Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas — Behavioral Risk Factor Surveillance System, United States, 2015

Problem Chronic conditions and disorders (e.g., diabetes, cardiovascular diseases, arthritis, and depression) are leading causes of morbidity and mortality in the United States. Healthy behaviors (e.g., physical activity, avoiding cigarette use, and refraining from binge drinking) and preventive practices (e.g., visiting a doctor for a routine check-up, tracking blood pressure, and monitoring blood cholesterol) might help prevent or successfully manage these chronic conditions. Monitoring chronic diseases, health-risk behaviors, and access to and use of health care are fundamental to the development of effective public health programs and policies at the state and local levels. Reporting Period January–December 2015. Description of the System The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit–dialed landline- and cellular-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 and use of health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico (Puerto Rico), and Guam and for 130 metropolitan and micropolitan statistical areas (MMSAs) (N = 441,456 respondents) for 2015. Results The age-adjusted prevalence estimates of health-risk behaviors, self-reported chronic health conditions, access to and use of health care, and use of preventive health services varied substantially by state, territory, and MMSA in 2015. Results are summarized for selected BRFSS measures. Each set of proportions refers to the median (range) of age-adjusted prevalence estimates for health-risk behaviors, self-reported chronic diseases or conditions, or use of preventive health care services by geographic jurisdiction, as reported by survey respondents. Adults with good or better health: 84.6% (65.9%–88.8%) for states and territories and 85.2% (66.9%–91.3%) for MMSAs. Adults with ≥14 days of poor physical health in the past 30 days: 10.9% (8.2%–17.2%) for states and territories and 10.9% (6.6%–19.1%) for MMSAs. Adults with ≥14 days of poor mental health in the past 30 days: 11.3% (7.3%–15.8%) for states and territories and 11.4% (5.6%–20.5%) for MMSAs. Adults aged 18–64 years with health care coverage: 86.8% (72.0%–93.8%) for states and territories and 86.8% (63.2%–95.7%) for MMSAs. Adults who received a routine physical checkup during the preceding 12 months: 69.0% (58.1%–79.8%) for states and territories and 69.4% (57.1%–81.1%) for MMSAs. Adults who ever had their blood cholesterol checked: 79.1% (73.3%–86.7%) for states and territories and 79.5% (65.1%–87.3%) for MMSAs. Current cigarette smoking among adults: 17.7% (9.0%–27.2%) for states and territories and 17.3% (4.5%–29.5%) for MMSAs. Binge drinking among adults during the preceding 30 days: 17.2% (11.2%–26.0%) for states and territories and 17.4% (5.5%–24.5%) for MMSAs. Adults who reported no leisure-time physical activity during the preceding month: 25.5% (17.6%–47.1%) for states and territories and 24.5% (16.1%–47.3%) for MMSAs. Adults who reported consuming fruit less than once per day during the preceding month: 40.5% (33.3%–55.5%) for states and territories and 40.3% (30.1%–57.3%) for MMSAs. Adults who reported consuming vegetables less than once per day during the preceding month: 22.4% (16.6%–31.3%) for states and territories and 22.3% (13.6%–32.0%) for MMSAs. Adults who have obesity: 29.5% (19.9%–36.0%) for states and territories and 28.5% (17.8%–41.6%) for MMSAs. Adults aged ≥45 years with diagnosed diabetes: 15.9% (11.2%–26.8%) for states and territories and 15.7% (10.5%–27.6%) for MMSAs. Adults aged ≥18 years with a form of arthritis: 22.7% (17.2%–33.6%) for states and territories and 23.2% (12.3%–33.9%) for MMSAs. Adults having had a depressive disorder: 19.0% (9.6%–27.0%) for states and territories and 19.2% (9.9%–27.2%) for MMSAs. Adults with high blood pressure: 29.1% (24.2%–39.9%) for states and territories and 29.0% (19.7%–41.0%) for MMSAs. Adults with high blood cholesterol: 31.8% (27.1%–37.3%) for states and territories and 31.4% (23.2%–42.0%) for MMSAs. Adults aged ≥45 years who have had coronary heart disease: 10.3% (7.2%–16.8%) for states and territories and 10.1% (4.7%–17.8%) for MMSAs. Adults aged ≥45 years who have had a stroke: 4.9% (2.5%–7.5%) for states and territories and 4.7% (2.1%–8.4%) for MMSAs. Interpretation The prevalence of health care access and use, health-risk behaviors, and chronic health conditions varied by state, territory, and MMSA. The data in this report underline the importance of continuing to monitor chronic diseases, health-risk behaviors, and access to and use of health care in order to assist in the planning and evaluation of public health programs and policies at the state, territory, and MMSA level. Public Health Action State and local health departments and agencies and others interested in health and health care can continue to use BRFSS data to identify groups with or at high risk for chronic conditions, unhealthy behaviors, and limited health care access and use. BRFSS data also can be used to help design, implement, monitor, and evaluate health-related programs and policies.


Introduction
Chronic conditions (e.g., cardiovascular diseases, diabetes, and arthritis) are leading causes of morbidity, mortality, and health care spending in the United States (1,2). Adopting healthy behaviors (e.g., eating a healthy diet, exercising, avoiding tobacco, and refraining from alcohol) and using preventive services (e.g., visiting a doctor, monitoring and treating blood pressure, and monitoring cholesterol) might prevent chronic disease and help effectively manage chronic conditions (2). At the population level, monitoring health behaviors, chronic conditions, and health care use can inform action to address these leading causes of death and disability.
The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based survey conducted via landline and cellular telephone. Since 1984, BRFSS has been conducted by U.S. states and territories with technical assistance from CDC. BRFSS is the largest continuously running healthbased telephone survey in the world (3). BRFSS is a principal source of data on health-risk behaviors, chronic diseases, and health care access and use at the state and local levels. States, counties, cities, and others use BRFSS data to set objectives, track progress, and evaluate the effectiveness of health-related initiatives. Beginning in 2002, BRFSS has calculated prevalence estimates for selected counties, metropolitan divisions, and metropolitan or micropolitan statistical areas (MMSAs). This report contains age-adjusted prevalence estimates for various chronic conditions, health-risk behaviors, and use of preventive health services by state, territory, and selected MMSA for 2015.

Methods
BRFSS is an ongoing, cross-sectional, random-digit-dialed telephone survey that completes approximately 400,000 interviews with adults residing in the United States or its territories each year. BRFSS is conducted by states and territories receiving technical assistance from CDC. BRFSS uses a multistage sampling design to select a representative sample of the noninstitutionalized adult population aged ≥18 years residing within each state and territory. The validity and reliability of the BRFSS survey have been reviewed in detail elsewhere (4).
In 2015, all 50 U.S. states, the District of Columbia, Puerto Rico, and Guam collected both landline and cellular telephone surveys (5). In the landline survey, one adult was randomly chosen from each selected household. In the cellular phone survey, each adult respondent was considered a oneperson household (6).
Participants reported their county of residence in the demographics section of the core questionnaire. Persons were assigned to MMSAs on the basis of American National Standards Institute county codes (7). MMSAs are defined by the U.S. Office of Management and Budget (7). This report contains age-adjusted prevalence estimates for general health status, health-risk behaviors, self-reported chronic health conditions, and access to and use of health care for all 50 states, the District of Columbia, Puerto Rico, and Guam and for 130 MMSAs containing ≥500 total respondents.

Questionnaire
The BRFSS questionnaire consists of three sections: a core component, optional modules, and state-added questions. All questions in the core component and optional modules undergo technical review, cognitive testing, and field testing (6).
States must ask all core component questions without modification (6). In 2015, questions in the BRFSS core component addressed participants' self-reported health status, number of physically and mentally healthy days in the past 30 days, health care access and use, high blood pressure awareness, high cholesterol awareness, chronic health conditions, demographics, tobacco use, alcohol consumption, fruit and vegetable consumption, physical activity, arthritis burden, seatbelt use, immunization, and testing for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (6).
In addition to the core questionnaire component, states could include up to 25 optional questionnaire modules. In 2015, a total of 24 optional modules were used by at least one state or territory as follows: adult asthma history (two states), adult human papillomavirus (nine states), anxiety and depression (five states), arthritis management (14 states), breast and cervical cancer screening (seven states), cardiovascular health (five states), caregiver (24 states), childhood asthma prevalence (32 states), clinical breast examination for breast cancer screening (three states), cognitive decline (35 states), colorectal cancer screening (12 states), diabetes (39 states), emotional support and life satisfaction (three states), industry and occupation (25 states), prediabetes (20 states), prostate cancer screening (three states), prostate cancer screening decision making (one state), sexual orientation and gender identity (22 states), shingles (nine states), social context (16 states), sodium or salt-related behavior (10 states), tetanus-diphtheria vaccination in adults (11 states), visual impairment and access to eye care (one state), and random child selection (36 states). The random child selection module collects demographic information on one randomly selected child in the household (data include age, sex, race/ethnicity, and relation of the child to the respondent). This module is also used to randomly select a child for the Asthma Call-back Survey, although various states that use the random child selection module do not participate in the Asthma Call-back Survey (8).
To address state-specific needs, states also can add their own questions to the BRFSS questionnaire. State-added questions were not evaluated by CDC and are not released in public-use data sets (6).
In 2015, certain states used a split questionnaire design. Up to three different questionnaire versions were permitted. Although core questions were required to be used in all versions, state-added questions and optional modules did not have this requirement. Using a split questionnaire design allowed states to include a larger variety of optional modules or state-added questions (6). CDC provided a Spanish translation of the BRFSS core questionnaire and optional modules in 2015. States could translate the BRFSS questionnaire into other languages (6).

Data Collection and Processing
Since 2007, BRFSS surveys have been collected monthly in all 50 states, the District of Columbia, Puerto Rico, and Guam. In 2015, all BRFSS interviews were conducted according to standard protocols, which ensure interview quality and confidentiality (9). Data collected by the states are submitted to CDC for processing, checking, and weighting.

Sampling
A BRFSS sample record was one telephone number in the list of all telephone numbers that were randomly selected for dialing (6). In 2015, Puerto Rico and Guam used simple random sampling to collect their landline samples, and all 50 states and the District of Columbia used disproportionate stratified sampling (DSS) for the landline portion of the sample. In the DSS approach, telephone numbers were separated into two strata (high-density and medium-density) on the basis of the number of listed telephone numbers in their hundred block. Both strata were expected to contain mostly household telephone numbers, but high-density strata were sampled at a higher rate than medium-density strata (6). The DSS design resulted in a probability sample of all households with telephones (6).
Cellular telephone sampling frames were provided by the Telecordia database of telephone exchanges. Cell phone numbers were randomly selected from these sampling frames (6). The target population for the cellular telephone sample was adults aged ≥18 years with a functioning cell phone who resided in a private residence or college housing. The states' cell phone samples often reached adults who had moved to a different state. These records were transferred to the appropriate state (i.e., the participant's state of residence) at the end of the year. In 2015, a total of 46 states or territories (all except the District of Columbia, Florida, Guam, North Dakota, Oregon, West Virginia, and Wyoming) sampled disproportionately by geographic stratum to ensure adequate sample sizes in sub-state geographic regions (6).

Data Weighting Design Weights
BRFSS created design weights that account for unequal selection probabilities, noncoverage, and nonresponse (6). Design weights of dual cell phone and landline users were adjusted to account for the complete overlap of cell phone and landline sampling frames. Design weights were truncated by quartile within geographic region or state (6). BRFSS used weight trimming to reduce the value of extremely high weights and to increase the value of extremely low weights, with the objective of reducing errors in prevalence estimates (6).

Raking
Beginning in 2011, BRFSS data have been weighted using a process known as iterative proportional fitting ("raking"), rather than previous poststratification methods. In the past, BRFSS poststratification weights were based only on three sociodemographic characteristics: age, sex, and race/ethnicity. In contrast, the new raking process permits the inclusion of additional sociodemographic characteristics (e.g., marital status and home ownership) as well as cellular telephone survey data (10). Raking allows the sociodemographic makeup of BRFSS to more closely match the known sociodemographic makeup of states and MMSAs (10).
The 2015 BRFSS data were raked using the following demographic characteristics: sex by age group, race/ ethnicity, education, marital status, home renter/owner, sex by race/ ethnicity, age group by race/ethnicity, and phone ownership (6). If states collected BRFSS data by geographic region, then BRFSS data were raked by four additional margins: region, region by age group, region by sex, and region by race/ethnicity (6). BRFSS data were raked to each of these margins in an iterative process until a convergence of a set value was reached.
Persons were assigned to MMSAs on the basis of American National Standards Institute county codes (7). For MMSAs with ≥500 respondents, BRFSS data were raked by five additional margins at the MMSA level: age group, sex, race/ ethnicity, sex by age group, and sex by race/ethnicity (7). More detailed information on MMSA weighting is located on the BRFSS SMART webpage (11).

Statistical Analyses
Age adjustment is a standard analytical technique used to compare estimates between populations with different age distributions (e.g., between states) and over time. In this report, prevalence estimates were directly age adjusted so that the reader can compare estimates across states and MMSAs with different age distributions. Age adjusted prevalence estimates were standardized to the 2000 projected U.S. population, which is consistent with recommendations from the CDC National Center for Health Statistics (12).
For prevalence estimates among adults aged ≥18 years, three age adjustment categories were used: 18-44 years (standardized proportion: 0.5305), 45-64 years (standardized proportion: 0.2992), and ≥65 years (standardized proportion: 0.1703). For prevalence estimates among adults aged 18-64 years, two age adjustment categories were used: 18-44 years (standardized proportion: 0.6394) and 45-64 years (standardized proportion: 0.3606). For prevalence estimates among adults aged ≥45 years, four age adjustment categories were used: 45-54 years (standardized proportion: 0.3869), 55-64 years (standardized proportion: 0.2504), 65-74 years (standardized proportion: 0.1895), and ≥75 years (standardized proportion: 0.1732). Age-adjusted prevalence estimates are taken from direct responses and are not the results of modeling. Age was imputed for the limited number of persons who were missing data on age. To account for BRFSS's complex sampling design, all prevalence estimates in this report were calculated using weights and strata in SAS version 9.3 (SAS Institute Inc., Cary, North Carolina) or SAS-callable SUDAAN Version 11 (RTI International, Research Triangle Park, North Carolina). Crude (unadjusted) estimates for each state and MMSA are available on the BRFSS website (13). Most prior BRFSS reports (i.e., those reporting on 2012 survey data and earlier) included crude prevalence estimates rather than age-adjusted prevalence estimates. The age-adjusted prevalence estimates in this BRFSS report should not be directly compared with crude prevalence estimates in most prior BRFSS reports.
This report presents unweighted sample sizes; age-adjusted, weighted prevalence estimates with standard errors; and 95% confidence intervals for the prevalence of chronic health conditions, health-risk behaviors, and use of preventive health care services by state, territory, and MMSA using 2015 BRFSS data. Only MMSAs with ≥500 respondents are included in this report. County-level estimates are not presented in this report. Modeled small area estimates at the county level will be released at a future date.
If the unweighted sample size of any jurisdiction or subpopulation was <50 or if the relative standard error was >30%, the findings were suppressed to avoid unstable estimates. Relative standard error was calculated by dividing the standard error of the estimated prevalence by the estimated prevalence and multiplying by 100 (for percent). Responses coded as "refused" or "do not know" were excluded from the given analysis.

About This Report
This report presents age-adjusted prevalence estimates and a discussion of the following topics: 1) health status indicators (general health status, poor physical health, poor mental health, and health care coverage for adults aged 18-64 years), 2) preventive practices (recent routine physical checkup, ever having blood cholesterol checked), 3) health-risk behaviors (current cigarette smoking, binge drinking, no leisure-time physical activity, consuming fruit less than once per day, and consuming vegetables less than once per day), and 4) chronic conditions (among adults aged ≥18 years: obesity, arthritis, depressive disorder, high blood pressure, and high blood cholesterol; among adults aged ≥45 years: diabetes, coronary heart disease, and stroke). Respondents self-reported their height and weight. Body mass index (BMI) was calculated by dividing weight (in kilograms) by height (in meters) squared. Obesity was defined as BMI ≥30.0 kg/m 2 . The prevalence of all other chronic conditions was based on self-report of the specific condition: i.e., participants were asked if they had ever been told 79.8% in Rhode Island (median: 69.0%) (Table 9). Among selected MMSAs, the 2015 age-adjusted prevalence estimates ranged from 57.1% in Spartanburg, South Carolina, to 81.1% in Providence-Warwick, Rhode Island-Massachusetts (median: 69.4%) (Table 10).

Ever Had Blood Cholesterol Checked
In 2015, the age-adjusted prevalence estimates of adults aged ≥18 years who reported ever having their blood cholesterol checked ranged from 73.3% in New Mexico to 86.7% in the District of Columbia (median: 79.1%) (Table 11). Among 130 selected MMSAs, the age-adjusted prevalence estimates ranged from 65.1% in Logan, Utah-Idaho to 87.3% in Raleigh, North Carolina (median: 79.5%) (Table 12).

Health-Risk Behaviors Current Cigarette Smoking
Adults were considered current smokers if they reported having smoked at least 100 cigarettes in their lifetime and currently smoked every day or on certain days. In 2015, the estimated age-adjusted prevalence of current smoking among adults aged ≥18 years ranged from 9.0% in Utah to 27.2% in West Virginia (median: 17.7%) (Table 13). Among 130 selected MMSAs, the age-adjusted prevalence estimates of current smokers ranged from 4.5% in Logan, Utah-Idaho, to 29.5% in Akron, Ohio (median: 17.3%) (Table 14).

Binge Drinking
Males were considered binge drinkers if they had five or more drinks on one or more occasions during the past 30 days. Females were considered binge drinkers if they had four or more drinks on one or more occasions during the past 30 days. The age-adjusted prevalence estimates of binge drinking among adults aged ≥18 years ranged from 11.2% in Tennessee to 26.0% in the District of Columbia in 2015 (median: 17.2%) (Table 15). Among selected MMSAs, the age-adjusted prevalence estimates of adults who reported binge drinking ranged from 5.5% in Provo-Orem, Utah, to 24.5% in Duluth, Minnesota-Wisconsin (median: 17.4%) (Table 16).

Depressive Disorder
Adults aged ≥18 years of age were identified as having a depressive disorder if they were ever told by a health professional that they had a depressive disorder (including depression, major depression, dysthymia, or minor depression). In 2015, the age-adjusted prevalence estimates of depressive disorder ranged from 9.6% in Guam to 27.0% in Oregon (median: 19.0%) (Table 29). Among selected MMSAs, the age-adjusted prevalence estimates of depressive disorder ranged from 9.9% in Los Angeles-Long Beach-Anaheim, California, to 27.2% in Spartanburg, South Carolina (median: 19.2%) (Table 30).

High Blood Pressure
Respondents were considered to have high blood pressure if they had ever been told by a health professional that they had high blood pressure (excluding high blood pressure during pregnancy). The 2015 age-adjusted prevalence estimates of high blood pressure among adults aged ≥18 years ranged from 24.2% in Minnesota to 39.9% in Mississippi (median: 29.1%) ( Table 31). Among selected MMSAs, the age-adjusted prevalence estimates ranged from 19.7% in Rochester, Minnesota, to 41.0% in Gulfport-Biloxi-Pascagoula, Mississippi (median: 29.0%) (Table 32).

High Blood Cholesterol
Adults were classified as having high cholesterol if, after having their blood cholesterol checked, they had ever been told by a health professional that their cholesterol was high. (Adults who had never had their blood cholesterol checked were excluded from analysis.) In 2015, the age-adjusted prevalence estimates of high blood cholesterol among adults aged ≥18 years ranged from 27.1% in Montana to 37.3% in Puerto Rico (median: 31.8%) (Table 33). Among selected MMSAs, the age-adjusted prevalence estimates of high blood cholesterol ranged from 23.2% in Aberdeen, South Dakota, to 42.0% in Kahului-Wailuku-Lahaina, Hawaii (median: 31.4%) (Table 34).

Coronary Heart Disease
Respondents were classified as having coronary heart disease if they had ever been told by a health professional that they had a heart attack (i.e., myocardial infarction) or angina. In 2015, the age-adjusted prevalence estimates of coronary heart disease among adults aged ≥45 years ranged from 7.2% in Hawaii to 16.8% in West Virginia (median: 10.3%) (Table 35). Among selected MMSAs, the age-adjusted prevalence estimates of adults aged ≥45 years who reported coronary heart disease ranged from 4.7% in San Jose-Sunnyvale-Santa Clara, California, to 17.8% in Wichita Falls, Texas (median: 10.1%) (Table 36).

Stroke
Adults were classified as having had a stroke if they had ever been told by a health professional that they had a stroke. In 2015, the age-adjusted prevalence estimates of stroke among adults aged ≥45 years ranged from 2.5% in Puerto Rico to 7.5% in Mississippi (median: 4.9%) (Table 37). Among selected MMSAs, the age-adjusted prevalence estimates of stroke among adults aged ≥45 years ranged from 2.1% in College Station-Bryan, Texas, to 8.4% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 4.7%) (Table 38).

Discussion
The findings in this report reveal considerable geographic variation in the age-adjusted estimated prevalence of health care access and use, health-risk behaviors, and chronic health conditions among U.S. adults at the state, territory, and MMSA level. Variations in age-adjusted prevalence estimates might be because of differences in sociodemographic characteristics, cultural contexts, behavioral risk factors for health conditions, health care access and affordability, state and municipal laws, or combinations of these factors. BRFSS is one of the main sources of health information at the state and local level. Prevalence estimates from BRFSS are used at the state and local level to monitor changes in population health status over time, to determine the needs of public health programming, and to evaluate the effectiveness of public health initiatives.

Health Status Indicators
Self-reported general health status is a strong risk factor for mortality independent of other medical and sociodemographic characteristics (18). Likewise, physical and mental healthy days measures are independent predictors of physician visits, hospitalization, and mortality (19). These self-reported health measures have been found to be reliable and valid (20,21). In the 2015 BRFSS, the estimated prevalence of self-reported fair or poor general health status ranged from 11.2% to 34.1% among states and territories and from 8.7% to 33.1% in selected MMSAs (i.e., this prevalence represents adults who did not report good or better general health status in Tables 1-2). The estimated prevalence of adults reporting poor physical or mental health for ≥14 of the last 30 days also varied by geographic region. To reduce the prevalence of poor physical and mental health status, it is essential to investigate and address the underlying causes of these conditions.

Health Care Coverage
According to BRFSS data, the median age-adjusted prevalence of health care coverage among adults aged 18-64 years increased from 78.4% in 2011 to 86.8% in 2015. The Affordable Care Act (ACA), passed in 2010, includes multiple provisions to increase access to health care coverage for the U.S. population. As of July 1, 2016, a total of 32 states had elected to expand Medicaid eligibility under ACA, extending eligibility to a new group of adults aged <65 years with incomes up to 138% of the federal poverty level (22). In addition, ACA offers tax credits to numerous families who purchase insurance coverage through the Health Insurance Marketplace to subsidize the cost of premiums (23). Furthermore, ACA prevents health insurers from denying coverage or charging more because of a pre-existing condition (24). ACA also requires insurers to allow children to remain on their parents' health insurance plans until age 26 years (25). As of March 2016, the number of uninsured persons in the United States (of all ages) had decreased by 21.3 million since the enactment of ACA (26). Despite this progress, approximately 13.2% (age-adjusted prevalence estimate) of adults aged 18-64 lacked health insurance coverage in 2015. Not having health insurance is associated with higher morbidity and mortality and poorer quality of life (27). Additional work to enhance insurance affordability and coverage might generate essential gains in health and other outcomes.

Recent Routine Physical Checkup
Although routine checkups are no longer generally recommended, they might provide opportunities to deliver certain types of high-value care (e.g., early detection of high blood pressure, high cholesterol, cancer, and other adverse health conditions), establish relationships between patients and providers, and gauge access to or use of health care (28,29).
In 2015, a large proportion of U.S. adults (up to 41.9% in Alaska) had not visited a doctor for a routine checkup during the preceding year. Lack of health insurance and transportation are barriers to health care for many adults (27,30). In addition, adults might not be aware of free or low-cost health care options in their community. The Health Resources and Services Administration provides a list of these health care centers by geographic region (31).

Current Cigarette Smoking
Tobacco use is the leading preventable cause of death in the United States (32). Annually, approximately 480,000 U.S. deaths are attributable to smoking or exposure to tobacco smoke; approximately 9% of these are caused by second-hand smoke (33).
Smoking causes coronary heart disease, stroke, diabetes, chronic obstructive pulmonary disease, and cancers of the lung, colon, stomach, and other areas of the body (34). Approximately 80% of lung cancer deaths among U.S. adults aged ≥35 years are attributable to smoking (33). During 2013-2015, the median age-adjusted prevalence estimate of current smoking decreased from 19.3% to 17.7%. However, the 2015 prevalence is still substantially higher than the Healthy People 2020 goal of ≤12.0% (35). Culturally appropriate tobacco prevention and control programs are needed, particularly among subgroups at high risk for tobacco use (e.g., adults of low socioeconomic status) (36). Tobacco prevention campaigns that discourage smoking initiation among adolescents might reduce the number of future adult smokers (37). More data are needed on the prevalence of electronic cigarette and marijuana use, which appear to be increasing (38,39). In 2016, BRFSS added questions about electronic cigarettes to the core questionnaire. Marijuana use was added as an optional BRFSS module in 2016.

Binge Drinking
Binge drinking costs the U.S. economy approximately $191 billion annually (40). Binge drinking increases the risk for alcohol poisoning, injury (e.g., falls and motor vehicle accidents), high blood pressure, and liver damage (41). Binge drinking also can contribute to sexually transmitted diseases and unplanned pregnancy (41). Younger adults are more likely to binge drink than older adults, but binge drinking remains a problem throughout life (42). Among states and territories in the 2015 BRFSS, 11.2%-26.0% of adults engaged in binge drinking within 30 days of participating in the survey.
Health care systems could screen for and counsel about risky or hazardous drinking (43). At the population level, certain policies have been proven effective against binge drinking. For instance, increasing alcohol taxes and limiting days or hours of sale are effective interventions against alcohol misuse (44).

No Leisure-Time Physical Activity
Physical activity might help reduce the risk for weight gain, high blood pressure, coronary heart disease, stroke, type 2 diabetes, depression, and various types of cancers (45). Federal guidelines recommend that adults engage in ≥2.5 hours of moderate intensity aerobic activity (e.g., brisk walking) or ≥1.25 hours of vigorous intensity aerobic activity (e.g., running) or an equivalent combination of moderate and vigorous intensity physical activity per week. In addition, adults should perform muscle-strengthening activities at least 2 days each week (46). In 2015, the proportion of adults who reported no leisure-time physical activity during the preceding month was substantial (median: 25.5%). Community-level policies that increase access to sidewalks, bicycle lanes, outdoor recreation spaces, and safe neighborhoods might help facilitate physical activity among U.S. adults (47).

No Daily Fruit or Vegetable Consumption
Regular fruit and vegetable consumption is associated with reduced risk for obesity, high blood pressure, high cholesterol, cardiovascular diseases, type 2 diabetes, and various cancers (48,49). Fruits and vegetables are rich in fiber, vitamins, and minerals, which have myriad health benefits (48,49). For example, certain fruits and vegetables are major sources of vitamin C, which plays an important role in tissue repair (48,49). Federal guidelines for fruit and vegetable consumption vary by age, sex, and level of physical activity (50). Sedentary adults (i.e., those who obtain less than 30 minutes of moderate exercise daily, not counting regular daily activities) should consume between 1.5 and 2 cup-equivalents of fruit per day and between 2 and 3 cup-equivalents of vegetables per day (50). Moderately active and active adults, who have increased caloric needs, should consume larger quantities (50). Results from the 2015 BRFSS indicate that a large proportion of U.S. adults fail to meet these guidelines. Among states and territories, 33.3%-55.5% of adults reported consuming fruit less than once daily during the preceding month, and 16.6%-31.3% of adults reported consuming vegetables less than once daily during the preceding month. The United States Department of Agriculture's MyPlate campaign encourages adults to fill half of their plates with fruits and vegetables and provides consumers with tips on how to increase consumption of healthy foods (51). In addition, the 2015-2020 Federal Dietary Guidelines describe strategies that persons, schools, workplaces, food retailers, and communities can implement to increase healthy eating (50).

Obesity
Obesity increases the risks for coronary heart disease, stroke, cancer, and type 2 diabetes, all of which are leading causes of death (1). Obesity is also associated with increased risk for metabolic syndrome, high blood pressure, and osteoarthritis (52). Annual obesity-related health care costs in the United States were estimated at $147 billion as of 2008 (53). Modifiable risk factors for obesity include sedentary lifestyle, excess caloric intake, and lack of sleep (54). Community-level interventions for obesity prevention include improving access to healthy foods and beverages and enhancing community infrastructure to support walking or bicycling (55,56).

Diabetes
Diabetes is the seventh leading cause of death in the United States (1). Approximately 29 million persons in the United States have diabetes (57). An additional 86 million have prediabetes; of these, 90% are unaware that they have this condition (58). Complications of diabetes include cardiovascular diseases, blindness, kidney failure, and amputation of extremities (58). Diagnosed diabetes costs the United States approximately $245 billion in medical costs and lost productivity per year (59). The age-adjusted prevalence estimate of diabetes among adults aged ≥45 years ranged from 11.2% to 26.8% among states and territories in the 2015 BFRSS. Interventions that promote physical activity and reduce obesity might be helpful in preventing diabetes. For persons at high risk, lifestyle interventions (e.g., the CDC's National Diabetes Prevention Program) are proven to help adults with prediabetes prevent type 2 diabetes by exercising, eating healthier, and losing weight (60).

Arthritis
There are approximately 100 types of arthritis, which is characterized by inflammation of the joints or connective tissue (e.g., cartilage) surrounding joints (61). Osteoarthritis is the most common type of arthritis (61). Common arthritis symptoms include joint pain, stiffness, and swelling (61). Approximately 40% of adults with arthritis encounter activity limitations (62), and approximately 30% experience work limitations (63). The age-adjusted prevalence estimates of arthritis among adults aged ≥18 years in 2015 ranged from 17.2% to 33.6% among states and territories. Women, older adults, and persons who have obesity are at increased risk for receiving an arthritis diagnosis (62,64). Physical activity and maintaining a healthy body weight might help arthritis patients successfully manage their condition (64,65).

Depressive Disorder
An estimated 16.1 million U.S. adults (6.7%) had one or more major depressive episodes in 2015 (66). Women and younger adults were at increased risk (66). The estimated lifetime prevalence of depressive disorder ranged from 9.6% to 27.0% among states and territories in the 2015 BRFSS.
Depression is associated with increased risk for anxiety disorders, sleep disturbance, substance abuse, smoking, and obesity (67). In the workplace, depression is associated with unemployment and lost productivity (67). Depression is also a risk factor for cardiovascular disease-related mortality and suicide (67). Approximately half of adults with depression do not seek treatment (68). Reducing stigma related to mental illness and increasing access to mental health care could help adults with depression better manage this condition.

High Blood Pressure
High blood pressure increases the risk for coronary heart disease, chronic kidney disease, and stroke (69). The estimated prevalence of high blood pressure was high in the 2015 BRFSS (median: 29.1% among states and territories). Approximately 17% of adults with high blood pressure remain undiagnosed (70). Enhancing systematic approaches to screening and treatment of hypertension in health care and community settings could improve high blood pressure detection and control (71)(72)(73). Public health initiatives should emphasize the importance of modifiable risk factors for high blood pressure, which include obesity, physical inactivity, diabetes, excess sodium consumption, excess alcohol use, and smoking (74). Addressing these lifestyle factors might also help adults with high blood pressure control their blood pressure (75).

Cholesterol Screening and High Blood Cholesterol
High blood cholesterol is associated with increased risk for coronary heart disease and stroke (76). Risk factors for high blood cholesterol include obesity, diabetes, lack of exercise, smoking, and a diet high in trans fat and saturated fat (77). The age-adjusted prevalence estimates of high cholesterol in adults aged ≥18 years ranged from 27.1% to 37.3% among states and territories in the 2015 BRFSS. Because high blood cholesterol is an asymptomatic condition, regular risk assessment, testing, and appropriate treatment is essential (78). Low-risk adults aged 40-75 years (i.e., adults who do not have heart disease, do not have diabetes, do not consume cholesterol medication, and who have low-density lipoprotein (LDL) cholesterol between 70-189 mg/dL) should have their blood cholesterol checked every 4 to 6 years (79). The potential benefits of cholesterol screening among low-risk younger adults is unknown (80). In 2015, 20.9% of the U.S. adult population reported that they had never had their blood cholesterol checked, and approximately 24% reported not having their blood cholesterol checked during the preceding 5 years (median age-adjusted prevalence at the state level). Furthermore, approximately half of U.S. adults with high cholesterol are not treated for this disorder (81). Health care system approaches to enhancing risk assessment, screening, and treatment for high cholesterol could help.

Coronary Heart Disease
Heart disease is the leading cause of death in the United States. In 2015, approximately 633,000 persons died because of heart disease in the United States; approximately 365,000 of these deaths were attributed to coronary heart disease (1). The median age-adjusted prevalence of coronary heart disease among adults aged ≥45 years was approximately 10% among states and territories in the 2015 BRFSS, and there were notable disparities by geographic region. Adults in the southern United States had a higher prevalence of coronary heart disease compared with adults in other parts of the United States. The highest prevalence was in West Virginia, where 16.8% of adults aged ≥45 years reported a history of coronary heart disease. Adults residing in the southern United States are also more likely to die from heart disease, compared with adults in other parts of the country (82). During 2012-2013, heart disease cost the U.S. economy approximately $199.6 billion annually. In addition, health costs of coronary heart disease specifically are predicted to double during 2013-2030 (83). Medical risk factors for coronary heart disease include diabetes, high blood pressure, high cholesterol, and obesity (84,85). Engaging in regular physical activity, eating a healthy diet (e.g., high in fruits and vegetables, low in red meats, and low in added sugars) and avoiding smoking and excessive alcohol consumption might reduce the risk for coronary heart disease (85,86).

Stroke
Stroke was the fourth most frequent cause of death among adults aged ≥45 years in 2015 (1). Stroke is also a leading cause of disability (87). The direct and indirect costs of stroke cost the U.S. economy approximately $34 billion each year (83). In 2015, approximately 5% of U.S. adults aged ≥45 years reported having a history of stroke (median age-adjusted prevalence at the state level). Stroke prevalence is higher among older adults, blacks, American Indians/Alaska natives, and those without a high school diploma (87). Risk factors for stroke include high blood pressure, high cholesterol, heart disease, diabetes, obesity, smoking, and physical inactivity (88,89).

Limitations
The findings in this report are subject to at least five limitations. First, these findings might not be generalizable to the U.S. population because the BRFSS survey design excludes persons who reside in military installations, correctional institutions, long-term care facilities, and nursing homes. Adults without telephone access are also excluded from the BRFSS. An estimated 2.4% of the U.S. population and approximately 5.7% of Puerto Rico's population did not have telephone access in 2015 (6).
Second, prevalence estimates from the BRFSS are based on self-reporting, which is likely to be less accurate than physical measurements (4). For example, survey respondents underreport their weight (90), recent alcohol intake (91), and tobacco use (92), and they overreport physical activity (93). These tendencies might be related to concerns about social desirability (4,94). Alternatively, respondents might have trouble recalling their past health behaviors or receipt of health care services, or they might not be aware of their underlying health conditions (e.g., high blood pressure) (4).
Third, the prevalence of chronic diseases might be underestimated in the BRFSS. BRFSS prevalence estimates are estimates of diagnosed disease. Multiple chronic diseases remain undiagnosed for long periods of time, so the actual prevalence of these conditions might be higher than what is captured in BRFSS.
Fourth, although BRFSS surveys are conducted in several languages other than English (i.e., Spanish, Mandarin, and Portuguese), the survey does not apply to persons who exclusively speak languages not represented in the BRFSS. Finally, because of small sample sizes or unstable estimates, the prevalence of certain conditions (e.g., stroke) could not be estimated for particular MMSAs.
The BRFSS data set has various strengths. BRFSS data have been shown to be valid and reliable for certain indicators (4). With certain exceptions, many prevalence estimates from the BRFSS are comparable to those of the National Health and Nutrition Examination Survey (NHANES) and National Health Interview Survey, which are conducted using face-toface interviews (95)(96)(97). However, obesity prevalence estimates in BRFSS (which are based on self-reported height and weight) are approximately 4%-10% lower than obesity prevalence estimates in NHANES (which are based on measured height and weight) (95,98). In addition, the estimated prevalence of U.S. adults who are physically active was 15%-18% higher in the 2005 BRFSS than in the 2005 National Health Interview Survey or 2005-2006 NHANES (99).
Questions on the BRFSS are cognitively tested to optimize the validity of survey response (6). Likewise, BRFSS interviewers are thoroughly trained, and their performance regularly evaluated, to ensure interview quality (6).
BRFSS is the largest continuously conducted, health-based telephone survey in the world (3) with approximately 440,000 interviews conducted in 2015. All 50 states and the District of Columbia, Puerto Rico, and Guam collected data via both landline and cell phones in 2015 (6). The telephone-based approach of BRFSS is cost-effective (3). BRFSS data are used in numerous capacities at the state and local level, including surveillance, needs assessments, and program evaluations (3).

Conclusion
This report highlights the estimated prevalence of selected chronic diseases, health-risk behaviors, and health care access and use among adults residing in the United States in 2015. The chronic conditions in this report are leading causes of U.S. morbidity and mortality. However, many of these conditions can be effectively managed or prevented through lifestyle modifications (e.g., avoiding tobacco use) and use of preventive health care services (e.g., blood pressure screening). Since 1984, BRFSS has been a unique source of data on chronic diseases and their risk factors. States and municipalities use BRFSS data to monitor health conditions and behaviors over time, design public health initiatives, conduct public health needs assessments, and evaluate the impact of public health programs and policies.