah: Jennifer Wrathall, MPH; Vermont: Rodney McCormick, PhD; Virgin Islands: Sharon Williams, MS; Virginia: Susan Spain; Washington: Katrina Wynkoop Simmons, PhD; West Virginia: Fred King; Wisconsin: Anne Ziege, PhD; Wyoming: Menlo Futa, MA.

2009 Behavioral Risk Factor Surveillance System Staff

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