Surveillance for Certain Health Behaviors Among States and Selected Local Areas — United States, 2010

Fang Xu, PhD1,2

Machell Town, PhD1

Lina S. Balluz, ScD1

William P. Bartoli, MS1,2

Wilmon Murphy1,2

Pranesh P. Chowdhury, MD1

William S. Garvin1

Carol Pierannunzi, PhD1

Yuna Zhong, MD1,2

Simone W. Salandy, PhD1,2

Candace K. Jones, MA1,2

Carol A. Crawford, PhD1

1Division of Behavioral Surveillance, Office of Surveillance, Epidemiology, and Laboratory Services, CDC

2Northrop Grumman Corporation, Atlanta, GA

Corresponding author: Carol A. Crawford, PhD, Division of Behavioral Surveillance, Office of Surveillance, Epidemiology, and Laboratory Services, CDC. Telephone: 404-498-6023; E-mail: cdg7@cdc.gov.

Abstract

Problem: Chronic diseases (e.g., heart disease, stroke, cancer, and diabetes) are the leading causes of morbidity and mortality in the United States. Engaging in healthy behaviors (e.g., quitting smoking and tobacco use, being more physically active, and eating a nutritious diet) and accessing preventive health-care services (e.g., routine physical checkups, screening for cancer, checking blood pressure, testing blood cholesterol, and receiving recommended vaccinations) can reduce morbidity and mortality from chronic and infectious disease and lower medical costs. Monitoring and evaluating health-risk behaviors and the use of health services is essential to developing intervention programs, promotion strategies, and health policies that address public health at multiple levels, including state, territory, metropolitan and micropolitan statistical area (MMSA), and county.

Reporting Period: January–December 2010.

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. This report presents results for 2010 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 192 MMSAs, and 302 counties.

Results: In 2010, the estimated prevalence of high-risk health behaviors, chronic diseases and conditions, access to health care, and use of preventive health services varied substantially by state and territory, MMSA, and county. In the following summary of results, each set of proportions refers to the range of estimated prevalence for the disease, condition, or behaviors, as reported by survey respondents. Adults reporting good or better health: 67.9%–89.3% for states and territories, 72.2%–92.1% for MMSAs, and 72.8%–95.8% for counties. Adults with health-care coverage: 69.4%–95.7% for states and territories, 45.7%–97.0% for MMSAs, and 45.7%–97.2% for counties. Adults who had a dental visit in the past year: 57.2%–81.7% for states and territories, 47.1%–83.5% for MMSAs, and 47.1%–88.2% for counties. Adults aged ≥65 years having had all their natural teeth extracted (edentulism): 7.4%–36.0% for states and territories, 4.8%–34.8% for MMSAs, and 2.4%–39.3% for counties. A routine physical checkup during the preceding 12 months: 53.8%–80.0% for states and territories, 49.5%–82.6% for MMSAs, and 49.5%–85.3% for counties. Influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 26.9%–73.4% for states and territories, 51.7%–77.1% for MMSAs, and 49.3%–87.8% for counties. Pneumococcal vaccination ever received among adults aged ≥65 years: 24.7%–74.0% for states and territories, 48.6%–79.9% for MMSAs, and 47.6%–83.1% for counties. Sigmoidoscopy or colonoscopy ever received among adults aged ≥50 years: 37.8%–75.7% for states and territories, 37.3%–79.9% for MMSAs, and 37.3%–82.5% for counties. Blood stool test received during the preceding 2 years among adults aged ≥50 years: 8.5%–27.0% for states and territories, 6.7%–51.3% for MMSAs, and 6.8%–57.2% for counties. Women who reported having had a Papanicolaou test during the preceding 3 years: 67.8%–88.9% for states and territories, 63.3%–91.2% for MMSAs, and 63.2%–95.7% for counties. Women aged ≥40 years who had a mammogram during the preceding 2 years: 63.8%–83.6% for states and territories, 60.3%–86.2% for MMSAs, and 59.3%–89.7% for counties. Current cigarette smokers: 5.8%–26.8% for states and territories, 5.8%–28.5% for MMSAs, and 5.9%–29.8% for counties. Binge drinking during the preceding month: 6.6%–21.6% for states and territories, 3.6%–23.0% for MMSAs, and 3.8%–24.0% for counties. Heavy drinking during the preceding month: 2.0%–7.2% for states and territories, 1.0%–10.0% for MMSAs, and 1.0%–14.2% for counties. Adults reporting no leisure-time physical activity: 17.5%–42.3% for states and territories, 13.1%–37.6% for MMSAs, and 8.5%–39.0% for counties. Adults who were overweight: 32.6%–40.7% for states and territories, 28.5%–42.5% for MMSAs, and 27.2%–46.4% for counties. Adults aged ≥20 years who were obese: 22.1%–35.0% for states and territories, 17.1%–42.1% for MMSAs, and 13.3%–42.1% for counties. Adults with current asthma: 5.2%–11.1% for states and territories, 3.4%–14.5% for MMSAs, and 3.3%–14.6% for counties. Adults with diagnosed diabetes: 5.3%–13.2% for states and territories, 4.6%–15.4% for MMSAs, and 2.6%–18.8% for counties. Adults with limited activities because of physical, mental or emotional problems: 10.8%–28.2% for states and territories, 13.5%–38.3% for MMSAs, and 11.7%–32.0% for counties. Adults using special equipment because of any health problem: 2.8%–10.6% for states and territories, 4.5%–15.5% for MMSAs, and 1.3%–15.5% for counties. Adults aged ≥45 years who have had coronary heart disease: 5.3%–16.7% for states and territories, 6.5%–19.6% for MMSAs, and 4.9%–19.6% for counties. Adults aged ≥45 years who have had a stroke: 2.4%–7.1% for states and territories, 2.3%–8.8% for MSMAs, and 1.7%–8.8% for counties.

Interpretation: The findings in this report indicate substantial variations in the health-risk behaviors, chronic diseases and conditions, access to health-care services, and the use of the preventive health services among U.S. adults at the state and territory, MMSA, and county levels. Healthy People 2010 (HP 2010) objectives were established to monitor health behaviors, conditions, and the use of preventive health services for the first decade of the 2000s. The findings in this report indicate that many of the HP 2010 objectives were not achieved by 2010. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases, and conditions and of the use of preventive health-care services.

Public Health Action: Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health-risk behaviors, chronic diseases, and conditions and to evaluate the use of preventive health-care services. BRFSS data also are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality from chronic conditions and corresponding health-risk behaviors.

Introduction

Chronic diseases (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of morbidity and mortality in the United States (1,2). Engaging in healthy behaviors (e.g., quitting smoking and tobacco use, being more physically active, and eating a nutritious diet) and accessing preventive health-care services (e.g., routine physical checkups, screening for cancer, checking blood pressure, testing blood cholesterol, and receiving recommended vaccinations) can reduce morbidity and mortality from chronic and infectious disease and lower medical costs (3). Ongoing state-based surveillance is essential to identify health issues and disparities and to design, implement, and evaluate health programs and policies; surveillance data indicate that the estimated prevalence of health-risk factors, chronic conditions, and use of preventive services varies substantially across the United States (4,5).

The Behavioral Risk Factor Surveillance System (BRFSS) is the world's largest ongoing telephone survey. Since 1984, CDC has assisted state and territorial health departments in conducting the BRFSS survey to track health conditions and health-risk behaviors. BRFSS is the one of the main sources of health information in the United States on chronic disease conditions, health-risk behaviors, emerging health problems, and the use of preventive health services. The data are used to set health goals and monitor public health progress at national, state, and local levels. Since 2002, the sufficient sample size in BRFSS has facilitated analysis of prevalence estimates from selected metropolitan and micropolitan statistical areas (MMSAs), metropolitan divisions, and their counties.

Healthy People objectives represent national goals to prevent diseases, decrease morbidity and mortality, and promote health. These objectives include specific objectives to be achieved by the end of each decade and can be used to monitor and develop health promotions and disease prevention programs at the state and local levels (6). Healthy People 2010 (HP 2010) objectives were based on several national data sources. This analysis used BRFSS data to track health-risk behaviors during 2010 to determine if HP 2010 objectives were met by states and localities. Healthy People 2020 (HP 2020) is available at http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Many of the HP 2020 objectives are continued from HP 2010. BRFSS provides data for state and local areas that might not be available from national data sources for these objectives. This report contains comparisons between 2010 BRFSS data and certain HP 2010 objectives related to chronic diseases, health-risk behaviors, and use of preventive health care services.

Methods

BRFSS is a cross-sectional, random-digit–dialed, state-based survey that includes annual data on approximately 400,000 adults aged ≥18 years who completed interviews (7). BRFSS uses a multistage sampling design to select a representative sample of the noninstitutionalized civilian population in each state and territory. Details of the validity and reliability of the BRFSS survey methodology have been described previously (8). This report provides comparable unweighted sample size, weighted prevalence estimates with standard errors and 95% confidence intervals for prevalence of selected risk behaviors, chronic conditions, use of preventive health-care services by states and territories, MMSAs, and counties.

Questionnaire

The standard BRFSS questionnaire comprises three parts: 1) core questions, 2) optional modules, and 3) state-added questions. Data collectors from all states, the District of Columbia, and U.S. territories ask the same core questions. The 2010 core questions included sections on demographics, health status, number of healthy days, health-care access, number of days feeling unrested, exercise, diagnosed diabetes, oral health, asthma, cardiovascular disease prevalence, disability (limited activity and use of special equipment), tobacco use, alcohol consumption, falls, seat belt use, drinking and driving, women's health, cancer screenings (colorectal cancer and breast cancer), immunization (seasonal influenza and pneumococcal vaccination), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), emotional support, and life satisfaction. Optional modules were chosen on the basis of the needs of state health departments and specific state programs to address specific health-related topics. State-added questions were designed to address state-specific health issues or track a state's health objectives.

In 2010, the following optional modules were included to address specific health issues: diagnosed prediabetes (35 states), diagnosed diabetes (38 states), healthy day–related symptoms (one state), visual impairment and access to eye care (five states), excess sun exposure (four states), inadequate sleep (nine states), family planning (five states), adult asthma history (five states), arthritis burden (five states), high-risk/health-care worker (three states), shingles (six states), adult tetanus diphtheria (four states), adult human papilloma virus (HPV) (five states), cancer survivorship (10 states), caregiver (two states), reactions to race (three states), anxiety and depression (13 states), social context (two states), general preparedness (two states), veterans' health (two states), adverse childhood experience (five states), random child selection (42 states), childhood asthma prevalence (34 states), childhood immunization (24 states), and child HPV (six states).

To compare 2010 BRFSS results with the HP 2010 objectives, this report focuses on six areas: 1) health status indicators (reported good or better health, health-care coverage, and oral health), 2) preventive practices (routine checkup, influenza vaccination, and pneumococcal vaccination for persons aged ≥65 years), 3) cancer screening (sigmoidoscopy or colonoscopy and blood stool test for persons aged ≥50 years and a Papanicolaou [Pap] test and a mammogram for women aged ≥40 years, 4) health-risk behaviors (current smoking, binge drinking, heavy drinking, and no leisure-time physical activity), 5) chronic conditions and disabilities (overweight or obesity for persons aged ≥20 years, current asthma, diagnosed diabetes, limited activities, and use of special equipment because of physical, mental, or emotional problems), and 6) cardiovascular disease (coronary heart disease and stroke for persons aged ≥45 years). The details are in the 2010 BRFSS questionnaire; all the other documents are available on the BRFSS website (9).

Data Collection and Processing

Since 2007, BRFSS data have been collected monthly in all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, and Guam. Trained interviewers administer the BRFSS survey using a computer-assisted telephone interviewing system. After the interview is conducted, data are submitted to CDC for editing, processing, weighting, reliability-checking, and analysis.

Data Weighting

At the end of the survey year, CDC edits and aggregates the monthly data files to create yearly samples for each state and territory. Each sample is weighted to the respondent's probability of selection and the age-, sex-, and race/ethnicity-specific distribution of the population using 2010 postcensus projections for each state and territory. State-level weights are adjusted to produce MMSA- and county-level weights. These sampling weights are used to calculate BRFSS state-, territory-, MMSA-, and county-level prevalence estimates. MMSAs were defined by the Office of Management and Budget. Respondents were assigned to a particular MMSA on the basis of their Federal Information Processing Standards (FIPS) county code. Aggregated data at the state level were used to produce national prevalence estimates. Detailed weighting and analytic methodologies have been documented (10).

Statistical Analyses

Prevalence estimates, standard errors, and 95% confidence intervals were computed on the basis of a statistical analysis using weights and strata to account for the complex survey design. To avoid presenting unstable estimates, statistics for certain MMSAs and counties were not reported if the unweighted sample size for the denominator was <50 or the half-width of the 95% confidence interval was >10. MMSAs were included only if there were ≥500 respondents and ≥19 respondents in all the final weighting classes and counties. Within each MMSA or county, weighting classes were based on age and sex cross-classification totals or age, sex, and race cross-classification totals. Responses coded as "do not know" or "refused" were excluded from the analysis. The analysis was conducted using SAS-Callable SUDAAN Version 10.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina).

Results

In 2010, a total of 54 states and territories, 192 MMSAs and 302 counties with sufficient sample sizes were reported. A total of 451,075 respondents completed (n = 425,013) or partially completed (n = 26,062) interviews (range: 784 in Guam to 35,109 in Florida; median: 6,898). On the basis of the Council of American Survey and Research Organizations (CASRO) standards (11), the 2010 BRFSS cooperation rate (defined as the proportion of respondents interviewed of all eligible units in which a respondent was contacted and selected) ranged from 56.8% in California to 86.1% in Minnesota (median: 76.9%). The 2010 BRFSS CASRO rate (defined as the number of complete and partial interviews divided by an estimate of the number of eligible units) ranged from 39.1% in Oregon to 68.8% in Nebraska (median: 54.6%) (12). This report presents weighted prevalence estimates with 95% confidence intervals at the state, MMSA, and county levels in the following sections.

Health Status Indicators

Health Status

Respondents were asked to rate their general health as excellent, very good, good, fair, or poor. The answers 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 2010, the estimated prevalence of self-reported good or better health among adults aged ≥18 years ranged from 67.9% in Puerto Rico to 89.3% in Alaska (median: 85.0%) (Table 1). Among selected MMSAs, the self-reported prevalence estimate of good or better health ranged from 72.2% in Huntington-Ashland, West Virginia-Kentucky-Ohio to 92.1% in Cambridge-Newton-Framingham, Massachusetts (median: 85.2%) (Table 2). Among selected counties, the estimated prevalence of self-reported good or better health ranged from 72.8% in Hinds County, Mississippi, to 95.8% in Douglas County, Colorado (median: 85.6%) (Table 3).

Health-Care Coverage

Health-care coverage was defined as any kind of coverage including health insurance, prepaid plans (e.g., health maintenance organizations), or government plan (e.g., Medicare or Medicaid). In 2010, the estimated prevalence of health-care coverage among adults aged ≥18 years ranged from 69.4% in the U.S. Virgin Islands to 95.7% in Massachusetts (median: 85.0%) (Table 4). Among selected MMSAs, the estimated prevalence ranged from 45.7% in McAllen-Edinburg-Mission, Texas, to 97.0% in Cambridge-Newton-Framingham, Massachusetts (median: 85.9%) (Table 5). Among selected counties, the estimated prevalence ranged from 45.7% in Hidalgo County, Texas, to 97.2% in Norfolk County, Massachusetts (median: 87.2%) (Table 6).

Oral Health

Dental Visit

Time since the most recent visit to a dentist or a dental clinic for any reason was measured. In 2010, the estimated prevalence of a dental visit within the previous year among adults aged ≥18 years ranged from 57.2% in Oklahoma to 81.7% in Massachusetts (median: 69.7%) (Table 7). Among selected MMSAs, the estimated prevalence ranged from 47.1% in Arcadia, Florida, to 83.5% in Fargo, North Dakota-Minnesota (median: 70.2%) (Table 8). Among selected counties, the estimated prevalence ranged from 47.1% in DeSoto County, Florida, to 88.2% in Middlesex County, Connecticut (median 72.4%) (Table 9).

All Natural Teeth Extracted

Oral health status was measured as the percentage of adults aged ≥65 years who had all of their permanent teeth removed (edentulism) because of tooth decay or gum diseases. In 2010, the estimated prevalence ranged from 7.4% in Hawaii to 36.0% in West Virginia (median: 17.1%) (Table 10). Among selected MMSAs, the estimated prevalence ranged from 4.8% in San José-Sunnyvale-Santa Clara, California, to 34.8% in Charleston, West Virginia (median: 15.2%) (Table 11). Among selected counties, the estimated prevalence ranged from 2.4% in Santa Clara County, California, to 39.3% in Sullivan County, Tennessee (median: 14.4%) (Table 12).

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 categorized as one that occurred within the preceding 12 months. In 2010, the estimated prevalence of having a recent routine checkup among adults aged ≥18 years ranged from 53.8% in Oregon to 80.0% in Massachusetts (median: 66.7%) (Table 13). Among selected MMSAs, the estimated prevalence ranged from 49.5% in Eugene-Springfield, Oregon, to 82.6% in Boston-Quincy, Massachusetts (median: 67.0%) (Table 14). Among selected counties, the estimated prevalence ranged from 49.5% in Lane County, Oregon, to 85.3% in Plymouth County, Massachusetts (median: 68.0%) (Table 15).

Influenza Vaccination

In 2010, the estimated prevalence of receiving an influenza vaccination among adults aged ≥65 years during the preceding 12 months at the state level ranged from 26.9% in Puerto Rico to 73.4% in Colorado (median: 67.4%) (Table 16). Among selected MMSAs, the estimated prevalence ranged from 51.7% in Miami-Fort Lauderdale-Miami Beach, Florida, to 77.1% in Barre, Vermont (median: 67.9%) (Table 17). Among selected counties, the estimated prevalence ranged from 49.3% in Miami-Dade County, Florida, to 87.8% in Douglas County, Colorado (median: 68.6%) (Table 18).

Pneumococcal Vaccination

In 2010, the estimated prevalence of ever having received a pneumonia injection or pneumococcal vaccine among adults aged ≥65 years ranged from 24.7% in Puerto Rico to 74.0% in Oregon (median: 68.6%) (Table 19). Among selected MMSAs, the estimated prevalence ranged from 48.6% in Laredo, Texas, to 79.9% in Naples-Marco Island, Florida (median: 70.0%) (Table 20). Among selected counties, the estimated prevalence ranged from 47.6% in Hudson County, New Jersey, to 83.1% in Potter County, Texas (median: 70.6%) (Table 21).

Cancer Screening

Sigmoidoscopy or Colonoscopy

Sigmoidoscopy and colonoscopy are examinations in which a tube is inserted into the rectum to view the colon and rectum for the signs of precancerous polyps and colorectal cancer. In 2010, the estimated prevalence of ever having sigmoidoscopy or colonoscopy among adults aged ≥50 years ranged from 37.8% in Guam to 75.7% in Connecticut (median: 64.2%) (Table 22). Among selected MMSAs, the estimated prevalence ranged from 37.3% in Laredo, Texas, to 79.9% in Fargo, North Dakota-Minnesota (median: 67.7%) (Table 23). Among selected counties, the estimated prevalence ranged from 37.3% in Webb county, Texas, to 82.5% in Washington County, Rhode Island (median: 68.8%) (Table 24).

Blood Stool Test

A blood stool test is one in which a special kit is used to determine whether the stool contains blood. In 2010, the estimated prevalence of adults aged ≥50 years who had a blood stool test during the preceding 2 years ranged from 8.5% in Guam to 27.0% in California (median: 16.8%) (Table 25). Among selected MMSAs, the estimated prevalence ranged from 6.7% in Provo-Orem, Utah, to 51.3% in Tallahassee, Florida (median: 17.6%) (Table 26). Among selected counties, the estimated prevalence ranged from 6.8% in Utah County, Utah, to 57.2% in Leon County, Florida (median: 17.8%) (Table 27).

Papanicolaou Test

A Papanicolaou (Pap) test is a test for cancer of the cervix. In 2010, the estimated prevalence of women aged ≥18 years who had a Pap test during the preceding 3 years ranged from 67.8% in Guam to 88.9% in Massachusetts (median: 81.0%) (Table 28). Among selected MMSAs, the estimated prevalence ranged from 63.3% in Provo-Orem, Utah, to 91.2% in Peabody, Massachusetts (median: 82.4%) (Table 29). Among selected counties, the estimated prevalence ranged from 63.2% in Utah County, Utah, to 95.7% in Johnston County, North Carolina (median: 83.1%) (Table 30).

Mammogram

A mammogram is a radiograph of each breast to test for breast cancer. The state-specific estimated prevalence of having a mammogram during the preceding 2 years among women aged ≥40 years ranged from 63.8% in Idaho to 83.6% in Massachusetts (median: 75.2%) (Table 31). Among selected MMSAs, the estimated prevalence ranged from 60.3% in Idaho Falls, Idaho, to 86.2% in Bangor, Maine (median: 76.5%) (Table 32). Among selected counties, the estimated prevalence ranged from 59.3% in Tooele County, Utah, to 89.7% in Queen Anne's County, Maryland (median: 77.1%) (Table 33).

Health-Risk Behaviors

Current Smoking

Current smoking was defined as having smoked at least 100 cigarettes in one's lifetime and reporting smoking every day or some days at the time of survey participation. The estimated prevalence of current smoking among adults aged ≥18 years ranged from 5.8% in the U.S. Virgin Islands to 26.8% in West Virginia (median: 17.3%) (Table 34). Among selected MMSAs, the estimated prevalence ranged from 5.8% in Provo-Orem, Utah, to 28.5% in Tuscaloosa, Alabama (median: 17.4%) (Table 35). Among selected counties, the estimated prevalence ranged from 5.9% in Utah County, Utah, to 29.8% in Valencia County, New Mexico (median: 16.1%) (Table 36).

Binge Drinking

Binge drinking was defined for men aged ≥18 years as having on average five or more drinks during one occasion and for women aged ≥18 years as having on average four or more drinks on one occasion during the preceding month. In 2010, the estimated prevalence of binge drinking among adults aged ≥18 years ranged from 6.6% in Tennessee to 21.6% in Wisconsin (median: 15.1%) (Table 37). Among selected MMSAs, the estimated prevalence ranged from 3.6% in Knoxville, Tennessee, to 23.0% in Kappa, Hawaii, and Key West-Marathon, Florida (median: 14.7%) (Table 38). Among selected counties, the estimated prevalence ranged from 3.8% in Utah County, Utah, to 24.0% in Suffolk County, Massachusetts (median: 15.1%) (Table 39).

Heavy Drinking

Heavy drinking was defined for men aged ≥18 years as having, on average, more than two drinks per day and for women aged ≥18 years as having, on average, more than one drink per day during the preceding month. In 2010, the estimated prevalence of heavy drinking among adults aged ≥18 years ranged from 2.0% in Tennessee to 7.2% in Vermont (median: 5.0%) (Table 40). Among selected MMSAs, the estimated prevalence ranged from 1.0% in Nashville-Davidson-Murfreesboro, Tennessee, to 10.0% in Key West-Marathon, Florida (median: 5.1%) (Table 41). Among selected counties, the estimated prevalence ranged from 1.0% in Tolland County, Connecticut, to 14.2% in Hampshire County, Massachusetts (median: 5.0%) (Table 42).

No Leisure-Time Physical Activity

No leisure-time physical activity was defined as nonparticipation in any physical activities (other than what is done during one's regular job) or exercises, such as running, calisthenics, golf, gardening, or walking during the preceding month. In 2010, the estimated prevalence of no leisure-time physical activity among adults aged ≥18 years ranged from 17.5% in Oregon to 42.3% in Puerto Rico (median: 24.0%) (Table 43). Among selected MMSAs, the estimated prevalence ranged from 13.1% in Fort Collins-Loveland, Colorado, to 37.6% in Kingsport-Bristol, Tennessee-Virginia (median: 23.7%) (Table 44). Among selected counties, the estimated prevalence ranged from 8.5% in Douglas County, Colorado, to 39.0% in Caddo Parish, Louisiana (median: 22.8%) (Table 45).

Chronic Conditions and Disabilities

Overweight

Self-reported weight and height were used to calculate body mass index (BMI) (weight [kg]/height [m2]). Overweight was defined as BMI ≥25.0 and <30.0. In 2010, the estimated prevalence of adults aged ≥18 years who were overweight ranged from 32.6% in Guam to 40.7% in Alaska (median: 36.2%) (Table 46). Among selected MMSAs, the estimated prevalence ranged from 28.5% in Fort Collins-Loveland, Colorado, to 42.5% in Atlantic City, New Jersey (median: 36.0%) (Table 47). Among selected counties, the estimated prevalence ranged from 27.2% in Dallas County, Texas, to 46.4% in Tolland County, Connecticut (median: 36.6%) (Table 48).

Obesity

Obesity was defined as BMI ≥30 among adults aged ≥20 years to compare with HP 2010 objectives. In 2010, the estimated prevalence of adults aged ≥20 years who were obese ranged from 22.1% in Colorado to 35.0% in Mississippi (median: 28.5%) (Table 49). Among selected MMSAs, the estimated prevalence ranged from 17.1% in Bridgeport-Stamford-Norwalk, Connecticut, and Key West-Marathon, Florida, to 42.1% in Wauchula, Florida (median: 28.3%) (Table 50). Among selected counties, the estimated prevalence ranged from 13.3% in Westchester County, New York, to 42.1% in Hardee County, Florida (median: 27.4%) (Table 51).

Current Asthma

Respondents aged ≥18 years were categorized as currently having asthma if they reported having ever been told by a doctor, nurse, or other health-care professional that they had asthma and still had it during the survey. In 2010, the estimated prevalence of current asthma among adults aged ≥18 years ranged from 5.2% in Guam to 11.1% in Vermont (median: 9.0%) (Table 52). Among selected MMSAs, the estimated prevalence ranged from 3.4% in Laredo, Texas, to 14.5% in Rutland, Vermont (median: 9.0%) (Table 53). Among selected counties, the estimated prevalence ranged from 3.3% in Washington County, Arkansas, and Davidson County, Tennessee, to 14.6% in Bronx County, New York (median: 8.9%) (Table 54).

Diabetes

Diagnosed diabetes was defined as having ever been told by a doctor that respondents had diabetes, excluding gestational diabetes, pre-diabetes, or borderline diabetes. In 2010, the estimated prevalence of diagnosed diabetes among adults aged ≥18 years ranged from 5.3% in Alaska to 13.2% in Alabama (median: 8.7%) (Table 55). Among selected MMSAs, the estimated prevalence ranged from 4.6% in Gainesville, Florida, to 15.4% in Wauchula, Florida (median: 8.9%) (Table 56). Among selected counties, the estimated prevalence ranged from 2.6% in Summit County, Utah, to 18.8% in Gadsden County, Florida (median: 8.6%) (Table 57).

Limited Activities

The estimated prevalence of reported limited activities in any way because of physical, mental, or emotional problems among adults aged ≥18 years ranged from 10.8% in Guam to 28.2% in West Virginia (median: 20.8%) (Table 58). Among selected MMSAs, the estimated prevalence ranged from 13.5% in Fargo, North Dakota-Minnesota, to 38.3% in Huntington-Ashland, West Virginia-Kentucky-Ohio (median: 20.6%) (Table 59). Among selected counties, the estimated prevalence ranged from 11.7% in Cass County, North Dakota, to 32.0% in Lane County, Oregon (median: 20.3%) (Table 60).

Use of Special Equipment

Respondents were asked whether any of their health problems required them to use special equipment (cane, wheelchair, special bed, or special telephone). The estimated prevalence of use of special equipment as a result of any health problems among adults aged ≥18 years ranged from 2.8% in Guam to 10.6% in Mississippi (median: 7.5%) (Table 61). Among selected MMSAs, the estimated prevalence ranged from 4.5% in Fargo, North Dakota-Minnesota, to 15.5% in Homosassa Springs, Florida (median: 7.5%) (Table 62). Among selected counties, the estimated prevalence ranged from 1.3% in Summit County, Utah, to 15.5% in Citrus County, Florida (median: 7.4%) (Table 63).

Cardiovascular Diseases

Coronary Heart Disease

Respondents were classified as having coronary heart disease if they had ever been told by a doctor, nurse, or other health-care professional that they had coronary heart disease including heart attack (myocardial infarction) and angina. The estimated prevalence of coronary heart disease among adults aged ≥45 years ranged from 5.3% in the U.S. Virgin Islands to 16.7% in Puerto Rico (median: 10.9%) (Table 64). Among selected MMSAs, the estimated prevalence ranged from 6.5% in Honolulu, Hawaii, to 19.6% in Homosassa Springs, Florida (median: 10.7%) (Table 65). Among selected counties, the estimated prevalence ranged from 4.9% in Montgomery County, Pennsylvania, to 19.6% in Citrus County, Florida (median: 10.4%) (Table 66).

Stroke

Respondents were classified as having had a stroke if they had ever been told by a doctor, nurse, or other health-care professional that they had a history of stroke. In 2010, the estimated prevalence of stroke among adults aged ≥45 years ranged from 2.4% in the U.S. Virgin Islands to 7.1% in Oklahoma (median: 4.5%) (Table 67). Among selected MMSAs, the estimated prevalence ranged from 2.3% in Rutland, Vermont, to 8.8% in Lakeland-Winter Haven, Florida (median: 4.4%) (Table 68). Among selected counties, the estimated prevalence ranged from 1.7% in Benton County, Arkansas, and Queen Anne's County, Maryland, and Catawba County, North Carolina, to 8.8% in Polk County, Florida, and Buncombe County, North Carolina (median: 4.3%) (Table 69).

Discussion

Substantial variations exist in the estimated prevalence of health status and risk behaviors, the use of preventive practices and cancer preventions, chronic conditions, cardiovascular diseases, and disability among U.S. adults at the levels of state and territory, MMSA, and county. The geographic variations in these estimates might reflect differences in demographics, socioeconomic status, spatial variation in social desirability, state laws or local ordinances, the availability of access to health-care facilities, the use of preventive health-care services, and the coverage of preventive screenings by insurance providers. These estimates can be used by local health-care policymakers and public health advisors to identify the burdens of health risks, monitor the change in the health-risk behaviors and diseases, and implement prevention strategies. Of note, the findings in this report reflect the direct (nonmodel-based) estimation methods selected, and the use of other methods might yield different results for certain variables.

HP 2010 set out the objectives of improvement in health status and public awareness of reduction in health-risk behavior to be achieved by 2010. However, the measures of some of the variables in BRFSS might be different from the other databases used to develop the HP 2010 objectives, and therefore some of the HP 2010 objective targets might not apply directly to the BRFSS data. Overall, the findings provided in this report indicate that certain HP 2010 goals (e.g., health-care insurance coverage and vaccination against influenza and pneumococcal diseases) were not met at any state or local level.

Health Status Indicators

Health Status

Self-reported health status usually rates the participant's own general health as excellent, very good, good, fair, or poor. Although it is a simple measure, it encompasses multidimensional health conditions and behaviors including physical and mental health, activity limitation, and health behavior risks (13). The measure of the overall health has been proved to be valid (14,15). Poor self-assessed general health has been found to be linked with socioeconomic status and subsequent mortality in a U.S. multiethnic cohort (16). In this report, self-reported health status measured respondents who reported that their health was excellent, very good, or good compared with those who reported that their health was fair or poor. The estimated prevalence of good or better health varied across states, territories, MMSAs, and counties, suggesting the geographic variations in the patterns of health-care access, treatment, and severity of chronic conditions.

Health-Care Coverage

In 2009, according to the U.S. Census Bureau, 50.7 million persons in the United States were without health-care coverage (17), and in 2010, one in four adults aged 18–64 years was not insured (18). This problem affects not only persons living in poverty but also middle-class persons. Persons without health-care coverage are less likely to receive preventive services or have adequate access to health care, and the uninsured also are more likely than their insured counterparts to receive a diagnosis of advanced-stage cancer, suffer from chronic-condition complications, and require emergency care. The advanced stages of these illnesses are associated with elevated mortality rates and increased medical costs (18,19). By 2010, no state or territory, MMSAs, or county achieved the HP 2010 objective (objective no. 1-1) (6) of 100% health-care coverage among residents (Table 70).

Oral Health

Dental caries is a demineralization of the tooth caused by bacterial infection. More than 25% of children aged 2–5 years and 50% of those aged 12–15 years have tooth decay (20). Routine dental visits and treatments can help prevent and control the most common oral diseases, which are dental caries (tooth decay) and periodontal diseases. The HP 2010 objective was to increase the proportion of children and adults who use the oral health-care system each year to 56% (objective no. 21-10) (Table 70). In 2010, a total of 4.2% of MMSAs and 4.6% of counties did not meet the target. However, BRFSS data on dental visits in the past year might be underestimated because children aged <18 years were not included in the questionnaire. Periodontal disease and dental caries are the leading causes for tooth loss and edentulism (21–23). Edentulism also is associated with poor oral hygiene, lack of access to oral health care, and lower socioeconomic status (24). Persons with complete edentulism are more likely to be smokers and to face elevated risk for poor nutrition and comorbidities such as diabetes and rheumatoid arthritis (25,26). The HP 2010 objective was to reduce the percentage of persons having had all their natural teeth extracted to less than 22% among adults aged ≥65 years (objective no. 21-4) (Table 70). In 2010, a total of 16.7% of the states and territories, 14.6% of MMSAs, and 10.6% of counties did not achieve that goal.

Preventive Practices

Routine Physical Checkup

A routine physical checkup is an important tool to help maintain good health, diagnose health problems in early stages, and prevent or control chronic diseases such as hypertension, cardiovascular diseases, diabetes, or chronic obstructive pulmonary disease (COPD). Being a younger adult, being unmarried, having a lower household income, lacking health insurance, and not participating in regular physical activity usually are associated with being less likely to receive a recent routine checkup (27). In 2010, a substantial geographic variation existed in the estimated prevalence of recent routine checkups in states and territories, MMSAs, and counties. Addressing health disparity and access to health care can improve the rates of routine checkups (28).

Pneumococcal and Influenza Vaccination

Pneumococcal disease is a type of bacterial infection that can cause pneumonia. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, which is a major source of morbidity and mortality among the very young and elderly (29,30). Overall, the case-facility rate is 15%–20% (31) and 30%–40% among the elderly, especially those with chronic conditions (32–34). Influenza also is a major cause of mortality and morbidity among the same groups at high risk for pneumococcal disease: the very young, the elderly, and those with high-risk conditions. Influenza-related complications are responsible for approximately 200,000 hospitalizations every year (35). Influenza epidemics caused approximately 3,000 deaths in 1976 and approximately 49,000 deaths in 2007. During this period, 90% of influenza-caused mortality occurred among the elderly (36). Pneumococcal disease, influenza, and the medical cost caused by the diseases can be largely reduced and controlled by vaccinations, especially among the elderly population, which is a high-risk group (37,38). The HP 2010 objectives set out to increase the proportion of adults vaccinated against influenza and pneumococcal diseases to 90% among persons aged ≥65 years (objective nos. 14-29a and 14-29b) (Table 70). This direct estimate might yield different results from season-specific estimates generated by CDC's National Center for Immunization and Respiratory Diseases (39). In 2010, no state or territory, MMSA, or county achieved the objective. Strategies that continue to improve immunization rates could be helpful at state and local levels (40).

Cancer Prevention

Colorectal Cancer Screening

Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer-related death in both men and women in the United States. In 2008, a total of 142,950 new cases and 52,857 deaths from colorectal cancer occurred (41). Over the last 2 decades, incidence and mortality have decreased, especially during 1998–2007, primarily because of the increase in screenings that detect and remove adenomatous polyps before cancer develops (42). The guidelines recommend that persons aged ≥50 years receive a colonoscopy, preferably a flexible sigmoidoscopy, if available, or a fecal occult blood test (43). The HP 2010 objective is to increase the number of persons who have had a fecal occult blood test within the previous 2 years to 33% (objective no. 3-12a) (Table 70). No state or territory achieved the goal in 2010; 2.1% of MMSAs and 3.6% of counties did. The target for sigmoidoscopy or colonoscopy is 50% (objective no. 3-12b) (Table 70). The goal was achieved by all states and territories except for Guam, Puerto Rico, and the U.S. Virgin Islands; all MMSAs except for Laredo, Texas, and Del Rio, Texas; and all counties except for Webb County, Texas, Val Verde County, Texas, and Passaic County, New Jersey.

Cervical Cancer Screening

Cervical cancer continues to be a public health issue with 12,410 new cases and 4,008 deaths in 2008 (44). The primary cause of cervical cancer is HPV. All women are at risk for developing cervical cancer with the highest incidence in women aged >30 years (45). Racial/ethnic and age disparities exist in the late stage of diagnosis and the incidence rate (46,47). Cervical cancer can be detected early with Pap tests. By detecting precancerous lesions, Pap tests have contributed to the decreasing incidence and mortality rates over the previous 2 decades (47). Since 2003, the rates have remained stable (42). In 2008, the age-adjusted incidence and mortality rates of cervical cancer were 8.0 and 2.6 per 100,000 females (48). Women aged ≥21 years should receive the Pap test to screen for cervical cancer at least every 3 years until age 65 years (49). The HP 2010 objective is to increase the use of Pap test within the preceding 3 years to 90% among women aged ≥18 years (objective no. 3-11b) (Table 70). In 2010, no state or territory achieved the target; 3.1% of MMSAs and 7.6% of counties achieved this goal.

Breast Cancer Screening

Breast cancer is the most commonly diagnosed cancer (excluding skin cancer) and second leading cause of cancer mortality in women. In 2008, a total of 210,203 women had breast cancer diagnosed, and 40,589 women died of this cancer (50). In 2012, an estimated 226,870 new cases of invasive breast cancer are expected to occur among women and an estimated 2,190 new cases are expected to occur among men in the United States; approximately 39,920 breast cancer-specific deaths are estimated to occur (42). There are varieties of risk factors for breast cancer. Older age is associated with the higher likelihood of having breast cancer (51). Women with a family history of breast cancer might carry genetic mutations that contribute to elevated risk for the disease (52). Mammograms are an important diagnostic tool for early detection of breast cancer. The United States Preventive Services Task Force currently recommends biennial screening mammography for women aged 50–74 years. During 1975–2000, the breast cancer specific mortality rate declined approximately 46% at least in part as a result of the use of mammograms (53). The HP 2010 objective is to increase the mammography rate to 70% (objective no. 3-13) (Table 70). In 2010, approximately 79.6% of states and territories, 87.5% of MMSAs, and 89.1% of counties achieved this goal.

Health-Risk Behaviors

Cigarette Smoking

Cigarette smoking is the leading preventable cause of disease and deaths in the United States (54,55). Many diseases (including many types of cancers, cardiovascular diseases, and COPD) are attributable to smoking (54). Cigarette smoke contains over 7,000 chemicals; hundreds of them are toxic, and many cause cancer (56). During 1965–2005, the prevalence of cigarette smoking among adults aged ≥18 years declined from 42.4% (57) to 20.9%; during 2005–2010, prevalence declined from 20.9%–19.3% (58). Smokers are more likely to be men, aged <65 years, and non-Hispanic American Indians or Alaska Natives as well as to have a low educational level and to live below the poverty level (58). The HP 2010 objective was to reduce the overall prevalence of cigarette smoking to 12% (objective no. 27-1a) (Table 70). Not all states and territories, MMSAs, or counties achieved the goal: 5.6% of states and territories, 10.9% of MMSAs, and 15.9% of counties met the goal. These findings suggest a need for continuing sustained and adequately funded tobacco control efforts at the state and local level (58,59).

Binge and Heavy Drinking

Excessive alcohol consumption, including binge and heavy drinking, is a leading preventable cause of death in the United States and accounted for an estimated average of 80,000 deaths and >2.3 million years of potential life lost (YPLL) each year during 2001–2005 (60) and for an estimated $223.5 billion in lost productivity, criminal justice costs, and health-care expenditures (61). Excessive alcohol use is a risk factor for many adverse health and social outcomes, including unintentional injuries (e.g., motor-vehicle accidents), violence, suicide, hypertension, acute myocardial infarction, certain cancers, sexually transmitted diseases, unintended pregnancy, fetal alcohol syndrome, and sudden infant death (62). The differences in binge and heavy drinking among states and territories, MMSAs, and counties might reflect cultural factors (63) and differences in state and local laws that affect the price, availability, and marketing of alcoholic beverages (64). Evidence-based population-level strategies to reduce and prevent excessive alcohol use and its related harms (e.g., measures to control access to alcohol and to increase prices) have been recommended by the Community Preventive Services Task Force (65).

No Leisure-Time Physical Activity

The risk for many chronic diseases including coronary heart disease, diabetes, arthritis, and some types of cancers can be reduced by engaging in physical activity. Physical activity also aids in weight control (66). The HP 2010 objective measures the proportion of adults aged ≥18 years who never or were unable to engage in light or moderate or vigorous exercise for at least 20 minutes. The objective is to reduce the proportion of adults aged ≥18 years engaging in no leisure-time physical activity to 20%. The 2010 BRFSS survey measured the proportion of adults aged ≥18 years who never engaged in any physical activity during the previous month. Because these two data sources used different questions and time frames to assess participation in leisure time physical activity, BRFSS prevalence estimates cannot be compared directly with the HP 2010 objective. However, BRFSS data indicate that continued efforts are required to increase the leisure-time physical activity of the population at state and territory, and local levels. In 2008, the U.S. Department of Health and Human Services published recommended amounts of physical activity for older adults, adults, children and adolescents, women during pregnancy, adults with disabilities, and persons with chronic medical conditions (66). Strategies to encourage persons to become more physically active are identified by the Community Guide (67) and by the U.S. National Physical Activity Plan (68).

Chronic Conditions

Overweight and Obesity

Recent data using participants' measured weight and height indicate that among adults aged ≥20 years, the age-adjusted prevalence of obesity (BMI ≥30) and overweight and obesity combined (BMI ≥25) are 35.7% and 68.8%, respectively (69). There are also racial and ethnic disparities in the temporal trend of prevalence of obesity in the United States (69). The prevalence of overweight and obesity remains a critical public health problem. Obesity is also an economic burden in the United States. In 2008, the associated medical cost of obesity was estimated to be $147 billion. Obesity is associated with numerous chronic conditions, diseases, and events including high blood pressure, coronary heart disease, stroke, type II diabetes, certain types of cancer, sleep apnea, osteoarthritis, infertility, and mental health conditions (70). Overweight and obesity are associated with mortality from diabetes (71). Obesity is associated with mortality from obesity-related cancers (72). A large prospective study demonstrated that obesity is strongly associated with risk for death regardless of sex, race, or ethnic group (73). The HP 2010 objective is to reduce the proportion of adults aged ≥20 years who are obese to 15% (objective no. 19-2). No state or territory or MMSA achieved this goal in 2010 (Table 70). Only three counties (Westchester County, New York; New York County, New York; and San Francisco County, California) met the target goal. However, the HP 2010 goal is based on measured weight and height whereas BRFSS is a self-reported survey. The obesity prevalence from self-reported data tends to be underestimated (74). Comprehensive strategies to improve nutrition and increase physical activity are needed and should be implemented across multiple settings and sectors to address the high prevalence of overweight and obesity and their public health burden (75,76).

Asthma

Asthma is a chronic respiratory disease that affects persons of all ages and is characterized by episodic and reversible attacks of wheezing, chest tightness, shortness of breath, and coughing (77). In 2001, a total of 20.3 million persons in the United States had received a diagnosis of asthma. By 2010, 25.7 million U.S. residents had received an asthma diagnosis (78,79). Certain environmental factors exacerbate asthma, including exposure to tobacco smoke, allergens, air pollution, microbial substances, infection, and diet (80). Although asthma cannot be cured, symptoms can be controlled with appropriate medical treatment, self-management education, and avoidance of exposure to environmental allergens and irritants that can trigger an attack (81). In 2010, the overall median prevalence of current asthma was 9.0% (interquartile range: 5.2%–11.1%). The variability in the estimated prevalence of asthma existed at MMSAs and county levels.

Diabetes

Diabetes is caused by lack of insulin in the body (Type I diabetes) and insulin resistance (Type II diabetes). The complications of diabetes are serious and extensive; they include vision loss, lower-extremity amputation, skin complications (e.g., itching and bacterial and fungal infection), heart and kidney diseases, periodontitis, poor mental health, neuropathy, and stroke, and they involve many other organs and tissues (82). Diabetic patients face elevated risks of developing cancer (83). An estimated 25.8 million persons in the United States have diabetes, including 7.0 million persons who have not received a diagnosis (84). In 2010, approximately 1.9 million adults aged ≥20 years received a new diagnosis of diabetes. In 2010, the prevalence of diagnosed diabetes at the state level ranged from 5.3%–13.2%. Persons with diabetes have shorter life expectancy and increased mortality compared with persons without diabetes. By 2050, new incidence of diabetes is expected to be 15 cases per 1,000 persons (85). In 2007, diabetes cost the United States approximately $174 billion (86). Eating right and being active can help to prevent type II diabetes. Given the high prevalence of diabetes and its likely future burden, implementation of effective interventions and strategies that can reduce risk for obesity and encourage physical activity, particularly among high-risk populations, can help to lower diabetes rates and keep existing diagnosed cases of the disease in better control. The National Diabetes Prevention Program aims to prevent or delay diabetes by bringing the evidence-based lifestyle change program to the community level (87).

Disability

Approximately 50 million persons in the United States live with a disability, which includes mental impairment or difficulties with hearing, vision, movement, thinking, remembering, learning, communication, and social relationships (88). Physical limitations can require the use of special equipment. Disability usually is associated with low socioeconomic status. Persons with disabilities are more likely to be poor and have barriers to education and employment (89). There is a racial disparity of self-reported health status among persons with disabilities (90). Many persons with disabilities also have at least one chronic condition (e.g., obesity, diabetes, depression, or mental illness). They are more likely to use an emergency department, to be hospitalized, and to have limited health-care access (91,92). Persons with disabilities account for 43% of Medicaid health-care expenditures (93). In 2005, among the total population, 18.7% had some level of disability, and 12.0% had a severe disability (94). Although the severe disability rate declined among the elderly population during the last 2 decades, the disability rate has increased among working-aged persons, especially among the obese population (95). Compared with the medians of prevalence of use of special equipment in 2008 (7.2%) and 2009 (7.0%), the rate did not decline in 2010 (7.5%). As the U.S. population ages, the need to improve quality of life, increase access to special equipment, and prevent hospital-associated disability complications among the disabled population will continue to be important (96).

Cardiovascular Diseases

Coronary Heart Disease

The most common type of heart disease is coronary heart disease, which is caused by the buildup of plaque that narrows the blood vessels that supply blood to the heart (97). Heart disease is the leading cause of death for both men and women in the United States (98). One in six deaths in 2010 could be attributed to coronary heart disease (99). In 2010, estimates from BRFSS data indicated that prevalence of coronary heart disease ranged from 5.3%–16.7% at the state level. Since the Framingham Heart Study, many risk factors are known to be associated with coronary heart disease, including age, sex, smoking status, diabetes, unhealthy systolic blood pressure and total cholesterol, and high low-density lipoprotein cholesterol (100,101). Chronic conditions including diabetes mellitus, obesity, high blood pressure, a low level of high-density lipoprotein cholesterol, and a high level of low-density lipoprotein are associated with developing coronary heart disease, as are unhealthy behaviors (e.g., tobacco use, excessive alcohol consumption, diets high in fat and sodium, and physical inactivity); being older, male, black or of American Indian descent; and having a family history of the disease (97,102). Risk for coronary heart disease can be lowered by maintaining a healthy lifestyle (including quitting smoking, losing weight, monitoring blood pressure, and controlling blood cholesterol by following a low-fat diet and engaging in regular aerobic exercise). Adopting guidelines that encourage healthy lifestyle choices and control of diabetes, blood pressure, and cholesterol can help lower overall rates of heart disease (103).

Stroke

Cerebrovascular disease is the fourth leading cause of mortality in United States (2). In 2010, stroke was responsible for one out of 18 deaths in the United States (99). Stroke occurs when a clot blocks the blood supply to the brain or a blood vessel in the brain bursts (104). If nonfatal, stroke can cause severe long-term physical disability (e.g., paralysis and speech problems). Each year, approximately 795,000 persons in the United States have new or recurrent strokes (105). The direct medical cost for stroke was $28.3 billion in 2010 and has been projected to be $95.6 billion in 2030 (106). The dominant risk factors associated with stroke are high blood pressure, impaired glucose tolerance, atrial fibrillation, current cigarette smoking, and physical inactivity. The incidence and treatment vary by age, gender, and race. Females are older than males at stroke onset (107). Blacks had a higher prevalence of stroke than whites (108). As a risk factor for ischemic stroke, dyslipidemia was less likely to be discovered, treated, or controlled in blacks than whites (109). Education and prevention programs that target high-risk populations can help cut rates of stroke. The recommendation and guidelines to prevent stroke are provided by CDC (110).

Importance of Reducing Health-Risk Behaviors

The health-risk behaviors and chronic conditions are correlated. For instance, prenatal and passive smoking exposure could increase the incidence of asthma (111). Binge drinking is not only deleterious to health but also contributes to high health-care costs attributable to alcohol-related crime, as well as productivity loss and other burdens to the community (61). Reducing unhealthy risk behaviors and improving adherence to preventive care could help to prevent the occurrence of the chronic conditions and ultimately decrease mortality and morbidity risk for all members of a community.

Limitations

The findings in this report are subject to at least five limitations. First, BRFSS is a household survey that does not collect information from persons in institutions, nursing homes, long-term–care facilities, military installations, and correctional institutions. For this reason, the results cannot be generalized to these populations. Second, increasing use of cell-phone–only households and telephone number portability might decrease the response rate in BRFSS landline surveys (112). In 2009, BRFSS began to collect data on cell-phone–only households as well as on traditional landline households. However, the data are not available for all states and territories and therefore are not included in this report. Third, although BRFSS is conducted in multiple languages (including English, Spanish, Mandarin Chinese, and Portuguese), data are not collected from persons speaking other languages or different dialects, so these persons are not able to participate. Fourth, as a result of the sample size or unreliable estimates, the prevalence for certain health indicators could not be obtained at certain MMSA and county levels. Finally, the data are self-reported and thus are subject to recall bias. Despite these limitations, 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 national, state, and local levels. Although different national surveys have different data collection modes and sampling frames, the fact that there are overall similarities in the prevalence estimates between BRFSS and other national surveys supports the reliability of BRFSS data (113,114). BRFSS is the only timely source of data available to many states and communities to assess local health conditions and to track progress of health promotion programs and strategies accurately (115).

Conclusion

The results in this report indicate the importance of continuing efforts to increase health-care coverage, vaccination against influenza and pneumococcal diseases, and use of cancer prevention services as well as to improve oral health and to decrease health-risk behaviors at state and local levels. In addition, BRFSS data can be used to identify emerging public health problems, help implement health policies and prevention programs at different stakeholder levels, and continue to monitor health problems during the next decade as the country moves toward achieving HP 2020 objectives (116).

References

1. CDC. Chronic diseases and health promotion. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/chronicdisease/overview/index.htm. Accessed April 11, 2013.
2. Heron M. Deaths: leading causes for 2008. Natl Vital Stat Rep 2012;60:1–94.
3. Nelson DE, Bland S, Powell-Griner E, et al. State trends in health risk factors and receipt of clinical preventive services among US adults during the 1990s. JAMA 2002;287:2659–67.
4. Hughes E, Kilmer G, Li Y, et al. Surveillance for certain health behaviors among states and selected local areas—United States, 2008. MMWR 2010;59(No. SS-10).
5. Li C, Balluz LS, Okoro CA, et al. Surveillance of certain health behaviors and conditions among states and selected local areas—Behavioral Risk Factor Surveillance System, United States, 2009. MMWR 2011;60(No. SS-9).
6. CDC. Healthy people 2010. Final review. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/nchs/data/hpdata2010/hp2010_final_review.pdf. Accessed April 11, 2013.
7. CDC. Health risks in the United States. Behavioral Risk Factor Surveillance System: at a glance 2010. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cy118119.com/chronicdisease/resources/publications/AAG/brfss.htm. Accessed April 11, 2013.
8. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soz Praventivmed 2001;46(Suppl 1):S3–42.
9. CDC. 2010 Behavioral Risk Factor Surveillance System questionnaire. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cy118119.com/brfss/annual_data/pdf-ques/2010brfss.pdf. Accessed April 11, 2013.
10. CDC. Behavioral Risk Factor Surveillance System operational and user's guide, version 3.0. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at ftp://ftp.cdc.gov/pub/Data/Brfss/userguide.pdf. Accessed April 11, 2013.
11. CASRO. CASRO Code of Standards and Ethics for Survey Research. Port Jefferson, NY: CASRO; 2013. Available at http://www.casro.org/?page=TheCASROCode. Accessed April 11, 2013.
12. CDC. Behavioral Risk Factor Surveillance System 2010 summary data quality report. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at ftp://ftp.cdc.gov/pub/Data/Brfss/2010_Summary_Data_Quality_Report.pdf. Accessed April 11, 2013.
13. Simon JG, DeBoer JB, Joung IM, Bosma H, Mackenbach JP. How is your health in general? A qualitative study on self-assessed health. Eur J Public Health 2005;15:200–8.
14. Chandola T, Jenkinson C. Validating self-rated health in different ethnic groups. Ethn Health 2000;5:151–9.
15. Lundberg O, Manderbacka K. Assessing reliability of a measure of self-rated health. Scand J Soc Med 1996;24:218–24.
16. McGee DL, Liao Y, Cao G, Cooper RS. Self-reported health status and mortality in a multiethnic US cohort. Am J Epidemiol 1999;149:41–6.
17. US Census Bureau. Income, poverty, and health insurance coverage in the United States: 2009. Washington, DC: US Department of Commerce, US Census Bureau; 2010. Available at http://www.census.gov/prod/2010pubs/p60-238.pdf. Accessed April 11, 2013.
18. CDC. Access to health care: a record number of adults 18–64 are uninsured. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cy118119.com/vitalsigns/pdf/2010-11-vitalsigns.pdf. Accessed April 11, 2013.
19. Hellander I. The deepening crisis in U.S. health care: a review of data. Int J Health Serv 2011;41:575–86.
20. CDC. Oral health: preventing cavities, gum disease, tooth loss, and oral cancers: at a glance 2011. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/chronicdisease/resources/publications/AAG/doh.htm. Accessed April 11, 2013.
21. Oliver RC, Brown LJ. Periodontal diseases and tooth loss. Periodontol 2000 1993;2:117–27.
22. Anonymous. Oral health in America: a report of the Surgeon General. J Calif Dent Assoc 2000;28:685–95.
23. US Department of Health and Human Services. U.S. oral health in America: a report of the Surgeon General. Washington, DC: US Department of Health and Human Services; 2000. Available at http://www2.nidcr.nih.gov/sgr/sgrohweb/welcome.htm. Accessed April 11, 2013.
24. Cunha-Cruz J, Hujoel PP, Nadanovsky P. Secular trends in socio-economic disparities in edentulism: USA, 1972–2001. J Dent Res 2007;86:131–6.
25. Felton DA. Edentulism and comorbid factors. Tex Dent J 2010;127:389–401.
26. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis—United States, 1988–1994 and 1999–2002. MMWR 2005;54(No. SS-3).
27. Culica D, Rohrer J, Ward M, Hilsenrath P, Pomrehn P. Medical checkups: who does not get them? Am J Public Health 2002;92:88–91.
28. Mays GP, Smith SA. Geographic variations in public health spending: correlates and consequences. Health Serv Res 2009;44:1796–817.
29. Pitsiou GG, Kioumis IP. Pneumococcal vaccination in adults: does it really work? Respir Med 2011;105:1776–83.
30. Huang SS, Johnson KM, Ray GT, et al. Healthcare utilization and cost of pneumococcal disease in the United States. Vaccine 2011;29:3398–412.
31. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No. RR-8).
32. Bennett NM, Buffington J, LaForce FM. Pneumococcal bacteremia in Monroe County, New York. Am J Public Health 1992;82:1513–6.
33. Mufson MA, Oley G, Hughey D. Pneumococcal disease in a medium-sized community in the United States. JAMA 1982;248:1486–9.
34. Campbell JF, Donohue MA, Mochizuki RB, Nevin-Woods CL, Spika JS. Pneumococcal bacteremia in Hawaii: initial findings of a pneumococcal disease prevention project. Hawaii Med J 1989;48:513–4, 517–8.
35. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292:1333–40.
36. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179–86.
37. Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med 2007;357:1373–81.
38. CDC. Pneumococcal vaccination. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cy118119.com/vaccines/vpd-vac/pneumo/default.htm#vacc. Accessed April 11, 2013.
39. CDC. Seasonal influenza (flu). Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cy118119.com/flu/index.htm. Accessed April 11, 2013.
40. CDC. Strategies for increasing adult vaccination rates. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cy118119.com/vaccines/recs/rate-strategies/adultstrat.htm. Accessed April 11, 2013.
41. CDC. U.S. cancer statistics: an interactive atlas. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://apps.nccd.cdc.gov/dcpc_inca/dcpc_inca.aspx. Accessed April 11, 2013.
42. American Cancer Society. Cancer facts & figures 2012. Atlanta, GA: American Cancer Society; 2012. Available at http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf. Accessed April 11, 2013.
43. US Preventive Services Task Force. Screening for colorectal cancer. Rockville, MD: US Preventive Services Task Force; 2008. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm. Accessed April 11, 2013.
44. CDC. Cervical cancer statistics. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/cancer/cervical/statistics. Accessed April 11, 2013.
45. CDC. Cervical cancer. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cy118119.com/cancer/cervical. Accessed April 11, 2013.
46. Henley SJ, King JB, German RR, Richardson LC, Plescia M. Surveillance of screening-detected cancers (colon and rectum, breast, and cervix)—United States, 2004–2006. MMWR 2010;59(No. SS-9).
47. Watson M, Saraiya M, Benard V, et al. Burden of cervical cancer in the United States, 1998–2003. Cancer 2008;113(Suppl):2855–64.
48. CDC. United States cancer statistics: 1999–2008 cancer incidence and mortality data. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://apps.nccd.cdc.gov/uscs/cancersbystateandregion.aspx. Accessed April 11, 2013.
49. US Preventive Services Task Force. Screening for cervical cancer: recommendations and rationale. Rockville, MD: US Preventive Services Task Force; 2013. Available at http://www.uspreventiveservicestaskforce.org/3rduspstf/cervcan/cervcanrr.htm. Accessed April 11, 2013.
50. CDC. Breast cancer statistics. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/cancer/breast/statistics. Accessed April 11, 2013.
51. CDC. Breast cancer risk by age. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cy118119.com/cancer/breast/statistics/age.htm. Accessed April 11, 2013.
52. American Cancer Society. What are the risk factors for breast cancer? Atlanta, GA: American Cancer Society: 2013. Available at http://www.cancer.org/Cancer/BreastCancer/OverviewGuide/breast-cancer-overview-what-causes. Accessed April 11, 2013.
53. Berry DA, Cronin KA, Plevritis SK, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353:1784–92.
54. CDC. 2004 Surgeon General's report—the health consequences of smoking. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.cy118119.com/tobacco/data_statistics/sgr/2004/index.htm. Accessed April 11, 2013.
55. World Health Organization. Why tobacco is a public health priority. Geneva, Switzerland: World Health Organization; 2013. Available at http://www.who.int/tobacco/health_priority/en. Accessed April 11, 2013.
56. CDC. 2010 Surgeon General's Report—how tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/tobacco/data_statistics/sgr/2010/index.htm. Accessed April 11, 2013.
57. National Library of Medicine. The reports of the Surgeon General: the 1964 report on smoking and health. Bethesda, MD: National Library of Medicine; 2013. Available at http://profiles.nlm.nih.gov/ps/retrieve/Narrative/NN/p-nid/60. Accessed April 11, 2013.
58. CDC. Vital signs: current cigarette smoking among adults aged ≥18 years—United States, 2005–2010. MMWR 2011;60:1207–12.
59. CDC. Best practices for comprehensive tobacco control programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cy118119.com/tobacco/stateandcommunity/best_practices/pdfs/2007/bestpractices_complete.pdf. Accessed April 11, 2013.
60. CDC. Alcohol and public health: alcohol-related disease impact (ARDI). Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://apps.nccd.cdc.gov/DACH_ARDI/Default/Default.aspx. Accessed April 11, 2013.
61. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 2011;41:516–24.
62. US Department of Health and Human Services. 10th special report to the U.S. Congress on alcohol and health. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism; 2000. Available at http://pubs.niaaa.nih.gov/publications/10report/intro.pdf. Accessed April 11, 2013.
63. Holt JB, Miller JW, Naimi TS, Sui DZ. Religious affiliation and alcohol consumption in the United States. The Geographical Review 2006;96:523–42. Available at http://www.amergeog.org/gr/oct06/holt.html. Accessed April 11, 2013.
64. National Institute on Alcohol Abuse and Alcoholism. Alcohol Policy Information System. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2013. Available at http://www.alcoholpolicy.niaaa.nih.gov. Accessed April 11, 2013.
65. Community Preventive Services Task Force. Preventing excessive alcohol consumption. Atlanta, GA: Community Preventive Services Task Force; 2013. Available at http://www.thecommunityguide.org/alcohol/index.html. Accessed April 11, 2013.
66. US Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington, DC: US Department of Health and Human Services; 2008. Available at http://www.health.gov/paguidelines/guidelines. Accessed April 11, 2013.
67. Community Preventive Services Task Force. Increasing physical activity. Atlanta, GA: Community Preventive Services Task Force; 2012. Available at http://www.thecommunityguide.org/pa/index.html. Accessed April 11, 2013.
68. National Physical Activity Plan. The plan. Columbia, SC: National Physical Activity Plan; 2010. Available at http://www.physicalactivityplan.org/theplan.php. Accessed April 11, 2013.
69. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491–7.
70. CDC. Obesity, halting the epidemic by making health easier: at a glance 2011. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/chronicdisease/resources/publications/aag/obesity.htm. Accessed April 11, 2013.
71. Batty GD, Kivimaki M, Smith GD, Marmot MG, Shipley MJ. Obesity and overweight in relation to mortality in men with and without type 2 diabetes/impaired glucose tolerance: the original Whitehall Study. Diabetes Care 2007;30:2388–91.
72. Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA 2007;298:2028–37.
73. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763–78.
74. Nawaz H, Chan W, Abdulrahman M, Larson D, Katz DL. Self-reported weight and height: implications for obesity research. Am J Prev Med 2001;20:294–8.
75. CDC. Recommended community strategies and measurements to prevent obesity in the United States. MMWR 2009;58(No. RR-7).
76. Institute of Medicine. Accelerating progress in obesity prevention: solving the weight of the nation. Washington, DC: Institute of Medicine; 2012. Available at http://www.iom.edu/Reports/2012/Accelerating-Progress-in-Obesity-Prevention.aspx. Accessed April 11, 2013.
77. Kliegman RM, Behrman RE, Jenson HB. Bonita Stanton Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Saunders; 2007.
78. CDC. Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001–2009. MMWR 2011;60:547–52.
79. Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010. NCHS Data Brief 2012(94):1–8.
80. Eder W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med 2006;355:2226–35.
81. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel report 3: guidelines for the diagnosis and management of asthma. Washington, DC: US Department of Health and Human Services; 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed April 11, 2013.
82. American Diabetes Association. Living with diabetes: complications. Alexandria, VA: American Diabetes Association; 2013. Available at http://www.diabetes.org/living-with-diabetes/complications. Accessed April 11, 2013.
83. Chodick G, Zucker I. Diabetes, gestational diabetes and the risk of cancer in women: epidemiologic evidence and possible biologic mechanisms. Womens Health (Lond Engl) 2011;7:227–37.
84. CDC. National diabetes fact sheet 2011. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/DIABETES//pubs/pdf/ndfs_2011.pdf. Accessed April 11, 2013.
85. Boyle JP, Thompson TJ, Gregg EW, et al. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr 2010;8:29.
86. American Diabetes Association. Economic costs of diabetes in the U.S. Diabetes Care 2008;31:596–615.
87. CDC. National Diabetes Prevention Program. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/diabetes/prevention/index.htm. Accessed April 11, 2013.
88. CDC. Disability and health. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/ncbddd/disabilityandhealth/index.html. Accessed April 11, 2013.
89. American Psychological Association. Disability and socioeconomic status. Washington, DC: American Psychological Association; 2013. Available at http://www.apa.org/pi/ses/resources/publications/factsheet-disability.aspx. Accessed April 11, 2013.
90. CDC. Racial/ethnic disparities in self-rated health status among adults with and without disabilities—United States, 2004–2006. MMWR 2008;57:1069–73.
91. Gulley SP, Rasch EK, Chan L. The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep 2011;126:495–507.
92. Gulley SP, Rasch EK, Chan L. If we build it, who will come? Working-age adults with chronic health care needs and the medical home. Med Care 2011;49:149–55.
93. Kaiser Commission on Medicaid and the Uninsured. Medicaid: a primer. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2005.
94. US Census Bureau. Americans with disabilities: 2005. Washington, DC: US Department of Commerce, US Census Bureau; 2008. Available at http://www.census.gov/prod/2008pubs/p70-117.pdf. Accessed April 11, 2013.
95. Bhattacharya J, Choudhry K, Lakdawalla D. Chronic disease and severe disability among working-age populations. Med Care 2008;46:92–100.
96. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure. JAMA 2011;306:1782–93.
97. PubMedHealth. Coronary heart disease. Bethesda, MD: US National Library of Medicine; 2013. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004449. Accessed April 11, 2013.
98. Heron M. Deaths: leading causes for 2007. Natl Vital Stat Rep 2011;59:1–95.
99. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics–2011 update: a report from the American Heart Association. Circulation 2011;123:e18–209.
100. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837–47.
101. Bogers RP, Bemelmans WJ, Hoogenveen RT, et al. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300,000 persons. Arch Intern Med 2007;167:1720–8.
102. CDC. Heart disease risk factors. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cy118119.com/heartdisease/risk_factors.htm. Accessed April 11, 2013.
103. CDC. Guidelines and recommendations to prevent heart disease. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/heartdisease/guidelines_recommendations.htm. Accessed April 11, 2013.
104. CDC. Stroke. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cy118119.com/stroke. Accessed April 11, 2013.
105. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation 2012;125:e2–220.
106. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123:933–44.
107. Petrea RE, Beiser AS, Seshadri S, Kelly-Hayes M, Kase CS, Wolf PA. Gender differences in stroke incidence and poststroke disability in the Framingham heart study. Stroke 2009;40:1032–7.
108. CDC. Prevalence of stroke—United States, 2006–2010. MMWR 2012;61:379–82.
109. Zweifler RM, McClure LA, Howard VJ, et al. Racial and geographic differences in prevalence, awareness, treatment and control of dyslipidemia: the reasons for geographic and racial differences in stroke (REGARDS) study. Neuroepidemiology 2011;37:39–44.
110. CDC. Stroke: related guidelines and recommendations. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/stroke/guidelines_recommendations.htm. Accessed April 11, 2013.
111. Burke H, Leonardi-Bee J, Hashim A, et al. Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis. Pediatrics 2012;129:735–44.
112. Kempf AM, Remington PL. New challenges for telephone survey research in the twenty-first century. Annu Rev Public Health 2007;28:113–26.
113. Nelson DE, Powell-Griner E, Town M, Kovar MG. A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. Am J Public Health 2003;93:1335–41.
114. Li C, Balluz LS, Ford ES, Okoro CA, Zhao G, Pierannunzi C. A comparison of prevalence estimates for selected health indicators and chronic diseases or conditions from the Behavioral Risk Factor Surveillance System, the National Health Interview Survey, and the National Health and Nutrition Examination Survey, 2007–2008. Prev Med 2012;54:381–7.
115. CDC. SMART: BRFSS city and county data. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cy118119.com/brfss/smart/index.htm. Accessed April 11, 2013.
116. US Department of Health and Human Services. Healthy people 2020: topics and objectives index. Washington, DC: US Department of Health and Human Services; 2012. Available at http://www.healthypeople.gov/2020/topicsobjectives2020. Accessed April 11, 2013.