Perfluoroalkyl acids, hyperuricemia and gout in adults: Analyses of NHANES 2009-2014.

BACKGROUND: Previous studies have reported a positive association of perfluoralkyl acids (PFAAs), including perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS), with hyperuricemia. The objective of the study is to investigate whether there is an association between concurrent serum levels of several PFAAs and gout, serum uric acid (SUA) or hyperuricemia in the U.S. adult population as represented by the National Health and Nutrition Examination Survey (NHANES) 2009-2014 sample (n = 4917). The PFAAs investigated include PFOA, perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), perfluorohexane sulfonic acid (PFHxS) and PFOS. METHODS: This cross-sectional study used multivariate logistic regressions to analyze the association of single PFAAs with hyperuricemia and self-reported gout; the association with SUA was analyzed by multivariate linear regression. Analyses were adjusted for race/ethnicity, age, sex, education, alcohol consumption, smoking, serum cotinine, BMI, diabetes, hypertension, chronic kidney disease, and SUA (for gout only). RESULTS: Higher quartile values of serum PFOA and PFHxS were associated with increased odds of self-reported gout. There was a positive association of SUA with increased levels of PFOA, PFNA, PFOS, PFHxS and PFDA. Higher quartile values of PFOA, PFNA, and PFHxS were associated with higher odds of hyperuricemia. CONCLUSIONS: In this population-based cross-sectional analysis, we found an association between selected PFAAs and self-reported gout. We also confirmed previous reports of an association between several PFAAs and hyperuricemia. Our study suggests that exposure to PFAAs may be a risk factor for hyperuricemia and gout.

Public Perceptions of Environmental Public Health Risks in the United States.

Understanding public perceptions about environmental health hazards, exposures, and health impacts can help environmental public health practitioners to target and prioritize community activities, policy needs, and communication strategies. The online cross-sectional 2013 summer wave of the ConsumerStyles survey sampled U.S. adults and used questions from the Centers for Disease Control's Environmental Public Health Tracking Program to measure public awareness of governmental efforts to track environmental exposures and links to health impacts, as well as perceptions of environmental health issues. Unadjusted and adjusted logistic regressions examined the associations between demographic characteristics and level of awareness of government environmental public health efforts or level of concern about health risks associated with environmental pollutants. Responses were received from 4033 participants, yielding a response rate of 66.0%. More than half of respondents (57.8%) noted concerns about health risks from environmental pollutants. More than one-third (40.0%) of respondents reported awareness of government efforts. Nearly 40% of respondents felt that none of the health impacts listed in the survey were related to environmental issues. Multiple logistic regression models showed that non-Hispanic blacks, other races, females, people with a college or higher education, and people living in the Midwest or South regions were more likely than their counterparts to be concerned about how the environment affects their health. Future work should focus on improving risk communication, filling the information gap on environmental health issues, and understanding how perceptions change over time.

Long-Term Exposure to Ozone and Life Expectancy in the United States, 2002 to 2008.

Long-term exposure to ground-level ozone is associated with increased risk of morbidity and mortality. The association remains uncertain between long-term exposure to ozone and life expectancy. We assessed the associations between seasonal mean daily 8-hour maximum (8-hr max) ozone concentrations measured during the ozone monitoring seasons and life expectancy at birth in 3109 counties of the conterminous U.S. during 2002 to 2008. We used latent class growth analysis to identify latent classes of counties that had distinct mean levels and rates of change in ozone concentrations over the 7-year period and used linear regression analysis to determine differences in life expectancy by ozone levels. We identified 3 classes of counties with distinct seasonal mean daily 8-hr max ozone concentrations and rates of change. When compared with the counties with the lowest ozone concentrations, the counties with the highest ozone concentrations had 1.7- and 1.4-year lower mean life expectancy in males and females (both P < 0.0001), respectively. The associations remained statistically significant after controlling for potential confounding effects of seasonal mean PM2.5 concentrations and other selected environmental, demographic, socio-economic, and health-related factors (both P < 0.0001). A 5 ppb higher ozone concentration was associated with 0.25 year lower life expectancy in males (95% CI: -0.30 to -0.19) and 0.21 year in females (95% CI: -0.25 to -0.17). We identified 3 classes of counties with distinct mean levels and rates of change in ozone concentrations. Our findings suggest that long-term exposure to a higher ozone concentration may be associated with a lower life expectancy.

Geographic Variation in the Association between Ambient Fine Particulate Matter (PM2.5) and Term Low Birth Weight in the United States.

BACKGROUND: Studies on the association between prenatal exposure to fine particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5) and term low birth weight (LBW) have resulted in inconsistent findings. Most studies were conducted in snapshots of small geographic areas and no national study exists. OBJECTIVES: We investigated geographic variation in the associations between ambient PM2.5 during pregnancy and term LBW in the contiguous United States. METHODS: A total of 3,389,450 term singleton births in 2002 (37-44 weeks gestational age and birth weight of 1,000-5,500 g) were linked to daily PM2.5 via imputed birth days. We generated average daily PM2.5 during the entire pregnancy and each trimester. Multi-level logistic regression models with county-level random effects were used to evaluate the associations between term LBW and PM2.5 during pregnancy. RESULTS: Without adjusting for covariates, the odds of term LBW increased 2% [odds ratio (OR) = 1.02; 95% CI: 1.00, 1.03] for every 5-µg/m(3) increase in PM2.5 exposure during the second trimester only, which remained unchanged after adjusting for county-level poverty (OR = 1.02; 95% CI: 1.01, 1.04). The odds did change to null after adjusting for individual-level predictors (OR = 1.00; 95% CI: 0.99, 1.02). Multi-level analyses, stratified by census division, revealed significant positive associations of term LBW and PM2.5 exposure (during the entire pregnancy or a specific trimester) in three census divisions of the United States: Middle Atlantic, East North Central, and West North Central, and significant negative association in the Mountain division. CONCLUSIONS: Our study provided additional evidence on the associations between PM2.5 exposure during pregnancy and term LBW from a national perspective. The magnitude and direction of the estimated associations between PM2.5 exposure and term LBW varied by geographic locations in the United States.

Ozone, Fine Particulate Matter, and Chronic Lower Respiratory Disease Mortality in the United States.

RATIONALE: Short-term effects of air pollution exposure on respiratory disease mortality are well established. However, few studies have examined the effects of long-term exposure, and among those that have, results are inconsistent. OBJECTIVES: To evaluate long-term association between ambient ozone, fine particulate matter (PM2.5, particles with an aerodynamic diameter of 2.5 µm or less), and chronic lower respiratory disease (CLRD) mortality in the contiguous United States. METHODS: We fit Bayesian hierarchical spatial Poisson models, adjusting for five county-level covariates (percentage of adults aged ≥65 years, poverty, lifetime smoking, obesity, and temperature), with random effects at state and county levels to account for spatial heterogeneity and spatial dependence. MEASUREMENTS AND MAIN RESULTS: We derived county-level average daily concentration levels for ambient ozone and PM2.5 for 2001-2008 from the U.S. Environmental Protection Agency's down-scaled estimates and obtained 2007-2008 CLRD deaths from the National Center for Health Statistics. Exposure to ambient ozone was associated with an increased rate of CLRD deaths, with a rate ratio of 1.05 (95% credible interval, 1.01-1.09) per 5-ppb increase in ozone; the association between ambient PM2.5 and CLRD mortality was positive but statistically insignificant (rate ratio, 1.07; 95% credible interval, 0.99-1.14). CONCLUSIONS: This study links air pollution exposure data with CLRD mortality for all 3,109 contiguous U.S. counties. Ambient ozone may be associated with an increased rate of death from CLRD in the contiguous United States. Although we adjusted for selected county-level covariates and unobserved influences through Bayesian hierarchical spatial modeling, the possibility of ecologic bias remains.

Engaging academia to advance the science and practice of environmental public health tracking.

Public health agencies at the federal, state, and local level are responsible for implementing actions and policies that address health problems related to environmental hazards. These actions and policies can be informed by integrating or linking data on health, exposure, hazards, and population. The mission of the Centers for Disease Control and Prevention׳s National Environmental Public Health Tracking Program (Tracking Program) is to provide information from a nationwide network of integrated health, environmental hazard, and exposure data that drives actions to improve the health of communities. The Tracking Program and federal, state, and local partners collect, integrate, analyze, and disseminate data and information to inform environmental public health actions. However, many challenges exist regarding the availability and quality of data, the application of appropriate methods and tools to link data, and the state of the science needed to link and analyze health and environmental data. The Tracking Program has collaborated with academia to address key challenges in these areas. The collaboration has improved our understanding of the uses and limitations of available data and methods, expanded the use of existing data and methods, and increased our knowledge about the connections between health and environment. Valuable working relationships have been forged in this process, and together we have identified opportunities and improvements for future collaborations to further advance the science and practice of environmental public health tracking.

Awareness of kidney disease among US adults: Findings from the 2011 behavioral risk factor surveillance system.

BACKGROUND: The prevalence of chronic kidney disease as measured by biomarkers is increasing, but the recognition for this condition remains low in the USA. Little is known about the awareness of kidney disease at the state level. METHODS: Data from 490,302 adults aged 18 years or older in all 50 states as well as the District of Columbia who participated in the 2011 Behavioral Risk Factor Surveillance System were analyzed. Kidney disease diagnosis, a measure of individual awareness, was ascertained by participants' self-report in the telephone survey. Prevalence ratios of self-reported kidney disease in subpopulations were estimated and tested using log-linear regression analyses with a robust variance estimator. RESULTS: The unadjusted prevalence of self-reported kidney disease was estimated to be 2.5%. After adjustment for age and all other selected covariates, Hispanics had a higher prevalence than non-Hispanic whites (adjusted prevalence ratio 1.2, 95% CI 1.0-1.4). Persons who were unemployed (adjusted prevalence ratio 1.4, 95% CI 1.2-1.5) had a higher prevalence than those who were employed. Persons who had hypertension (adjusted prevalence ratio 1.9, 95% CI 1.7-2.1), diabetes (adjusted prevalence ratio 1.7, 95% CI 1.5-1.8), cardiovascular disease (coronary heart disease, myocardial infarction or stroke; adjusted prevalence ratio 1.5, 95% CI 1.4-1.6) or cancer (adjusted prevalence ratio 1.5, 95% CI 1.3-1.6) had a higher prevalence of self-reported kidney disease than those without these conditions. CONCLUSION: The overall awareness of kidney disease was low in the general population. Efforts are needed to promote the awareness and early detection of kidney disease in public health services and clinical practice.

Influenza-like illness, the time to seek healthcare, and influenza antiviral receipt during the 2010-2011 influenza season-United States.

BACKGROUND: Few data exist describing healthcare-seeking behaviors among persons with influenza-like illness (ILI) or adherence to influenza antiviral treatment recommendations. METHODS: We analyzed adult responses to the Behavioral Risk Factor Surveillance System in 31 states and the District of Columbia (DC) and pediatric responses in 25 states and DC for January-April 2011 by demographics and underlying health conditions. RESULTS: Among 75 088 adult and 15 649 child respondents, 8.9% and 33.9%, respectively, reported ILI. ILI was more frequent among adults with asthma (16%), chronic obstruction pulmonary disease (COPD; 26%), diabetes (12%), heart disease (19%), kidney disease (16%), or obesity (11%). Forty-five percent of adults and 57% of children sought healthcare for ILI. Thirty-five percent of adults sought care ≤ 2 days after ILI onset. Seeking care ≤ 2 days was more frequent among adults with COPD (48%) or heart disease (55%). Among adults with a self-reported physician diagnosis of influenza, 34% received treatment with antiviral medications. The only underlying health condition with a higher rate of treatment was diabetes (46%). CONCLUSIONS: Adults with underlying health conditions were more likely to report ILI, but the majority did not seek care promptly, missing opportunities for early influenza antiviral treatment.

Health behaviors and obesity among Hispanics with depression, United States 2006.

OBJECTIVE: To examine the differences in health behaviors, and obesity between Hispanics and non-Hispanic Whites with depression. DESIGN: Depression data were gathered from 38 states, the District of Columbia, Puerto Rico, and the US Virgin Islands using the 2006 Behavioral Risk Factor Surveillance System, a state-based random-digit-dialed telephone survey of adults aged > or =18 years (n=156,991). The Patient Health Questionnaire 8 was used to determine current depression. Lifetime diagnosis of depression was assessed by self-report of physician diagnosis. Prevalence ratios were calculated to examine the racial/ethnic differences in leisure-time physical activity, cigarette smoking, binge drinking, heavy drinking and obesity among people with current depression and lifetime diagnosis of depression. RESULTS: There were significant differences in age, education, and health care coverage between Hispanics and non-Hispanic Whites with current depression and lifetime diagnosis of depression. Hispanics with current depression and with lifetime diagnosis of depression were more likely to be obese than non-Hispanic Whites. After adjusting for demographic factors, health care coverage, and self-rated health status, Hispanics with current depression were 17% more likely not to participate in leisure-time physical activity and 42% less likely to be a current cigarette smoker compared with non-Hispanic Whites. Hispanics with lifetime diagnosis of depression were 14% more likely not to participate in leisure-time physical activity and 44% less likely to be a current cigarette smoker than non-Hispanic Whites after adjusting for confounders. CONCLUSIONS: Public health intervention programs are needed to promote healthy behaviors especially physical activity participation with in the Hispanic community, and paying particular attention to people who already are depressed.

Physical activity patterns among U.S. adults with and without serious psychological distress.

OBJECTIVE: A physically active lifestyle is recommended for overall health--both physical and mental. Serious psychological distress (SPD) is associated with adverse health behaviors. We compared patterns of physical activity (PA) among adults with and without SPD using current public health guidelines for PA and examined whether adults with SPD were physically active at recommended levels. METHODS: We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to assess SPD using the Kessler 6 (K6) scale of nonspecific psychological distress and PA categories based on the 2008 U.S. Department of Health and Human Services guidelines. Complete data were available for 78,886 adults in 16 states that used an optional BRFSS mental illness and stigma module containing the K6 scale. We performed multiple logistic regression analyses to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: The unadjusted prevalence of SPD was 3.9% (95% CI 3.6, 4.2), and the age-adjusted prevalence of SPD was 3.8% (95% CI 3.5, 4.1). After adjusting for age, sex, race/ethnicity, education, employment, body mass index, smoking status, and heavy drinking, adults with SPD were significantly less likely to be physically active at recommended levels than adults without SPD. PRs were attenuated but remained significant after further adjustment for limitations to PA. CONCLUSION: Adults with SPD are less likely to meet current PA recommendations than adults without SPD, highlighting the need for targeted interventions.

Vital signs: communication between health professionals and their patients about alcohol use--44 states and the District of Columbia, 2011.

INTRODUCTION: Excessive alcohol use accounted for an estimated 88,000 deaths in the United States each year during 2006-2010, and $224 billion in economic costs in 2006. Since 2004, the U.S. Preventive Services Task Force (USPSTF) has recommended alcohol misuse screening and behavioral counseling (also known as alcohol screening and brief intervention [ASBI]) for adults to address excessive alcohol use; however, little is known about the prevalence of its implementation. ASBI will also be covered by many health insurance plans because of the Affordable Care Act. METHODS: CDC analyzed Behavioral Risk Factor Surveillance System (BRFSS) data from a question added to surveys in 44 states and the District of Columbia (DC) from August 1 to December 31, 2011, about patient-reported communication with a health professional about alcohol. Elements of ASBI are traditionally delivered via conversation. Weighted state-level prevalence estimates of this communication were generated for 166,753 U.S. adults aged ≥18 years by selected demographic characteristics and drinking behaviors. RESULTS: The prevalence of ever discussing alcohol use with a health professional was 15.7% among U.S. adults overall, 17.4% among current drinkers, and 25.4% among binge drinkers. It was most prevalent among those aged 18-24 years (27.9%). However, only 13.4% of binge drinkers reported discussing alcohol use with a health professional in the past year, and only 34.9% of those who reported binge drinking ≥10 times in the past month had ever discussed alcohol with a health professional. State-level estimates of communication about alcohol ranged from 8.7% in Kansas to 25.5% in DC. CONCLUSIONS: Only one of six U.S. adults, including binge drinkers, reported ever discussing alcohol consumption with a health professional, despite public health efforts to increase ASBI implementation. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Increased implementation of ASBI, including systems-level changes such as integration into electronic health records processes, might reduce excessive alcohol consumption and the harms related to it. Routine surveillance of ASBI by states and communities might support monitoring and increasing its implementation.

Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: the NHANES linked mortality study.

BACKGROUND: Regular physical activity elicits multiple health benefits in the prevention and management of chronic diseases. We examined the mortality risks associated with levels of leisure-time aerobic physical activity and muscle-strengthening activity based on the 2008 Physical Activity Guidelines for Americans among US adults. METHODS: We analysed data from the 1999 to 2004 National Health and Nutrition Examination Survey with linked mortality data obtained through 2006. Cox proportional HRs with 95% CIs were estimated to assess risks for all-causes and cardiovascular disease (CVD) mortality associated with aerobic physical activity and muscle-strengthening activity. RESULTS: Of 10 535 participants, 665 died (233 deaths from CVD) during an average of 4.8-year follow-up. Compared with participants who were physically inactive, the adjusted HR for all-cause mortality was 0.64 (95% CI 0.52 to 0.79) among those who were physically active (engaging in ≥150 min/week of the equivalent moderate-intensity physical activity) and 0.72 (95% CI 0.54 to 0.97) among those who were insufficiently active (engaging in >0 to <150 min/week of the equivalent moderate-intensity physical activity). The adjusted HR for CVD mortality was 0.57 (95% CI 0.34 to 0.97) among participants who were insufficiently active and 0.69 (95% CI 0.43 to 1.12) among those who were physically active. Among adults who were insufficiently active, the adjusted HR for all-cause mortality was 44% lower by engaging in muscle-strengthening activity ≥2 times/week. CONCLUSIONS: Engaging in aerobic physical activity ranging from insufficient activity to meeting the 2008 Guidelines reduces the risk of premature mortality among US adults. Engaging in muscle-strengthening activity ≥2 times/week may provide additional benefits among insufficiently active adults.

Trends in cigarette smoking rates and quit attempts among adults with and without diagnosed diabetes, United States, 2001-2010.

INTRODUCTION: Quitting smoking is a critical step toward diabetes control. It is not known whether smoking rates in adults with diabetes are similar to rates among adults who do not have the disease or whether people with diabetes have increased motivation to quit. We examined prevalence trends of current smoking and quit attempts among US adults with and without diagnosed diabetes from 2001 through 2010. METHODS: We used data from the 2001 through 2010 Behavioral Risk Factor Surveillance System, a state-based telephone survey of noninstitutionalized US adults, and conducted linear trend analysis and log linear regression. RESULTS: The adjusted prevalence of cigarette smoking among adults with diagnosed diabetes was 9% less than adults without diagnosed diabetes (adjusted prevalence ratio [APR], 0.91; 99% confidence interval [CI], 0.89-0.93). Declines in smoking prevalence were greater among adults without diabetes than adults with diagnosed diabetes (P < .001). Among smokers, the adjusted prevalence of quit attempts among adults with diagnosed diabetes was 13% higher than among adults without diagnosed diabetes (APR, 1.13; 99% CI, 1.11-1.15). Among adult smokers with diagnosed diabetes, quit attempts were stable over time for those aged 18 to 44 years and those with a high school education or less. Quit attempts were also stable for older smokers, non-Hispanic African Americans, and Hispanic smokers, regardless of diagnosed diabetes status. CONCLUSION: A large proportion of smokers with diagnosed diabetes seemed to have quit smoking, but more research is needed to confirm success and how difficult it was to achieve.

Trends in modifiable lifestyle-related risk factors following diagnosis in breast cancer survivors.

PURPOSE: Evidence suggests that high-risk lifestyle behaviors exacerbate the health of cancer survivors and increase cancer mortality. This study examined the prevalence of lifestyle-related risk factors among female breast cancer survivors by duration of survivorship in the United States. METHODS: We analyzed data from 7,443 women aged ≥18 years who participated in the 2009 Behavioral Risk Factor Surveillance System and reported having ever-diagnosed breast cancer. Adjusted prevalence with 95 % confidence interval for lifestyle-related risk factors (including current smoking, excessive alcohol drinking, obesity, engaging in physical activity ≥150 min/week, and consuming fruits and vegetables ≥5 times/day) was estimated using log-linear regression while controlling for confounders. RESULTS: Overall, the prevalence estimates for lifestyle-related risk factors were 10.2 % for current smoking, 6.8 % for excessive alcohol drinking, 24.7 % for obesity, 53.8 % for engaging in physical activity ≥150 min/week, and 33.9 % for consuming fruits and vegetables ≥5 times/day among female breast cancer survivors. After adjustment for covariates, with increasing years of survivorship, a linearly increasing trend was observed for current smoking (P = 0.038), and quadratic trends were observed for excessive alcohol drinking (P < 0.001) and obesity (P = 0.048). The adjusted prevalence estimates for engaging in physical activity ≥150 min/week and consuming fruits and vegetables ≥5 times/day did not vary significantly by duration of survivorship. CONCLUSION: Continuing efforts on counseling and encouraging breast cancer survivors to adopt healthy lifestyles are needed to improve their health. IMPLICATIONS FOR CANCER SURVIVORS: Understanding the trends of modifiable lifestyle-related risk factors among breast cancer survivors with varying duration of survivorship may assist health care providers to provide appropriate counseling for breast cancer patients to improve their health. Clinical and public health intervention programs should seek to maximize the number of recommended healthy behaviors especially in those women who are at high risk for failing to comply with the healthy lifestyle guidelines.

Surveillance for certain health behaviors among States and selected local areas - United States, 2010.

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.

A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004-2011.

BACKGROUND: In recent years response rates on telephone surveys have been declining. Rates for the behavioral risk factor surveillance system (BRFSS) have also declined, prompting the use of new methods of weighting and the inclusion of cell phone sampling frames. A number of scholars and researchers have conducted studies of the reliability and validity of the BRFSS estimates in the context of these changes. As the BRFSS makes changes in its methods of sampling and weighting, a review of reliability and validity studies of the BRFSS is needed. METHODS: In order to assess the reliability and validity of prevalence estimates taken from the BRFSS, scholarship published from 2004-2011 dealing with tests of reliability and validity of BRFSS measures was compiled and presented by topics of health risk behavior. Assessments of the quality of each publication were undertaken using a categorical rubric. Higher rankings were achieved by authors who conducted reliability tests using repeated test/retest measures, or who conducted tests using multiple samples. A similar rubric was used to rank validity assessments. Validity tests which compared the BRFSS to physical measures were ranked higher than those comparing the BRFSS to other self-reported data. Literature which undertook more sophisticated statistical comparisons was also ranked higher. RESULTS: Overall findings indicated that BRFSS prevalence rates were comparable to other national surveys which rely on self-reports, although specific differences are noted for some categories of response. BRFSS prevalence rates were less similar to surveys which utilize physical measures in addition to self-reported data. There is very little research on reliability and validity for some health topics, but a great deal of information supporting the validity of the BRFSS data for others. CONCLUSIONS: Limitations of the examination of the BRFSS were due to question differences among surveys used as comparisons, as well as mode of data collection differences. As the BRFSS moves to incorporating cell phone data and changing weighting methods, a review of reliability and validity research indicated that past BRFSS landline only data were reliable and valid as measured against other surveys. New analyses and comparisons of BRFSS data which include the new methodologies and cell phone data will be needed to ascertain the impact of these changes on estimates in the future.

Drinking pattern and blood pressure among non-hypertensive current drinkers: findings from 1999-2004 National Health and Nutrition Examination Survey.

CONTEXT AND OBJECTIVE: Epidemiological studies show the apparent link between excessive alcohol consumption and hypertension. However, the association between alcohol intake and blood pressure among non-hypertensive individuals is scarcely examined. METHODS: This analysis included participants in the 1999-2004 National Health and Nutrition Examination Survey who were aged 20 to 84 years without a diagnosis of cardiovascular disease, hypertension or pregnancy, whose systolic/diastolic blood pressure (SBP/DBP) was lower than 140/90 mmHg, who were not on antihypertensive medication, and who consumed 12 drinks or more during the past 12 months (N = 3957). Average drinking volume (average alcohol intake per day), usual drinking quantity (drinks per day when drinking) and frequency of binge drinking were used to predict SBP/DBP. Covariates included age, gender, race/ethnicity, education level, smoking status, average physical activity level, and daily hours spent on TV/ video/computer. RESULTS: Drinking volume was directly associated with higher SBP in a linear dependent manner (an increment of 10 g of alcohol per day increased average SBP by 1 mmHg among both men and women). Drinking above the US Dietary Guidelines (men more than two drinks and women more than one drink per drinking day) was associated with higher SBP. Binge drinking was associated with both higher SBP and higher DBP. Average intake greater than two drinks per day was particularly associated with higher DBP among women (P = 0.0003). CONCLUSION: This analysis from a population-based survey indicates a direct association between higher alcohol consumption and a higher prevalence of prehypertension among non-hypertensive drinkers.

Prevalence of diagnosed cancer according to duration of diagnosed diabetes and current insulin use among U.S. adults with diagnosed diabetes: findings from the 2009 Behavioral Risk Factor Surveillance System.

OBJECTIVE: To estimate the prevalence of diagnosed cancer according to duration of diagnosed diabetes and current insulin use among U.S. adults with diagnosed diabetes. RESEARCH DESIGN AND METHODS: We analyzed data from 25,964 adults aged ≥ 18 years with diagnosed diabetes who participated in the 2009 Behavioral Risk Factor Surveillance System. RESULTS: After adjustment for potential confounders, we found that the greater the duration of diagnosed diabetes, the higher the prevalence of diagnosed cancers (P < 0.0001 for linear trend). Among adults with diagnosed type 2 diabetes, the prevalence estimate for cancers of all sites was significantly higher among men (adjusted prevalence ratio 1.6 [95% CI 1.3-1.9]) and women (1.8 [1.5-2.1]) who reported being diagnosed with diabetes ≥ 15 years ago than among those reporting diabetes diagnosis <15 years ago. The prevalence estimate for cancers of all sites was ~1.3 times higher among type 2 diabetic adults who currently used insulin than among those who did not use insulin among both men (1.3 [1.1-1.6]) and women (1.3 [1.1-1.5]). CONCLUSIONS: Our results suggest that there is an increased burden of diagnosed cancer among adults with a longer duration of diagnosed diabetes and among type 2 diabetic adults who currently use insulin.

Has the use of complementary and alternative medicine therapies by U.S. adults with chronic disease-related functional limitations changed from 2002 to 2007?

OBJECTIVES: This study examined changes in the use of complementary and alternative medicine (CAM) therapies by U.S. adults aged 18 years or older with chronic disease-related functional limitations between 2002 and 2007. DESIGN: The study was a cross-sectional survey. SETTING/LOCATION: The study was conducted in the United States. SUBJECTS: The study comprised adults aged 18 years or older with chronic disease-related functional limitations. METHODS: Data were obtained from the 2002 and 2007 U.S. National Health Interview Survey to compare the use of 22 CAM therapies (n=9313 and n=7014, respectively). Estimates were age adjusted to the year 2000 U.S. standard population. RESULTS: The unadjusted and age-standardized prevalence of overall CAM use (22 therapies comparable between both survey years) was higher in 2007 than in 2002 (30.6% versus 26.9%, p<0.001 and 34.4% versus 30.6%, p<0.001, respectively). Adults with functional limitations that included changing and maintaining body position experienced a significant increase in CAM use between 2002 and 2007 (31.1%-35.0%, p<0.01). The use of deep breathing exercises was the most prevalent CAM therapy in both 2002 and 2007 and increased significantly during this period (from 17.9% to 19.9%, p<0.05). The use of meditation, massage, and yoga also increased significantly from 2002 and 2007 (11.0%-13.5%, p<0.01; 7.0%-10.9%, p<0.0001; and 5.1% to 6.6%, p<0.05, respectively), while the use of the Atkins diet decreased (2.2%- 1.4%, p<0.01). CONCLUSIONS: Among U.S. adults with chronic disease-related functional limitations, the overall increase in CAM use from 2002 to 2007 was significant, particularly among those with changing and maintaining body position limitations.