Surveillance for Certain Health Behaviors Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2011

Fang Xu, PhD1

Tebitha Mawokomatanda, MS1

David Flegel, MS1

Carol Pierannunzi, PhD2

William Garvin2

Pranesh Chowdhury, MD2

Simone Salandy, PhD1

Carol Crawford, PhD2

Machell Town, PhD2

1Northrop Grumman Corporation, Atlanta, Georgia

2Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Abstract

Problem: Chronic conditions (e.g., heart diseases, cerebrovascular diseases, malignant neoplasms, and diabetes), infectious diseases (e.g., influenza and pneumonia), and unintentional injuries are the leading causes of morbidity and mortality in the United States. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, always wearing seatbelts in automobiles) and accessing preventive health-care services (e.g., getting routine physical checkups, receiving recommended vaccinations on appropriate schedules, checking blood pressure and cholesterol and maintaining them at healthy levels) can reduce morbidity and mortality from chronic and infectious diseases. Monitoring the health-risk behaviors of a community's residents as well as their participation in and access to health-care services provides information critical to the development and maintenance of intervention programs as well as the implementation of strategies and health policies that address public health problems at the levels of state and territory, metropolitan and micropolitan statistical area (MMSA), and county.

Reporting Period: January–December 2011.

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, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disabilities in the United States. In 2011, BRFSS adopted a new weighting methodology (iterative proportional fitting, or raking) and for the first time included data from respondents who solely use cellular telephones (i.e., do not use landlines). This report presents results for the year 2011 for all 50 states, the District of Columbia, and participating U.S. territories including the Commonwealth of Puerto Rico and Guam, 198 MMSAs, and 224 counties.

Results: In 2011, the estimated prevalence of health-risk behaviors, chronic conditions, access to health care, and use of preventive health services substantially varied by state and territory, MMSA, and county. The following portion of this abstract summarizes selected results by some BRFSS measures. Each set of proportions refers to the range of estimated prevalence of the behaviors, diseases, or use of preventive health-care services as reported by survey respondents. Adults with good or better health: 65.5%−88.0% for states and territories, 72.0%−92.4% for MMSAs, and 74.3%−94.2% for counties. Adults aged <65 years with health–care coverage: 65.4%−92.3% for states and territories, 66.8%−94.7% for MMSAs, and 61.3%−95.6% for counties. Influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 28.6%−70.2% for states and territories, 42.0% −80.0% for MMSAs, and 41.1%−78.2% for counties. Adults meeting the federal physical activity recommendations for both aerobic physical activity and muscle–strengthening activity: 8.5%–27.3% for states and territories, 7.3%–32.0% for MMSAs, and 11.0%–32.0% for counties. Current cigarette smokers: 11.8%–30.5% for states and territories, 8.4%–30.6% for MMSAs, and 8.1%–35.2% for counties. Binge drinking during the last month: 10.0%–25.0% for states and territories, 7.0%–32.5% for MMSAs, and 7.0%–32.5% for counties. Adults always wearing seatbelts while driving or riding in a car: 63.9%−94.1% for states and territories, 51.8%−96.9% for MMSAs, and 51.8%−97.0% for counties. Adults aged ≥18 who were obese: 20.7%–34.9% for states and territories, 15.1%–37.2% for MMSAs, and 15.1%−41.0% for counties. Adults with diagnosed diabetes: 6.7%–13.5% for states and territories, 3.9%–15.9% for MMSAs, and 3.5%–18.3% for counties. Adults with current asthma: 4.3%–12.1% for states and territories, 2.9%–14.1% for MMSAs, and 2.9%–15.6% for counties. Adults aged ≥45 years who have had coronary heart disease: 7.1%–16.2% for states and territories, 5.0%–19.4% for MMSAs, and 3.9%–18.5% for counties. Adults using special equipment because of any health problem: 5.1%–11.3% for states and territories, 3.9%–13.2% for MMSAs, and 2.4%–14.7% for counties.

Interpretation: Because of the recent change in the BRFSS methodology, the results should not be compared with those from previous years. The findings in this report indicate that substantial variations exist in the reported health-risk behaviors, chronic diseases, disabilities, access to health-care services, and the use of preventive health services among U.S. adults at state and territory, MMSA, and county levels. The findings underscore the continued need for surveillance of health-risk behaviors, chronic conditions, and use of preventive health-care services as well as surveillance-informed programs designed to help improve health-related risk behaviors, levels of chronic disease and disability, and the access to and use of preventive services and health-care resources.

Public Health Action: State and local health departments and agencies can continue to use BRFSS data to identify populations at high risk for certain unhealthy behaviors and chronic conditions. Additionally, they can use the data to inform the design, implementation, direction, monitoring, and evaluation of public health programs, policies, and use of preventive services that can lead to a reduction in morbidity and mortality among U.S. residents.

Introduction

Chronic conditions (e.g., heart diseases, cerebrovascular diseases, malignant neoplasms, and diabetes), infectious diseases (e.g., influenza and pneumonia), and unintentional injuries are the leading causes of morbidity and mortality in the United States (1,2). Engaging in healthy behaviors (e.g., quitting smoking and all other tobacco use, increasing physical activity), accessing preventive health-care services (e.g., having routine physical checkups, checking blood pressure, testing blood cholesterol, and receiving recommended vaccinations), and reducing risks of injuries (e.g., always wearing a seatbelt while in an automobile) can reduce morbidity and mortality from those diseases and injuries as well as lower medical costs associated with treating them (3).

Ongoing state-based surveillance is essential to monitor health issues and disparities and to design, implement, and evaluate health programs and policies that address the public health needs of a community or region. Published reports indicate the estimated prevalence of health-risk behaviors, chronic conditions, and use of preventive services vary substantially across the United States (4,5).

The Behavioral Risk Factor Surveillance System (BRFSS) is the world's largest ongoing telephone survey (6). Since 1984, CDC has assisted state and territorial health departments in conducting the BRFSS survey each year as they track health conditions and health-risk behaviors. The survey is one of the main data sources that public health officials and practitioners use to track chronic conditions, health-risk behaviors, use of preventive health services, and emerging health problems at state, county, and metropolitan and micropolitan statistical areas (MMSA) levels. The data are frequently used to set health goals as well as to monitor progress and success of public health programs and policy implementation at national, state, and local levels. Since 2002, the sufficient sample size in BRFSS has facilitated analysis of prevalence estimates for selected MMSAs, metropolitan divisions, and their counties. This report includes 2011 BRFSS findings related to selected chronic conditions, health-risk behaviors, and use of preventive health-care services.

Methods

BRFSS is a cross-sectional, random-digit–dialed, state-based survey that includes more than 400,000 adult participants aged ≥18 years who completed interviews annually (7). BRFSS uses a multistage sampling design to select a representative sample of the noninstitutionalized adult population in each state and territory. Details of the validity and reliability of the measures of BRFSS survey methodology have been described elsewhere (8,9).

Questionnaire

The standard BRFSS questionnaire consists of three sections: core questions, optional modules, and state-added questions. Eligible respondents answer the same core questions in all states, the District of Columbia, and participating U.S. territories. The 2011 core questions were used to inquire about participants' health status, number of healthy days in the past 30 days, health-care access, hypertension awareness, cholesterol awareness, chronic health conditions, tobacco use, demographics, consumption of fruits and vegetables, physical activity, disability, arthritis-related conditions, seatbelt use, immunization, alcohol consumption, and screening of and risk for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

States also add questions to BRFSS that are specifically designed to address state-specific health issues or to track a state's health objectives. Optional modules were selected by states based on the specific needs and goals of the programs in each state's health department. In 2011, the following optional models were used by at least one state: actions to control high blood pressure (nine states), adult asthma history (one state), adult human papilloma virus immunization (three states), adverse childhood experience (five states), anxiety and depression (two states), arthritis management (five states), breast/cervical cancer screening (two states), cardiovascular health (six states), child immunization—influenza (five states), childhood asthma (17 states), chronic obstructive pulmonary disease (nine states), cognitive impairment (seven states), colorectal cancer screening (one state), diabetes (14 states), heart attack and stroke (three states), inadequate sleep (three states), pre-diabetes (16 states), preconception health/family planning (three states), prostate cancer screening (one state), random child selection (18 states), shingles immunization (two states), smoking cessation (one state), social context (three states), sugar-sweetened beverages and menu labeling (three states), and veteran's health (two states).

For certain modules collected by landline telephone only, states could have chosen to split the modules by dividing the samples so only a portion of the respondents answer certain module questions. In 2011, there were up to three module versions; there were no split versions of a module whose data were collected only by cellular telephone. Modules that appear in every version of a state's questionnaire are called "common" modules and provide data that might have been collected by combined cellular telephone/landline telephone or by landline telephone only. All the responses were self-reported.

Data Collection and Processing

Since 2007, BRFSS surveys have been collected monthly in all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, and Guam. In 2011, the U.S. Virgin Islands did not collect BRFSS data. A computer-assisted telephone interviewing system is used to conduct the survey. State-collected data are submitted to CDC for processing, checking, and weighting.

New BRFSS Methodology Adopted in 2011

Sampling

In 2011, one of BRFSS's major protocol changes included reaching and interviewing survey participants on their cellular telephones. Before 2011, BRFSS contacted survey participants on their landline telephones only. Using a dual-frame survey including combined landline and cellular telephones improved validity, reliability, and representativeness of BRFSS data (10). In addition, beginning in 2011, a new weighting methodology (raking) replaced poststratification, which had been used to weight the data every year before 2011. Also known as iterative proportional fitting, raking is performed by adjusting one demographic variable at a time in an iterative process until a convergence of a set value is reached. Details of the protocol changes are described in the discussion.

Data Weighting

State-level weights were adjusted to produce MMSA- and county-level weights. Respondents were assigned to an MMSA based on their county FIPS (Federal Information Processing Standards) codes. MMSAs were selected in the MMSA data if there were ≥500 respondents. Unlike previous years, counties that had ≥500 respondents were selected in 2011, regardless of whether they were defined within boundaries of MMSAs. Information about weighting MMSA and county BRFSS data can be found on the BRFSS SMART webpage (11).

Statistical Analyses

Data in this report are presented as direct estimates. To account for the complex survey design of BRFSS, this report provides comparable unweighted sample size, weighted prevalence estimates with standard errors and 95% confidence intervals for prevalence of chronic conditions, risk behaviors, and use of preventive health-care services by states and territories, MMSAs, and counties using 2011 BRFSS data. If the unweighted sample size was represented by <50 survey participants or the relative standard error (RSE) was >30%, the results for certain MMSAs or counties were suppressed to avoid unstable estimates. In 2011, RSE replaced the previous criterion that the half-width of the 95% confidence interval was >10. RSE was calculated by dividing the standard error of the estimate by the estimate and multiplying by 100 (for percent). Estimates where RSEs were <30% provide more reliable results (13). Responses coded as "do not know", or "refused" were excluded from the analyses. The analysis was conducted using statistical software.

About This Report

This report presents statistical analyses and discussion of the following topics: 1) health status indicators (self-rated health status, health-care coverage), 2) preventive practices (recent routine physical checkup, influenza vaccination, and pneumococcal vaccination for persons aged ≥65 years, blood cholesterol check, and physical activity), 3) health-risk behaviors (current cigarette smoking, binge drinking, heavy drinking, no leisure-time physical activity, and always wearing a seatbelt), 4) chronic conditions (obesity for persons aged ≥18 years, diabetes, cancer survivors, current asthma, arthritis, and depression), 5) cardiovascular conditions (high blood pressure, high blood cholesterol, coronary heart disease, and stroke for persons aged ≥45 years), and 6) disability (activity limitation and use of special equipment because of physical, mental, or emotional problems). The 2011 questionnaire and all related support documents are available on the BRFSS webpage (12).

Results

In 2011, approximately 506,000 adults completed interviews on landline telephones and cellular telephones. The BRFSS data set comprised results from 54 states and territories, 198 MMSAs, and 224 counties with sufficient sample sizes. For data collected by landline telephone, 450,285 respondents completed the BRFSS survey interview. Numbers of participants ranged from 3,302 in Alaska to 20,837 in Nebraska (median: 7,440). For data collected by cellular telephone, 73,518 respondents completed the survey interview, with participant numbers ranging from 76 in Tennessee to 5,613 in Nebraska (median: 1,109). Since 2011, response rates for BRFSS have been calculated using the standard set by the American Association of Public Opinion Research (AAPOR) response rate formula 4, which is the number of respondents who completed the survey as a proportion of all eligible and likely eligible persons (14). For landline telephone data, the AAPOR response rate ranged from 37.4% in California to 66.5% in South Dakota (median: 53.0%). For cellular telephone data, the AAPOR response rate ranged from 20.2% in Pennsylvania to 54.0% in Iowa (median: 27.9%). For combined landline telephone and cellular telephone data, the weighted response rate ranged from 33.8% in New York to 64.1% in South Dakota (median: 49.7%). Detailed information on response, cooperation, and refusal rates can be found in the BRFSS 2011 Summary Data Quality Report (15).

Health Status Indicators

Health Status

Respondents rated their general health as being excellent, very good, good, fair, or poor. The responses were then categorized into two groups: those who reported that their health was excellent, very good, or good and those who reported that their health was fair or poor. In 2011, the estimated prevalence of self-reported good or better health among adults aged ≥18 years ranged from 65.5% in Puerto Rico to 88.0% in Minnesota (median: 82.8%) (Table 1). Among selected MMSAs, the self-reported prevalence estimate of good or better health ranged from 72.0% in Kingsport-Bristol, Tennessee-Virginia, to 92.4% in Brookings, South Dakota (median: 83.7%) (Table 2). Among selected counties, the estimated prevalence of self-reported good or better health ranged from 74.3% in Kanawha County, West Virginia, to 94.2% in Douglas County, Colorado (median: 84.4%) (Table 3).

Health-Care Coverage

Health-care coverage was defined as currently having any kind of coverage including health insurance, prepaid plans (e.g., health maintenance organizations) or a government plan (e.g., Medicare or Medicaid) among adults aged <65 years. In 2011, the estimated prevalence of health-care coverage among adults aged <65 years ranged from 65.4% in Texas to 92.3% in Massachusetts (median: 78.7%) (Table 4). Among selected MMSAs, the estimated prevalence ranged from 66.8% in Myrtle Beach-Conway-North Myrtle Beach, South Carolina, to 94.7% in Cambridge-Newton-Framingham, Massachusetts (median: 80.5%) (Table 5). Among selected counties, the estimated prevalence ranged from 61.3% in Miami-Dade County, Florida, to 95.6% in Norfolk County, Massachusetts (median: 80.8%) (Table 6).

Preventive Practices

Recent Routine Physical Checkup

A routine physical checkup was defined as a visit to a doctor for a general physical examination rather than for a specific injury, illness, or condition. A recent routine checkup was defined as one visit that occurred within the last 12 months. In 2011, the estimated prevalence of having a recent routine physical checkup among adults aged ≥18 years ranged from 53.5% in Wyoming to 79.0% in Delaware (median: 66.5%) (Table 7). Among selected MMSAs, the estimated prevalence ranged from 45.6% in Bozeman, Montana, to 80.6% in Barnstable Town and Peabody, Massachusetts (median: 66.8%) (Table 8). Among selected counties, the estimated prevalence ranged from 45.6% in Gallatin County, Montana, to 82.8% in Bristol County, Massachusetts (median: 66.5%) (Table 9).

Influenza Vaccination

Seasonal influenza vaccination was administered in two ways: either by an injection into the arm or introduction of a spray, mist, or drop into the nose (FluMist). In 2011, the estimated prevalence of influenza vaccine among adults aged ≥65 years during the preceding 12 months ranged from 28.6% in Puerto Rico to 70.2% in Iowa and Louisiana (median: 60.7%) (Table 10). Among selected MMSAs, the estimated prevalence ranged from 42.0% in Havre, Montana, to 80.0% in Sioux City, Iowa-Nebraska-South Dakota (median: 62.4%) (Table 11). Among selected counties, the estimated prevalence ranged from 41.1% in Matanuska-Susitna Borough, Alaska, to 78.2% in Polk County, Iowa (median: 61.8%) (Table 12).

Pneumococcal Vaccination Among Adults Aged ≥65 Years

In 2011, the estimated prevalence of ever having received a pneumococcal vaccine injection among adults aged ≥65 years ranged from 22.9% in Puerto Rico to 76.0% in Oregon (median: 70.0%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 50.2% in Aberdeen, South Dakota, to 85.3% in Eugene-Springfield, Oregon (median: 71.3%) (Table 14). Among selected counties, the estimated prevalence ranged from 46.2% in Miami-Dade County, Florida, to 85.3% in Arapahoe County, Colorado, and Lane County, Oregon (median: 71.4%) (Table 15).

Blood Cholesterol Check During the Last 5 Years

In 2011, the estimated prevalence of having had a blood-cholesterol check during the preceding 5 years among adults (who might or might not have ever had one) aged ≥18 ranged from 61.9% in Guam to 83.7 in Massachusetts (median: 75.5) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 59.0% in Missoula, Montana, to 87.8% in Barnstable Town, Massachusetts (median: 75.7%) (Table 17). Among selected counties, the estimated prevalence ranged from 59.0% in Missoula County, Montana, to 87.8% in Barnstable County, Massachusetts (median: 76.2%) (Table 18).

Meeting Federal Physical Activity Recommendations

Current federal physical activity guidelines included recommendations for aerobic and for muscle strengthening activity. To assess the recommendation for aerobic physical activity (16), the time spent in moderate (3.0–5.9 metabolic equivalents [METs]) and vigorous (≥6.0 METs) intensity activity was calculated based on the two most frequently reported activities using previously described methods (17). Another variable was generated to indicate whether or not muscle-strengthening activities were done 2 or more days a week.

In 2011, the estimated prevalence of adults aged ≥18 years who engaged in moderate aerobic physical activity for at least 150 minutes per week, or vigorous activity for at least 75 minutes per week, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity during the past month ranged from 33.8% in Puerto Rico to 61.8% in Colorado (median: 51.6%) (Table 19). Among selected MMSAs, the estimated prevalence ranged from 36.4% in Chattanooga, Tennessee-Georgia, to 72.5% in Boulder, Colorado (median: 52.1%) (Table 20). Among selected counties, the estimated prevalence ranged from 34.4% in Dakota County, Nebraska, to 72.5% in Boulder County, Colorado (median: 52.9%) (Table 21).

In 2011, the estimated prevalence of adults aged ≥18 years who engaged in moderate aerobic physical activity for at least 300 minutes per week or vigorous activity for at least 150 minutes per week or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity during the past month, ranged from 15.0% in Puerto Rico to 40.7% in Colorado and Oregon (median: 32.0%) (Table 22). Among selected MMSAs, the estimated prevalence ranged from 21.2% in Watertown, South Dakota, to 48.1% in Heber, Utah (median: 31.8%) (Table 23). Among selected counties, the estimated prevalence ranged from 20.0% in Dakota County, Nebraska, to 48.1% in Wasatch County, Utah (median: 32.6%) (Table 24).

In 2011, the estimated prevalence of adults aged ≥18 years who performed muscle-strengthening activities on 2 or more days per week during the past month ranged from 12.1% in Puerto Rico to 36.1% in the District of Columbia (median: 29.6%) (Table 25). Among selected MMSAs, the estimated prevalence ranged from 13.5% in Kingsport-Bristol, Tennessee-Virginia, to 43.4% in Midland, Texas (median: 30.1%) (Table 26). Among selected counties, the estimated prevalence ranged from 17.0% in Eastland County, Texas, to 43.4% in Midland County, Texas (median: 31.0%) (Table 27).

In 2011, the estimated prevalence of adults who met the objectives for aerobic physical activities and for muscle-strengthening activities during the past month ranged from 8.5% in Puerto Rico to 27.3% in Colorado (median: 20.9%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 7.3% in Chattanooga, Tennessee-Georgia, to 32.0% in Boulder, Colorado (median: 21.0%) (Table 29). Among selected counties, the estimated prevalence ranged from 11.0% in Dakota County, Nebraska, to 32.0% in Boulder County, Colorado (median: 21.8%) (Table 30).

Health-Risk Behaviors

Current Cigarette Smoking

Current cigarette smokers were defined as respondents who reported they had smoked at least 100 cigarettes in their lifetime and, at the time of the interview, smoked every day or some days. In 2011, the estimated prevalence of current cigarette smokers aged ≥18 years ranged from 11.8% in Utah to 30.5% in Guam (median: 21.2%) (Table 31). Among selected MMSAs, the estimated prevalence ranged from 8.4% in Provo-Orem, Utah, to 30.6% in Casper, Wyoming, and Monroe, Louisiana (median: 21.0%) (Table 32). Among selected counties, the estimated prevalence ranged from 8.1% in Douglas County, Colorado, to 35.2% in Thurston County, Nebraska (median: 19.3%) (Table 33).

Binge Drinking

A survey participant was considered to be a binge drinker if, in the past month, he was a man aged ≥18 years who had an average of five or more drinks during one occasion or she was a woman aged ≥18 years who had an average of four or more drinks during one occasion. In 2011, the estimated prevalence of binge drinkers ranged from 10.0% in Tennessee to 25.0% in the District of Columbia (median: 18.3%) (Table 34). Among selected MMSAs, the estimated prevalence ranged from 7.0% in Tyler, Texas, to 32.5% in Midland, Texas (median: 18.7%) (Table 35). Among selected counties, the estimated prevalence ranged from 7.0% in Smith County, Texas, to 32.5% in Midland County, Texas (median: 18.8%) (Table 36).

Heavy Drinking

A survey participant was considered to be a heavy drinker if he was a man aged ≥18 years who had an average of more than two drinks per day during the last month or she was a woman aged ≥18 years who had an average of more than one drink per day during the last month. In 2011, the estimated prevalence of heavy drinkers ranged from 3.4% in Tennessee to 9.8% in Wisconsin (median: 6.6%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 2.4% in Hagerstown-Martinsburg, Maryland-West Virginia, to 12.1% in Tallahassee, Florida (median: 6.9%) (Table 38). Among selected counties, the estimated prevalence ranged from 2.3% in Queens County, New York, to 13.3% in Hunterdon County, New Jersey (median: 6.9%) (Table 39).

No Leisure-time Physical Activity

No leisure-time physical activity was defined as not participating in any physical activity or exercise (e.g., running, calisthenics, golf, gardening, or walking for exercise) during the preceding month. This variable is based on a different question from those used to assess meeting federal physical activity recommendations.

In 2011, the estimated prevalence of no leisure-time physical activity among adults aged ≥18 years ranged from 16.5% in Colorado to 47.3% in Puerto Rico (median: 26.2%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 11.1% in Fort Collins-Loveland, Colorado, to 40.7% in Kingsport-Bristol, Tennessee-Virginia (median: 25.1%) (Table 41). Among selected counties, the estimated prevalence ranged from 10.6% in Douglas County, Colorado, to 36.7% in Wyandotte County, Kansas, and Dakota County, Nebraska (median: 23.8%) (Table 42).

Always Wearing a Seatbelt

If a participant reported that he or she always wore a seatbelt while in an automobile, he or she was considered an all-the-time seatbelt wearer for this report. In 2011, the estimate of always wearing seatbelt among adults aged ≥18 years ranged from 63.9% in South Dakota to 94.1% in Oregon (median: 86.3%) (Table 43). Among selected MMSAs, the estimated prevalence ranged from 51.8% in Spearfish, South Dakota, to 96.9% in Tyler, Texas (median: 86.2%) (Table 44). Among selected counties, the estimated prevalence ranged from 51.8% in Lawrence County, South Dakota, to 97.0% in San Bernardino County, California, and Washington County, Oregon (median: 86.8%) (Table 45).

Chronic Conditions

Obesity

Obesity was defined as having a body mass index ≥30 among adults aged ≥18 years. In 2011, the estimated prevalence of adults aged ≥18 years who were obese ranged from 20.7% in Colorado to 34.9% in Mississippi (median: 27.7%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 15.1% in Boulder, Colorado, to 37.2% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 27.3%) (Table 47). Among selected counties, the estimated prevalence ranged from 15.1% in Boulder County, Colorado, to 41.0% in Thurston County, Nebraska (Median: 26.3%) (Table 48).

Diabetes

Diagnosed diabetes was defined as participants reporting that they had ever been told by a doctor that they had diabetes. Participants reporting gestational diabetes, prediabetes, or borderline diabetes were not considered as having diabetes. In 2011, the estimated prevalence of diagnosed diabetes among adults aged ≥18 years ranged from 6.7% in Colorado and Utah to 13.5% in Puerto Rico (median: 9.5%) (Table 49). Among selected MMSAs, the estimated prevalence ranged from 3.9% in Missoula, Montana, to 15.9% in Kingsport-Bristol, Tennessee-Virginia (median: 9.1%) (Table 50). Among selected counties, the estimated prevalence ranged from 3.5% in Douglas County, Colorado, to 18.3% in Thurston County, Nebraska (median: 9.0%) (Table 51).

Cancer Survivors

Respondents were defined as having cancer if they had ever been diagnosed with any type of cancer at any point in their lives. In 2011, the estimated prevalence of cancer survivors among adults aged ≥18 years ranged from 2.7% in Guam to 14.5% in Florida (median: 11.2%) (Table 52). Among selected MMSAs, the estimated prevalence ranged from 7.0% in Minot, North Dakota, to 19.6% in Barnstable Town, Massachusetts (median: 11.1%) (Table 53). Among selected counties, the estimated prevalence ranged from 4.9% in Prince George´s County, Maryland, to 19.6% in Barnstable County, Massachusetts (median: 10.8%) (Table 54).

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 at the time of survey participation. In 2011, the estimated prevalence of current asthma ranged from 4.3% in Guam to 12.1% in Maine (median: 9.1%) (Table 55). Among selected MMSAs, the estimated prevalence ranged from 2.9% in Brookings, South Dakota, to 14.1% in Augusta-Waterville, Maine, and Springfield, Massachusetts (median: 8.8%) (Table 56). Among selected counties, the estimated prevalence ranged from 2.9% in Brookings County, South Dakota, to 15.6% in Cleveland County, Oklahoma (median: 8.7%) (Table 57).

Arthritis

Arthritis was defined as respondents aged ≥18 years reporting having had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia among adults aged ≥18 years. Arthritis diagnoses included rheumatism, polymyalgia rheumatica, osteoarthritis (not osteoporosis), tendonitis, bursitis, bunions, tennis elbow, carpal tunnel syndrome, tarsal tunnel syndrome, or joint infection. In 2011, the estimated prevalence of arthritis ranged from 10.6% in Guam to 35.9% in West Virginia (median: 24.4%) (Table 58). Among selected MMSAs, the estimated prevalence ranged from 13.5% in Lawrence, Kansas, to 37.0% in Kingsport-Bristol, Tennessee-Virginia (median: 24.3%) (Table 59). Among selected counties, the estimated prevalence ranged from 13.5% in Douglas County, Kansas, to 35.3% in Horry County, South Carolina (median: 23.8%) (Table 60).

Depression

Depression among participants was defined as having ever been told by a health professional that the participants have a depressive disorder, which includes depression, major depression, dysthymia, or minor depression among adults aged ≥18 years. In 2011, the estimated prevalence of depression ranged from 7.6% in Guam to 24.4% in Maine (median: 17.5%) (Table 61). Among selected MMSAs, the estimated prevalence ranged from 9.1% in Santa Ana-Anaheim-Irvine, California, to 28.5% in Kingsport-Bristol, Tennessee-Virginia (median: 17.8%) (Table 62). Among selected counties, the estimated prevalence ranged from 7.6% in Fort Bend County, Texas, to 28.3% in Penobscot County, Maine (median: 17.6%) (Table 63).

Cardiovascular Conditions

High Blood Pressure

High blood pressure was defined as participants (aged ≥18 years excluding pregnant women) reporting ever having been told by a doctor, nurse, or other health-care professional they had high blood pressure. In 2011, the estimated prevalence of high blood pressure ranged from 22.5% in Guam to 41.3% in Alabama (median: 31.6%) (Table 64). Among selected MMSAs, the estimated prevalence ranged from 20.0% in Boulder, Colorado, to 47.6% in Kingsport-Bristol, Tennessee-Virginia (median: 31.5%) (Table 65). Among selected counties, the estimated prevalence ranged from 20.0% in Boulder County, Colorado, and Douglas County, Colorado, to 44.1% in Orangeburg County, South Carolina (median: 30.9%) (Table 66).

High Blood Cholesterol

Adults aged ≥20 years were categorized as having high blood cholesterol if, after having their cholesterol checked, they had ever been told by a doctor, nurse, or other health-care professional that it was high. In 2011, the estimated prevalence of high blood cholesterol ranged from 33.6% in Guam to 42.9% in Mississippi (median: 38.9%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 22.2% in Brookings, South Dakota, to 47.2% in Monroe, Louisiana (median: 37.6%) (Table 68). Among selected counties, the estimated prevalence ranged from 22.2% in Brookings County, South Dakota, to 48.9% in Aroostook County, Maine (median: 37.3%) (Table 69).

Coronary Heart Disease

Respondents were identified as having coronary heart disease if they reported that they had ever been told by a doctor, nurse, or other health-care professional that they had a heart attack (myocardial infarction) or angina. In 2011, the estimated prevalence of coronary heart disease among adults aged ≥45 years ranged from 7.1% in Colorado to 16.2% in Puerto Rico (median: 10.9%) (Table 70). Among selected MMSAs, the estimated prevalence ranged from 5.0% in Boulder, Colorado, to 19.4% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 10.8%) (Table 71). Among selected counties, the estimated prevalence ranged from 3.9% in Dakota County, Minnesota, to 18.5% in Orangeburg County, South Carolina, and Eastland County, Texas (median: 10.3%) (Table 72).

Stroke

Respondents were identified as having had a stroke if they reported that they had ever been told by a doctor, nurse, or other health-care professional that they had a stroke. In 2011, the estimated prevalence of stroke among adults aged ≥45 years ranged from 3.0% in Puerto Rico to 7.2% in Alabama (median: 4.8%) (Table 73). Among selected MMSAs, the estimated prevalence ranged from 1.4% in Davenport-Moline-Rock Island, Iowa-Illinois, to 10.2% in Tuscaloosa, Alabama (median: 4.7%) (Table 74). Among selected counties, the estimated prevalence ranged from 2.1% in Monmouth County, New Jersey, to 8.4% in Vermilion Parish, Louisiana (median: 4.4%) (Table 75).

Disability

Activity Limitation

Respondents were asked if they were limited in any way in performing any activities because of physical, mental, or emotional problems. In 2011, the estimated prevalence of limited activities among adults aged ≥18 years ranged from 16.7% in Guam to 31.4% in West Virginia (median: 23.6%) (Table 76). Among selected MMSAs, the estimated prevalence ranged from 15.9% in Kapaa, Hawaii, to 36.3% in Lewiston, Idaho-Washington (median: 23.6%) (Table 77). Among selected counties, the estimated prevalence ranged from 15.0% in Fort Bend County, Texas, to 34.2% in Lewis and Clark County, Montana (median: 23.2%) (Table 78).

Use of Special Equipment

Respondents were asked if they currently had any health problem that required them to use special equipment (e.g., a cane, a wheelchair, a special bed, or a special telephone), which included occasional use or use in certain circumstances. In 2011, the estimated prevalence of using special equipment because of any health problem among adults aged ≥18 years ranged from 5.1% in Guam to 11.3% in Kentucky and West Virginia (median: 7.9%) (Table 79). Among selected MMSAs, the estimated prevalence ranged from 3.9% in Fairbanks, Alaska, to 13.2% in Mobile, Alabama (median: 7.8%) (Table 80). Among selected counties, the estimated prevalence ranged from 2.4% in Dakota County, Minnesota, to 14.7% in Thurston County, Nebraska (median: 7.4%) (Table 81).

A summary of prevalence estimates for 2011 for each selected BRFSS measure is presented by median and ranges by states/territories, MMSAs, and counties (Table 82).

Discussion

Notable changes in BRFSS over time have included the telephone survey design and preparation of data for release. The 2011 survey was the first time cellular telephone interviews were included in the survey. The inclusion of cellular telephone interviews and the adoption of new statistical weighting methodology in 2011 has maintained survey validity and improved the representativeness of data collected by BRFSS. Because of the change in the weighting methodology and the inclusion of cellular telephone respondents, some changes have been made to the prevalence estimates, especially for certain variables (18); therefore, users should not compare 2011 prevalence estimates with those from previous years, or conduct a trend analysis from previous years, but instead use 2011 results as a baseline to compare with subsequent survey results.

In recent years, the use of cellular telephones has increased substantially. Research suggests 31.6% of U.S. homes had only cellular telephones during the first half of 2011, and this percentage continued to increase (18). The difference in demographic characteristics is also noted in households using only cellular telephones. For instance, younger adults, men, adults living in poverty, and Hispanics tend to live in households using cellular telephones only (18). To resolve selection bias and survey validity issues resulting from undercoverage, BRFSS survey methodology was adjusted by including participants using cellular telephones only. Incorporating cellular- and landline-collected interview data into a dual-frame survey has improved the representativeness of the BRFSS survey by ensuring more coverage of persons with any type of phone (10).

In addition to including cellular telephone interviews in the BRFSS data collection, a new weighting methodology called "raking" replaced post stratification in 2011. Poststratification had required knowing the proportion of the weighting variable. Raking, a more-complex weighting procedure, overcame this requirement and is used to adjust for noncoverage and nonresponse in the survey respondent population to predetermined proportions of age, sex, race and ethnicity, and regions (19). Raking allows the use of additional demographic variables and can match more accurately the sample distributions to known population demographic characteristics. This technique reduces potential selection bias and ultimately improves representativeness by introducing more demographic variables including education level, marital status, and home ownership status. Raking fits a dual-frame survey design, which includes landline-telephone only, cellular-telephone only, and combined landline telephone and cellular telephone. The technical change of weighting method has been documented for BRFSS users on the BRFSS webpage (20).

The findings in this report indicate substantial geographic variations in the estimated prevalence of health-care coverage and access, use of preventive care, health-risk behaviors, and chronic conditions among adults in the United States at the levels of state and territory, MMSA, and county. These variations from the crude estimates might reflect the differences in demographic characteristics, socioeconomic and cultural contexts, health-care use and spending, state laws, and local ordinances, or combinations of these factors. The estimated prevalences are useful to local public health advisors and health policy makers in tracking disease estimates, setting priorities in addressing public health needs at various levels, identifying obstacles to health-care access and use, monitoring high-risk behaviors, and implementing prevention programs and policies. The prevalences in this report were direct estimates and were not based on models; therefore, the results might differ somewhat compared with those based on models from other resources (22).

Health Status Indicators

BRFSS uses self-reported general health status, which has been validated as an independent predictor of mortality (23). In this report, the median value of state- and local-level participants reporting not having good or better health was approximately 18%, indicating a limit in daily functional ability (24). In 2011, the median prevalence for adults aged <65 years at the same state- and local-level reporting that they had health-care coverage was approximately 80%. Those lacking health-care coverage were less likely to receive preventive treatments and screenings and, therefore, faced greater risk for advanced-stage cancer diagnosis and death from uncontrolled chronic diseases, trauma, or other acute conditions (25,26).

Preventive Practices

Recent Routine Physical Checkup

A routine checkup and its associated screenings might reveal the presence of a disease or other health problem when it still is in its early stages and is most likely to be treated successfully (27). In 2011, the median prevalence of having received a routine physical checkup among adults, at the state or local level, is approximately 66%. In addition to geographic variation, access to health care can vary by racial background of residents and socioeconomic factors such as education and income level (28).

Influenza Vaccination

For the elderly, influenza and pneumococcal vaccinations are especially important because these infections can increase morbidity and mortality (29,30), and their associated risks can be lowered by vaccinations (31,32). In 2011, the median prevalence of having received an influenza vaccination during the preceding 12 months or a pneumococcal vaccination ever among adults aged ≥65 was approximately 61% and 71%, respectively. The estimation was based on data collected in 2011, which might be different from season-specific vaccination coverage. CDC recommendations and guidelines are available on how to promote adult vaccinations; strategies include patient and provider reminder programs and improvements in health-care access and vaccination practice, including assessment, administration, and other measures (33).

Physical Activity

Regular physical activity can help persons maintain a healthy body weight, strengthen bones and muscles, improve mental health and mood, and reduce the risk for cardiovascular diseases, type II diabetes, and some cancers (34). In 2011, physical activity variables were derived in the BRFSS survey to follow 2008 Physical Activity Guidelines for Americans (35), which recommend aerobic physical activity of at least moderate intensity and muscle strengthening. Data from the 2011 BRFSS show that the median prevalences of meeting federal physical activity recommendations were approximately 52% and 32% for moderate and vigorous aerobic physical activities, respectively, and 30% for muscle strengthening activities alone. In addition to measuring physical activity level, BRFSS also includes a question regarding no leisure-time physical activity. The median prevalence of having no leisure-time physical activity at state level was 26.2%. The results further indicate geographic discrepancies in prevalence estimates. To address these discrepancies, states and local communities can help more of their residents meet these recommendations using strategies such as those recommended in the Community Guide (36).

Health-Risk Behaviors

Cigarette Smoking

Tobacco use results in approximately 5 million deaths worldwide per year, yet it is the single-most preventable cause of disease and death (37). In the United States, the prevalence of current cigarette smoking has declined significantly from 20.9% in 2005 to 19.3% in 2010, although the decline was not consistent on a year-to-year basis (38). In 2011, approximately 20% of adults (median prevalence at state or local level) reported they were current smokers and had ever smoked at least 100 cigarettes. The findings underscore the need for tobacco-control efforts to continue and even to be enhanced so the prevalence of cigarette smoking can be lowered in more areas.

Excessive Alcohol Use

Excessive alcohol use, including binge and heavy drinking, is the third-leading preventable cause of death in the United States (39). In 2011, the median prevalences of binge and heavy drinking were approximately 18% and 7%, respectively, at state and local levels. This finding suggests that excessive alcohol use among adult U.S. residents can be addressed with effective collaboration between federal, state, and community agencies (40).

Unintentional Injuries

Accidents (unintentional injuries) are the fifth-leading cause of death in the United States (1); motor vehicle crashes are one of the leading causes of unintentional injury death. An estimated 33,783 persons died in motor vehicle crashes in 2011 in the United States (41). The findings in this report indicate that many persons do not wear seatbelts while driving or riding in a vehicle, and there is great variation across states, making some populations at increased risk for crash-related injury or death. To help protect persons from injuries caused from motor vehicle crashes, CDC recommends implementation of evidence-based interventions such as ones identified by the Task Force for Community Preventive Services, including primary enforcement of seatbelt laws and enhanced enforcement programs (42).

Chronic Conditions and Disability

Obesity

Obesity is a chronic health condition as well as a risk factor for other chronic conditions. Based on participants' measured weight and height, data from the National Health and Nutrition Examination Survey 2011–2012 revealed that the prevalence of age adjusted obesity was 33.5% among adult men and 36.1% among adult women (44). Obesity is caused by many factors, including genetics, metabolism, behavior, environment, and socioeconomic status, but environmental and behavioral factors are two main contributors (45). The median prevalence of self-reported obesity in this report was approximately 28% at the state or local level; however, self-reported obesity was approximately 28% at the state or local level. Self-reported obesity prevalence tends to be underestimated (46).

Diabetes

Diabetes is another critical chronic condition that is associated with many health problems (47). In 2011, the median prevalence of self-reported diabetes was 9.5% at the state level. Because BRFSS did not include undiagnosed diabetes, the actual prevalence might be higher. By 2012 in the United States, 29.1 million persons aged ≥20 years have had undiagnosed and diagnosed diabetes; approximately 27.8% of persons with diabetes are undiagnosed (48). Although treatment and care are important for persons already living with diabetes, effective preventive strategies need to be undertaken, especially among groups at high risk for developing type II diabetes.

Cancer

Cancer is the second-leading cause of death in the United States (1). By 2011, approximately 13.4 million persons in the United States had survived cancer (49,50). Cancer survivors had 14% higher risks for developing a new malignancy (51) and were more susceptible to other chronic conditions (52) compared with those who never had cancer. In 2011, the median prevalence of cancer survivors was approximately 11% at the state or local level.

Asthma

The number of persons with current asthma increased by 2.9% each year from 2001 to 2010, reaching 25.7 million in 2010, of whom 72.8% were adults (53). In 2011, the median prevalence of current asthma was 9% at the state or local level. No cure exists for asthma, but the symptoms often can be controlled by taking medicines, getting self-management education, and avoiding exposure to asthma triggers (54). To improve asthma management, high-risk populations should be identified for targeted prevention programs.

Arthritis

During 2010 and 2012, approximately 52.5 million (22.7%) adults aged ≥18 years had self-reported they had been diagnosed with arthritis, and 22.7 million had arthritis-attributable activity limitation (55). In 2011, the median prevalence of diagnosed arthritis was approximately 24% at the state or local level. Arthritis often can be controlled and managed by medication, maintaining healthy body weight, and by being physically active.

Depression

Depression is a health condition, often unrecognized, that might be correlated with other chronic conditions and risk behaviors. Mental health problems were most common in smokers (56), and those with mental health issues were at increased risk for having high blood pressure and high blood cholesterol (57). In 2011, the median prevalence of having had any depressive disorder including major depression, dysthymia, and minor depression at the state or local level was approximately 17%.

Heart Disease

Heart disease is the leading cause of death in both men and women in the United States (1) and contributed to approximately 24.2% of total deaths in the United States in 2010 (58). Stroke can cause serious long-term disability (59) and is the fourth-leading cause of death in the United States (1). In 2011, the median prevalence of having had coronary heart disease and stroke among adults aged ≥45 years was 10.9% and 4.8%, respectively, at the state level. High blood pressure and high blood cholesterol are the two primary risk factors for both coronary heart disease and stroke (60). Many factors can increase the risk for developing high blood pressure and having a high blood cholesterol level, particularly a family history of the diseases, being an older person, being of black descent, having diabetes, consuming a diet high in sodium, being overweight and physically inactive, using tobacco, and using alcohol excessively (61). In 2011, the median prevalence of high blood pressure was approximately 31% and high blood cholesterol among adults aged ≥20 years was approximately 38% at the state or local level. High blood pressure and cholesterol can be prevented or controlled by eating a healthy diet, maintaining a healthy weight, exercising regularly, quitting smoking, limiting alcohol use, managing diabetes, monitoring blood pressure, getting a blood test, and taking medications as needed.

Disability

Approximately 56.6 million persons in the United States have a disability, and 38.3 million of these have a serious disability (62). Persons with disabilities also had higher rates of emergency department use and hospitalization, yet they had more problems with health-care access than those without disabilities (63). Because of their vulnerabilities from their physical condition, persons with disabilities might face many challenges in accessing health care. In 2011, the median prevalence of using special equipment for any health problem at a state or local level was 7%. As the nation's population continues to age, persons with disabilities will require additional attention to optimize health and daily coping strategies.

Limitations

The findings in this report are subject to at least four limitations. First, BRFSS results might not be generalizable to the entire U.S. population. The BRFSS survey design excludes persons from institutions, nursing homes, long-term care facilities, military installations, and correctional institutions. Because BRFSS is conducted by telephone interview, it excludes persons who do not have telephones for personal use. Second, although BRFSS is conducted in several languages other than English (i.e., Spanish, Mandarin, and Portuguese), the survey does not apply to persons who speak other languages only. Third, because of the small sample size or unreliable estimates, the prevalence of certain variables could not be obtained at certain MMSA or county levels. Finally, because BRFSS data are self-reported, information is subject to recall bias and, as with all surveys, potential for bias exists from question wording or order. However, the major improvement of 2011 BRFSS—which involved including survey data from participants using cellular telephones in addition to landline telephone-collected data—increases the representativeness and accuracy.

Overall, BRFSS is a cost-effective, timely, and flexible survey that provides reliable estimates of health status, health-risk behaviors, chronic conditions, disabilities, and access to preventive services at state and local levels. Although different surveys use different sampling frames and data collection modes, BRFSS was compared with other surveys and its prevalence estimates were consistent with other national survey databases (64,65), and the validity and reliability have been tested (9). BRFSS is the only source of large data sets available to many state health departments and local communities to assess health conditions and to track progress of health promotion programs and strategies in a timely and accurate way (66).

Conclusion

The results in this report suggest the importance of continuing to monitor high-risk behaviors and chronic conditions and increase the use of vaccination against influenza and pneumococcal diseases at state and local levels. Reducing unhealthy behaviors, adopting a healthy lifestyle, and increasing awareness of health promotion strategies could help prevent or control chronic conditions. BRFSS continues to serve as an important data source to help state and local health departments identify emerging public health problems and help states and local communities implement health prevention programs and strategies that help decrease morbidity and mortality risk.

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