THE BURDEN OF CHRONIC DISEASE Nevada

Transcription

1 THE BURDEN OF CHRONIC DISEASE Nevada Department of Health and Human Services Nevada State Health Division Chronic Disease Section Brian Sandoval, Governor State of Nevada Apr 2013 Michael J Willden, Director e 1.0 Department of Health and Human Services Richard Whitley, MS, Administrator Health Division Tracey Green, MD, State Health Officer Health Division

2 Table of Contents Acknowledgements... iv Executive Summary... 1 Introduction and Purpose... 3 Data Sources and Methods... 4 Behavioral Risk Factor Surveillance System (BRFSS, Appendix II)... 4 Healthy People 2020 (Appendix I)... 4 Office of Vital Statistics... 5 Nevada Central Cancer Registry (NCCR)... 5 Inpatient Hospital Discharge Database... 5 Technical Notes... 6 Definitions... 6 The Burden of Chronic Disease National Perspective Heart Disease... 7 Stroke... 7 Cancer... 7 Diabetes... 7 Arthritis... 8 Respiratory Diseases... 8 Oral Conditions... 8 Burden of Chronic Disease in Nevada... 9 Demographics Health Insurance Mortality Counts by Chronic Disease Prevalence Heart Disease Stroke Cancer Diabetes Arthritis Overweight/Obese i The Burden of Chronic Disease in Nevada 2012

3 Respiratory Diseases Oral Conditions Risk Factors Associated with Chronic Disease Lack of Physical Activity Poor Nutrition Tobacco Use Excessive Alcohol Use Nevada and Chronic Disease Risk Factors Lack of Physical Activity: High Blood Pressure: High Blood Cholesterol: Poor Nutrition: Tobacco Use: Excessive Alcohol Use: Future Implications Quit Smoking Diet and Exercise Maintain a Healthy Blood Pressure/Blood Cholesterol Level Instilling Healthy Behaviors Young Community Water Fluoridation Get Screened Regularly Early Diagnosis, Early Treatment Early Management Health Disparities and Inequities in Chronic Disease Increased Age, Increased Chronic Disease Race/Ethnicity = A Determinant of Health Disparity Less Education = Poorer Health Less Income = Poorer Health Higher BMI = Poorer Health Less Active = Poorer Health Low Vegetables and Fruit = Poorer Health Health Disparity Profiles Latinos/Hispanics in Nevada ii The Burden of Chronic Disease in Nevada 2012

4 Blacks in Nevada Economic Costs of Chronic Disease in Nevada Most Costly Chronic Diseases Direct Costs Indirect Costs Economic Impact on Nevada Presenteeism Summary and Implications Next Steps for Chronic Disease and Nevada References Glossary of Terms Appendix Healthy People Arthritis Cancer Diabetes Heart Disease and Stroke Nutrition and Weight Status Oral Health.78 Physical Activity Tobacco Use Respiratory Disease Chronic Obstructive Pulmonary Disease (COPD) II. Prevalence Tables iii The Burden of Chronic Disease in Nevada 2012

5 Acknowledgements This report was prepared by the Nevada State Health Division, with support from the Office of Public Health Informatics and Epidemiology in the Bureau of Health Statistics, Planning, Epidemiology, and Response. Special thanks are extended to Julia Peek, Brad Towle, Kyra Morgan, Jennifer Thompson, and Theron Huntamer for providing mortality and morbidity statistics, current surveillance information and their time. This report would not have been possible without their support. iv The Burden of Chronic Disease in Nevada 2012

6 Executive Summary Why is Attention to Chronic Disease Important? Chronic diseases are prolonged conditions that often do not improve and are rarely cured completely. They are also the leading causes of death and disability in the United States. These diseases account for 7 of every 10 deaths and affect the quality of life of 90 million Americans (CDC, 2012e). In Nevada, heart disease, stroke, cancer, diabetes and arthritis are among the most common, costly, and preventable of all health problems today. In 2011, of the 2,700,551 people (U.S. Census Bureau, 2007) in the state of Nevada: At least 1 million adults had at least one chronic illness (BRFSS, 2011). 465,121 adults were living with arthritis which could increase activity limitations (CDC, 2011b). 228,185 adults were living with some form of cancer (BRFSS, 2011; CDC, 2011b). 209,661 adults were living with diabetes which remains one of the leading causes of kidney failure, non-traumatic lower-extremity amputations and blindness in adults, aged (BRFSS, 2011; CDC, 2011b) The annual estimated costs of chronic disease is $ billion (direct cost = $4.063 billion and indirect costs = $16.25 billion) (United Health Foundation, 2011). There are four modifiable health risk behaviors that can greatly influence chronic disease outcomes: physical activity, nutrition, tobacco use and alcohol consumption (CDC, 2009). 60.2% of the adult population is either obese (498,709 Nevadans) or overweight (726,689 Nevadans). Being obese or overweight increases one s risk of heart disease, stroke, type-2 diabetes, and certain types of cancer which can lead to death (CDC, 2011b). 79% of the adult population (1,608,079 Nevadans) does not meet the daily recommended aerobic and strength guidelines for physical activity (CDC, 2011b). 83% of the adult population (1,681,563 Nevadans) reported not eating 5 or more servings of fruit and vegetables per day (BRFSS, 2011). 22.9% of all adults 18 years of age and older are currently smokers, and in 2009, 17.0% of high school students smoked one or more cigarettes in the previous month (CDC, 2011b; CDC, 2011i; CDC, 2008e). 1 The Burden of Chronic Disease in Nevada 2012

7 38.6% of high school students reported consuming alcohol in the past 30 days and a large number of studies provide strong evidence that drinking alcohol is a risk factor for liver cancer, breast cancer and colorectal (colon) cancer (CDC, 2008e). 2 The Burden of Chronic Disease in Nevada 2012

8 Chronic disease has become one of the most significant public health challenges of the 21 st century with more than two-thirds of adults in the U.S. expressing that the healthcare system should place more emphasis on chronic disease preventive care. The Centers for Disease Control and Prevention has set the vision for the nation in which all people lead healthy lives free of chronic disease. Toward the realization of this vision, CDC instituted their own call to action in 2009 (CDC, 2009b). Naming tangible ways to achieve this goal, this call to action highlights the following key areas: Well-being Policy Promotion Health Equity Research Translation Workforce Development Preliminary 2011 data from Nevada indicates that the ranked causes of death were as follows: diseases of the heart (25%), malignant neoplasms (22%), chronic lower respiratory diseases (6%), cerebrovascular diseases (5%) and diabetes mellitus (2%) (BRFSS, 2011). In 2011, the causes of death in Nevada closely reflected national percentages. Most of these chronic diseases are preventable through modifiable behavior changes. The purpose of this document is to provide a snapshot of the burden of chronic disease in Nevada and to understand health disparities and social determinants of health that are risk factors for all chronic diseases. Introduction and Purpose Causes of Death In Nevada 2011* Count % Diseases of the Heart 4, % Malignant Neoplasms (Cancer) 4, % Chronic Lower Respiratory Diseases 1, % Cerebrovascular Diseases (Stroke) % Nephritis, Nephrotic Syndrome and Nephrosis % Diabetes Mellitus % Alzheimer's Disease % Chronic Liver Disease and Cirrhosis % Septicemia % Essential Hypertensive Renal Disease % Assault (Homicide) % Atherosclerosis % Note: Population estimates were provided by the Nevada State Demographer in March Note: Counts are not final and are subject to changes. [Appendix II, Table 1] Research indicates that there is a relationship between health outcomes and socioeconomic status, race/ethnicity, level of education and geographic region (Truman, Smith, Roy, Chen, & Moonesigne, 2011). Research also indicates a relationship between health outcomes, level of productivity, and cost to a state (Goetzel, Ozminkowski, Hawkins, Wang, & Lynch, 2004). By compiling localized data, comparing it to national targets, and calculating estimated cost associated with the burden of chronic disease, Nevada will have a clearer justification for emphasizing education, interventions, and programs to build a healthier state. 3 The Burden of Chronic Disease in Nevada 2013

9 Data Sources and Methods The main source of data for this report is the Behavioral Risk Factor Surveillance System (BRFSS). In addition, the Office of Public Health Informatics and Epidemiology provided select hospital inpatient billing and emergency department statistics and information from the Nevada Central Cancer Registry. Data was compared to Healthy People 2020 national targets in order to provide a roadmap to improve health outcomes in Nevada. This comparison will highlight disparities or immutable characteristics such as race/ethnicity, socio-economic status, and geographic residency in disease prevalence, as well as highlight disparities in access to health care prevention and resources to attain optimal health and life without chronic disease. Behavioral Risk Factor Surveillance System (BRFSS, Appendix II) BRFSS is a state-based system of telephone health surveys that collects information on health risk behaviors, preventive health practices, and health care access related to chronic disease and injury. The annual survey of adults 18 and older has been conducted since 1984 by the Centers for Disease Control and Prevention (CDC). BRFSS is based on self-reports and assesses risk factors for diseases and conditions related to the ten leading causes of death in the U.S. population. The data collected through BRFSS is routinely used to capture health information on demographically defined subgroups such as gender, ethnicity, age, educational level, and geographic location. More than 350,000 adults are interviewed each year, making BRFSS the largest telephone health survey in the world. States use BRFSS data to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs. (CDC website - (CDC, 2008a). Throughout this report, specific questions regarding BRFSS are highlighted for reference to specific prevalence of chronic disease risk factors. Not all questions are asked annually, some questions are only asked biannually; therefore, not all data reflects the most recent year, Methodological changes in BRFSS occurred in 2011 that potentially effect prevalence estimates. Data is now collected from cell phone users to extend the reach of the survey and ultimately produce a more representative description of the health of the nation. Due to this change, trend data does not include BRFSS 2011 data. Most prevalence charts are displayed appropriately as they occur throughout the report; however, for further information, reference to full tables can be made in Appendix II. Table number is specified under most charts. Healthy People 2020 (Appendix I) Healthy People is a 10-year initiative that is evidence-based and provides national objectives for improving the health of all Americans. Three decades old now, Healthy People continues to establish benchmarks and monitor progress to (Healthy People: (Healthy People, 2012): Encourage collaborations across communities and sectors. Empower individuals to make informed health decisions. Measure the impact of prevention activities. Four foundation health measures will serve as an indicator of progress towards achieving these goals: General Health Status Health-Related Quality of Life and Well-Being Determinants of Health Disparities 4 The Burden of Chronic Disease in Nevada 2013

10 Measures utilized to indicate progress are broken down further: General Health Status Life expectancy Healthy life expectancy Years of potential life lost Physically and mentally unhealthy days Self-assessed health status Limitation of activity Chronic disease prevalence Health-Related Quality of Life and Well-Being Physical, mental, and social health-related quality of life Well-being/satisfaction Participation in common activities Determinants of Health A range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. Determinants of health include such things as biology, genetics, individual behavior, access to health services, and the environment in which people are born, live, learn, play, work, and age. Disparities Race/ethnicity Gender Physical and mental ability Geography Healthy People 2020 includes over 600 objectives with 1,200 measures. Healthy People relies on data sources derived from: A national census of events like the National Vital Statistics System Nationally representative sample surveys like the National Health Interview Survey Office of Vital Statistics The Nevada Office of Vital Statistics is overseen by the Bureau of Health Statistics, Planning, Epidemiology and Response and collects, processes, and maintains birth and death records. Funeral directors, or persons acting as such, are legally responsible for filing death certificates. The vital records database includes individuals who died in Nevada (residents and non-residents) and Nevada residents who died outside the state of Nevada. Mortality data in this report includes only Nevada residents. Nevada Central Cancer Registry (NCCR) NCCR is a population-based registry that maintains data on all cancer patients in Nevada. NCCR collects data on all reportable cancers from hospitals, outpatient facilities, and pathology laboratories throughout the state. In accordance with the National Program of Cancer Registries (NPCR) and the North American Association of Central Cancer Registries (NAACCR) standards, NCCR strives to achieve and maintain 95% complete case ascertainment within 24 months of diagnosis date. The data is compiled, aggregated, and submitted to federal agencies annually. Once submitted, NCCR data is reviewed by each diagnosis year for completeness, accuracy, and timeliness. Hospital Inpatient Billing Data Hospital inpatient billing data provides information about patients discharged from non-federal acute care hospitals in Nevada. Data is collected by the standard Uniform Billing (UB-92) form that hospitals use to bill for their charges. This data includes patients who spent at least 24 hours as an inpatient but does not include 5 The Burden of Chronic Disease in Nevada 2013

11 patients who were discharged from the emergency department. It captures demographic characteristics, diagnoses (identified by International Classification of Disease codes 9 (ICD-9)), diagnostic and operative procedures, charges billed, length of stay, and discharge destination. The data identify billed charges only and not payments received. The ICD-9 system is used to code and classify morbidity data from inpatient records. Technical Notes Age-specific rates shown in this report are per 100,000 age-specific population. Age-adjusted rates shown in this report are adjusted to the US standard population and are per 100,000 Nevada residents. Population estimates used in this report were from 2009 and provided by the Nevada State Demographer in April Due to changes in methodology, rates for subgroups published in this edition may not match or be directly comparable to past years and should be used with caution when compared to other published rates. Definitions Crude Rate: In this report, crude rates are the number of cases which occur per 100,000 Nevada population and are not adjusted for other factors, such as age. Gender and/or race/ethnicity of specific populations are used in the denominator when applicable. Age-adjusted Incidence Rate (direct method): Observed age-specific crude rates are applied to the 2000 U.S. standard population 11 age groups to make populations with different age distributions comparable. Standard Population: Standard population, or weights, are used in the calculation of age-adjusted rates to serve as an index (Beckles & Truman, 2011). The 2000 U.S. standard population has been used in this report and is used by many national agencies as well. 6 The Burden of Chronic Disease in Nevada 2013

12 The Burden of Chronic Disease National Perspective According to the Centers for Disease Control and Prevention (2012e), the most common and costly chronic diseases are heart disease, stroke, cancer, diabetes, and arthritis which also happen to be the most preventable diseases in the United States. Other chronic diseases that significantly affect our nation are respiratory diseases and oral conditions. Heart Disease The Healthy People 2020 objective is to increase overall cardiovascular health in the U.S. population. Currently, mortality due to diseases of the heart ranks number one in the nation and is the leading cause of death for men, women and most races/ethnicities. In 2012, CDC stated that coronary heart disease was the most common heart disease in 2010 and cost the U.S. an estimated $108.9 billion (CDC, 2012f). Stroke A stroke usually occurs when there is a blockage in the blood supply to the brain or when a blood vessel in the brain bursts. Stroke is the leading cause of long-term disability causing paralysis, speech difficulties, and emotional problems. The Healthy People 2020 objective is to reduce deaths due to stroke to 33.9 per every 100,000 people. Stroke is ranked as one of the five leading causes of death across every race/ethnicity. On average someone has a stroke every 40 minutes, and every 4 minutes somebody dies as a result of having a stroke. The estimated cost to the U.S. was $53.9 billion in 2010 according to CDC (CDC, 2011g). Cancer Cancer is defined by abnormal cell growth and can involve tissue from all parts of the body. Nationally, cancer is the second leading cause of death, and 1 in every 4 deaths is cancer related. The top three most common cancers are prostate, breast and lung/bronchus cancer. In 2010, the estimated national cost of cancer was $ billion and was estimated to reach $158 billion by 2020 (National Cancer Institute, 2012). The Healthy People 2020 objectives are to reduce the overall cancer death rate from per 100,000 people to per 100,000 people and to increase the proportion of cancer survivors who live 5 years or longer after diagnosis by 72.8% (Healthy People, 2012b). Diabetes Diabetes is a disease wherein the body suffers a shortage of insulin, a decreased ability to use insulin, or both. Damage can occur to vital organs when diabetes is not controlled and glucose and fats remain in the blood. In 2007 in the United States, 25.8 million people had diabetes, and another 7 million had diabetes but were not diagnosed. Diabetes is the seventh leading cause of death in the nation and can cause blindness, kidney failure and amputations of the feet, and legs not related to accidents or injury. CDC estimated that in 2007, the total direct and indirect costs of diabetes was $174 billion (CDC, 2008c). The Healthy People The Burden of Chronic Disease in Nevada 2013

13 objectives are to reduce the number of new cases and the number of deaths and to increase the proportion of persons diagnosed with diabetes. Arthritis Arthritis is the most common cause of disability in the U.S. The basic definition of arthritis is joint inflammation; however, CDC uses the term to address over 100 rheumatic diseases that affect the joints, surrounding tissue, connective tissue and the location of symptoms. From , 1 in 5 (50 million) adults were diagnosed with arthritis. The disease tends to affect women more than men (CDC, 2006). It is estimated that by 2030, 67 million people ages 18 and older will be diagnosed with arthritis. The total cost attributed to arthritis and other rheumatic conditions in the U.S. was estimated in 2003 at $128 billion (CDC, 2009c). Healthy People 2020 objectives are to reduce the mean level of joint pain among adults diagnosed and to reduce the proportion of adults diagnosed who experience a limitation in activity due to arthritis or joint symptoms. Respiratory Diseases Respiratory diseases, or chronic obstructive pulmonary disease (COPD), refers to a group of diseases that are defined by an airflow blockage or breathing related problem. CDC identified in 2002 that emphysema, chronic bronchitis, and asthma are the most commonly diagnosed respiratory disorders. According to CDC, over 12 million Americans have been diagnosed with COPD (CDC, 2009a). In the U.S., 75% of COPD cases can be attributed to tobacco use, however, exposure to air pollutants, genetics and respiratory infections can also play a role in disease development. It was projected that COPD would cost the U.S. $49.9 billion in 2010 (U.S. Department of health and Human Services, 2009). Healthy People 2020 objectives for COPD include reducing activity limitations and deaths from COPD among adults, COPD related hospitalizations and increasing the proportion of adults with abnormal lung function who were diagnosed with COPD. Oral Conditions Oral conditions include mouth and throat diseases such as tooth decay, periodontal (gum) disease and oral cancers. According to CDC (2011f), tooth decay affects more than one-fourth of U.S. children aged 2-5 years old and half of those aged years. Advanced gum disease affects 4%-12% of U.S. adults. Half of severe gum diseases can be attributable to cigarette smoking (CDC, 2011f). One-fourth of U.S. adults aged 65 or older have lost all of their teeth and more than 7,800 Americans die from oral and pharyngeal (throat) cancers each year (U.S. Department of Health and Human Services, 2000). Current research is starting to indicate a relationship between oral health and other chronic diseases such as diabetes and heart disease. Most oral diseases are preventable and each year cost the U.S. an estimated $108 billion dollars in dental services (CDC, 2011f). Healthy People 2020 objectives for oral health include reducing the proportion of children experiencing dental caries (cavities), reducing natural tooth loss in older adults, increasing oral and pharyngeal cancer screenings, and increasing the proportion of people receiving dental services and preventive care. 8 The Burden of Chronic Disease in Nevada 2013

14 Burden of Chronic Disease in Nevada Geographically, Nevada is the 7 th largest state in the United States, but a large portion of the state is sparsely populated. The state is comprised of 17 counties that cover over 110,000 square miles of land. Of the 17 counties, 3 are considered urban (Clark, Washoe, Carson City), accounting for 87.7% of the population; the remaining 14 counties are divided among rural (Douglas, Lyon, Storey) and frontier counties. Frontier counties are populated with 7 persons or less per square mile. Nevada s rural and frontier counties account for 12.3% of the state population, but 86.8% of the total state land mass (Griswold & Packham, 2011). Until recently, Nevada was considered one of the four fastest-growing states in the nation by population estimates. However, 2011 marked the first time in over 30 years that Nevada s population growth rate (0.84% - Ranked 26 th ) fell below the United States national average of 0.91% (Griswold & Packham, 2011). This drop in population growth could be an indication that the dynamics of the population are changing and therefore prevalence rates and risk factors associated with chronic disease could also change in the future. Nevada has a minority population over 40% but is not considered a majority-minority state. Minority populations tend to have disproportionately higher rates of disease, birth, and uninsured/underinsured. The Nevada State Health Division plans to assist these groups with the help of the research and analysis laid out in this burden document. Mortality Rate of Heart Disease in Nevada, Source: National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention, The Burden of Chronic Disease in Nevada 2013

15 Demographics Basics Demographics are broken down into the following categories: Age, Sex, Race/Ethnicity, Education Level, Household Income, and Geographic Location within the state of Nevada. Each category in demographics will add up to 100%. The color scheme for each category that is maintained through the document. Age Sex 37% of Nevadans were between the ages of 18 and 44, 14% middle aged (45-54) and 24% 55 years of age or older. There was almost an even distribution of males (51%) and females (50%). Race/Ethnicity Nevadans predominantly reported being White (60%) followed by Hispanic (25%) when stating racial/ethnic background. Geographic Location 73% of the Nevadans lived in Clark County followed by 15% in Washoe County and 12% in the rural and frontier areas years years years years years 65+ years Male Female White Black Hispanic Other Race <HS HS or GED Some Post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark Washoe Balance of State [Appendix II, Table 2, 3] Nevada Population Demographics, US Census Bureau, 2010 Educational Attainment 8.0% 7.1% 8.0% 8.2% 8.7% 14.2% 14.0% 11.7% 11.9% 10.7% 14.4% 15.7% 14.1% 15.2% 12.3% 20.9% 25.3% 25.5% 29.7% 29.1% 37.5% 50.5% 49.5% 59.6% 72.5% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 30% of Nevadans had a high school diploma or equivalent, 29% a college degree, 26% some post high school education, and 16% less than a high school diploma. Household Income 58% of Nevadans earned a household income of $50,000 or more with 38% making $75,000 or more. 42% of Nevadans earned a household income of $49,999 or less. 10 The Burden of Chronic Disease in Nevada 2013

16 Health Insurance The United Health Foundation (2012) ranked Nevada as the 42 nd healthiest state in the U.S., up from 47 th in Nevada also ranked 47 th in the nation for healthcare coverage (United Health Foundation, 2011). Racial/ethnic minorities often face barriers to care and receive poorer quality of care when accessed (U.S. Department of Health and Human Services, 2012). N r tr5 [Appendix II, Table 4] Adults in Nevada Who Do Not Have Any Kind of Health Care Coverage, including Health Insurance, Prepaid Plans such as HMOs or Government Plans such as Medicare, BRFSS, 2011 National Overall Adults 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65+ years Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State 17.9% 27.0% 44.2% 38.1% 28.8% 25.6% 25.0% 3.2% 28.0% 26.0% 19.1% 20.4% 47.0% 29.7% 48.8% 29.1% 23.7% 11.3% 52.0% 45.6% 32.0% 17.7% 22.2% 22.1% 20.5% 7.8% 10.2% 0.0% 20.0% 40.0% 60.0% 80.0% Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System (BRFSS), Prevalence and Trends Data, 2011 Note: National median percentage is the median percentage of all the states including DC. 11 The Burden of Chronic Disease in Nevada 2013 Nevadans without Health Insurance 27% of Nevadans surveyed did not have any sort of health insurance coverage. Prevalence was slightly higher among males (28%) as compared to females (26%). Almost half of Nevadans without insurance were Hispanic (47%). 43% of Nevadans without health insurance were between the ages of 18 and 24 years. Almost half (49%) of Nevadans without health insurance had less than a high school education. Over half (52%) of Nevadans without health insurance had a household income of less than $15,000. There was a fairly equal distribution of uninsured people in metro and rural/frontier counties.

17 Mortality Counts by Chronic Disease Cerebrovascular Diseases (Stroke) Chronic Lower Respiratory Diseases Diabetes Diseases of the Heart Malignant Neoplasms (Cancer) State total 859 1, ,860 4,427 Clark ,244 3,029 Washoe All others In 2011, the leading cause of chronic disease deaths in Nevada was diseases of the heart, followed by malignant neoplasms, chronic lower respiratory diseases, accidents and cerebrovascular diseases (stroke) * In 2011, the leading cause of chronic disease deaths in all counties including the two most populated counties in Nevada, Clark and Washoe, were heart disease followed by malignant neoplasms, chronic lower respiratory diseases, cerebrovascular diseases (stroke), and diabetes * Number of Deaths Leading Cause of Death by County and State, Nevada, State total Clark Washoe All others Source: Office of Public Health Informatics and Epidemiology, Nevada State Health Division, 2011 Note: Numbers are preliminary and subject to change. The primary cause of death in Nevada can be attributed to diseases of the heart. 12 The Burden of Chronic Disease in Nevada 2013

18 BFRSS 6.1/6.2 Heart Disease Has a doctor, nurse, or other health professional ever told you that you had coronary heart disease? (BRFSS, 2011) Do you know the signs and symptoms of a heart attack? Pain or discomfort in the jaw, neck, or back Feeling weak, light-headed, or faint Chest pain or discomfort Pain or discomfort in arms or shoulder Shortness of breath Prevalence Although only 4% of adults have been diagnosed with some form of heart disease in Nevada, it still ranks as the leading cause of death in the state. There was a higher prevalence of heart disease in Blacks (7%) which was above the overall state average. Older adults 65+ (12%) had a higher prevalence of heart disease followed by ages 55 to 64 (8%). There was a higher prevalence of heart disease for households with an income between $15,000 to $24,999 (7%). Prevalence is fairly equal across Clark County (4%), Washoe county (4%), and in the rural and frontier regions (5%). [Appendix II, Table 5] Note: National median percentage is the median percentage of all the states including DC. 13 The Burden of Chronic Disease in Nevada 2013

19 Trend Graphs Percentage Heart Disease Trends, BRFSS, Has a doctor, nurse, or other health professional ever told you that you had coronary heart disease? National Nevada Although the prevalence of heart disease in Nevada and nationally has not varied dramatically from 2005 to 2010, hovering around 4%, heart disease remains one of the most deadly chronic diseases and the number one cause of deaths in Nevada. The prevalence trends for Nevada did not vary much from 2005 to 2010 (hovering around 3%); however, from 2009 to 2010 there was a 22.6% increase in stroke prevalence. Percentage Stroke Trends, BRFSS, Has a doctor, nurse, or other health professional ever told you that you had a stroke? National Nevada The Burden of Chronic Disease in Nevada 2013

20 BFRSS 6.3 Stroke Has a doctor, nurse, or other health professional ever told you that you had a stroke? (BRFSS, 2011) Do you know the signs and symptoms of stroke? Sudden numbness or weakness of the face, arms or legs Sudden confusion or trouble speaking or understanding others Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headache with no known cause Prevalence 3% of Nevadans were diagnosed as having had a stroke in Stroke was the 5 th leading cause of death in Nevada. Stroke Prevalence by Demographics in NV, BRFSS, 2011 National Overall Adults 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65+ years Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State 2.9% 3.2% 0.0% 4.5% 9.3% 2.8% 3.6% 3.2% 7.5% 4.4% 3.0% 3.6% 7.0% 4.7% 3.1% 2.9% 4.0% 0.4% 1.3% 1.9% 1.7% 1.8% 2.1% 2.2% 2.4% 2.9% 4.7% 0.0% 5.0% 10.0% 15.0% [Appendix II, Table 6] Note: National median percentage is the median percentage of all the states including DC. The highest prevalence of stroke was among Blacks (7%), followed by people aged 65+ (9%), those who have a high school education or lower (4%), and those who had a household income of $15,000 or less (7%). Stroke prevalence did not vary much between rural and frontier territories (4%), and urban areas such as Clark County (3%) and Washoe County (3%). 15 The Burden of Chronic Disease in Nevada 2013

21 Prevalence 11% of Nevadans had been diagnosed with some form of cancer. There was a higher prevalence of cancer in females (13%) as compared to males (10%). Prevalence of cancer was highest among Whites (14%), followed by Blacks (9%), Hispanics (7%) and other races (6%). There was a gradient relationship between cancer prevalence and age with the highest prevalence among ages 65+ years (28%), followed by people aged 55 to 64 years (17%). There was a slightly higher prevalence of cancer among those with less than a high school education (13%). Prevalence of cancer was higher among those whose household income was less than $15,000 (13%) and those with a household income between $25,000 and $34,999 (13%). Cancer prevalence was higher in the rural and frontier areas (16%) compared to the more prominent metro areas, Clark County (10%) and Washoe County (11%). Cancer Have you ever been told you had skin cancer or other types of cancer (combined cancers*)? (BRFSS, 2011) National Overall Adults 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65+ years Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State Combined Cancer Prevalence by Demographics in NV, BRFSS, % 11.2% 9.4% 17.2% 27.6% 9.5% 13.0% 14.3% 12.5% 10.3% 11.9% 10.7% 13.0% 10.7% 12.9% 10.2% 10.2% 11.9% 10.4% 11.0% 15.8% 2.1% 4.7% 6.3% 7.0% 5.7% 9.0% BFRSS % 10.0% 20.0% 30.0% 40.0% [Appendix II, Table 7, 8] Note: National median percentage is the median percentage of all the states including DC. 16 The Burden of Chronic Disease in Nevada 2013

22 BFRSS 6.13 Diabetes Have you ever been told by a doctor that you have diabetes (BRFSS, 2011)? Prevalence 10% of Nevada adults had been diagnosed with diabetes. [Appendix II, Table10] Note: National median percentage is the median percentage of all the states including DC. There was a slightly higher prevalence of males (11%) being diagnosed with diabetes compared to females (9%). Blacks were twice as likely to be diagnosed with diabetes (18%) than Whites (9%) and almost twice as likely as Hispanics (10%). There was a correlation between diabetes and age, with a higher prevalence of diabetes occurring among ages 65+ (22%), followed by ages 55 to 64 years (15%) and ages 45 to 54 years (14%). There was a higher prevalence of diabetes among individuals with less than a high school education (14%), followed by those with some post high school education (12%). Income brackets below $34,999 had the highest prevalence of diabetes. Prevalence did not vary from rural and frontier territories (10%) to the state metro areas such as Clark County (10%) and Washoe County (10%). 17 The Burden of Chronic Disease in Nevada 2013

23 Trend Graphs Percentage Diabetes Trends, BRFSS, Has a doctor, nurse, or other health professional ever told you that you did/did not have diabetes, had pre-diabetes, or borderline diabetes? National Nevada There was a steady increase in the prevalence of diabetes both nationally and in Nevada from 2000 to From 2000 to 2010, the prevalence of Nevadans diagnosed with diabetes increased by 2% compared to national prevalence, which went up 3%. Note: National median percentage is the median percentage of all the states including DC. Both nationally and in Nevada, the prevalence of arthritis went up 3% from 2001 to Percentage Arthritis Trends, BRFSS, Has a doctor, nurse, or health professional ever told you that you have any form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia? National Nevada Note: National median percentage is the median percentage of all the states including DC. 18 The Burden of Chronic Disease in Nevada 2013

24 Prevalence 23% of Nevadans were afflicted by arthritis. BFRSS 6.9 Arthritis Has a doctor, nurse, or other health professional EVER told you that you have any form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia? (BRFSS, 2011) There was a slightly higher prevalence of arthritis among females (25%) compared to males (21%). The highest prevalence of arthritis was among Whites (27%) followed by Blacks (24%) and Hispanics (17%). There was a relationship between age and onset of arthritis with the highest prevalence among ages 65+ (50%) followed by ages 55 to 64 years (42%) and ages 45 to 54 years (23%) of age. The highest prevalence of arthritis was among individuals with less than a high school education (30%), and households with incomes of less than $15,000 a year (20%). There was a higher prevalence of arthritis in the frontier and rural territories (30%) compared to the prominent metro areas, Clark County (22%) and Washoe County (22%). National Overall Adults 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65+ years Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State Arthritis Prevalence by Demographics in NV, BRFSS, % 22.9% 1.1% 14.6% 23.0% 41.8% 50.4% 21.0% 24.8% 26.9% 24.5% 16.5% 13.8% 29.5% 20.8% 24.1% 18.7% 30.4% 24.5% 27.2% 21.6% 22.5% 17.4% 21.7% 22.3% 29.7% 5.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% [Appendix II, Table11] Note: National median percentage is the median percentage of all the states including DC. 19 The Burden of Chronic Disease in Nevada 2013

25 BFRSS 8.11/8/12 Overweight/Obese About how much do you weigh without shoes? About how tall are you without shoes? According to the 2010 Dietary Guidelines for Americans (U.S. Department of Health and Human Services, 2010) Category Adults (BMI)* Underweight Less than 18.5 Healthy Weight 18.5 to 24.9 Overweight 25.0 to 29.9 Obese 30.0 or greater *BMI is a measure of weight in kilograms (kg) relative to height in meters (m) squared and is the weight classification utilized by CDC. National Overall Adults 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65+ years Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State Adults who are Overweight or Obese (BMI > 25 kg/m 2 ) in NV, BRFSS, % 60.2% 35.8% 62.2% 63.8% 65.2% 66.0% 59.8% 68.3% 51.2% 58.3% 67.1% 65.1% 54.3% 62.1% 61.9% 59.0% 58.0% 62.4% 62.3% 57.5% 61.1% 65.3% 61.0% 59.5% 59.7% 64.3% Prevalence 60% of Nevadans were considered overweight or obese. More males were overweight/obese (68%) compared to females (51%). There was a slightly higher rate of Blacks (67%) and Hispanics (65%) being overweight/obese compared to Whites (58%) and other races (54%). The highest prevalence of overweight/obese people were between the ages of 25 and 64 with an average prevalence of 64%. 64% of people in the rural and frontier areas were considered either overweight or obese. 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% [Appendix II, Table12] Note: National median percentage is the median percentage of all the states including DC. 20 The Burden of Chronic Disease in Nevada 2013

26 Trend Graphs Percentage Overweight and Obesity Trends, BRFSS, About how much do you weigh without shoes? About how tall are you without shoes? Note: National median percentage is the median percentage of all the states including DC. National Nevada There was a steady climb from 2000 to 2010 in overweight and obesity trends both nationally and in Nevada. The prevalence of Nevadans who were overweight and/or obese rose 7% from 2000 to Nationally, the prevalence of those who were overweight and/or obese rose 7% from 2000 to A risk factor associated with being overweight and/or obese is a lack of physical activity. In Nevada, more people were physically active from 2000 to 2010 by 2%; however, in 2010, 23% of Nevadans did not participate in any physical activity or exercise in the past 30 days that was not job related. This was in line with the national average (23%). Percentage Lack of Physical Activity Trends, BRFSS, Adults not participating in physical activity or exercise in the past 30 days, non-job related National Nevada Note: National median percentage is the median percentage of all the states including DC. 21 The Burden of Chronic Disease in Nevada 2013

27 Prevalence 7% of Nevadans were diagnosed with COPD. BFRSS 6.4/6.8 Respiratory Diseases Has a doctor, nurse, or other health professional EVER told you that you have chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis (BRFSS, 2011)? There was a slightly higher prevalence of COPD among females (7%) compared to males (6%). There was a disproportionately high prevalence of COPD among Blacks (13%) followed by Whites (9%). There was a higher prevalence of COPD in older populations, with 15% of the people with COPD in the 65+ group, and 14% being between the ages of years of age. There was a relationship between educational attainment, household income and prevalence of COPD, with 12% of those with COPD having less than a high school education and 13% having a household income of less than $15,000. There was a disproportionately high number of individuals living with COPD in rural and frontier areas (10%), followed by Clark County (7%), and the least prevalence in Washoe County (6%). [Appendix II, Table13] Note: National median percentage is the median percentage of all the states including DC. 22 The Burden of Chronic Disease in Nevada 2013

28 Oral Conditions BFRSS (2010) 7.1/7.2 How long has it been since you last visited a dentist or dental clinic? How many permanent teeth have been removed because of tooth decay or gum disease? *Taken BRFSS (2010) Oral health conditions are only assessed every two years. Adults in Nevada Who Have Never Seen A Dentist or Have Not Seen A Dentist/Dental Clinic in 5-Years or More, BRFSS, 2010 National 10.7% Overall Adults 11.7% 18 to 24 years 13.4% 25 to 34 years 7.0% 35 to 44 years 11.5% 45 to 54 years 14.4% 55 to 64 years 8.7% 65+ years 16.3% Males 13.3% Females 10.1% White 10.7% Black 13.5% Hispanic 13.0% Other Race 15.3% <HS Education 26.5% HS / GED 15.8% Some post HS 10.6% College Graduate 5.4% <$15, % $15,000 to $24, % $25,000 to $34, % $35,000 to $49, % $50,000 to $74, % $75, % Clark County 11.4% Washoe County 10.1% Balance of the State 15.3% Prevalence 12% of Nevadans had not been to a dentist or dental clinic in 5 years or more or not at all, which was a little higher than the national average (11%). Those with the highest prevalence of not seeking care or not getting dental health care in the past 5 years were: o Males (13%) o o o o o Other Race (15%) followed by Blacks (14%) Ages 65+ (16%) followed by ages (14%) years of age Those with less than a high school education (26%) Those with a household income of $15,000 or less (21%) Those who live in rural or frontier territories (15%) 0.0% 10.0% 20.0% 30.0% 40.0% [Appendix II, Table 15] Note: National median percentage is the median percentage of all the states including DC. 23 The Burden of Chronic Disease in Nevada 2013

29 Trend Graphs Percentage Oral Conditions Trends, BRFSS, Have Never Seen A Dentist or Have Not Seen a Dentist/Dental Clinic in 5-Years or More National Nevada The prevalence of Nevadans who had not seen a dentist or dental clinic in the past 5 years or more did not vary much from 2002 to 2010, hovering around 12%, which was higher than the national average. Note: National median percentage is the median percentage of all the states including DC. The prevalence of Nevadans who had not had a teeth cleaning in 5 or more years or not at all remained relatively consistent from 2002 to 2010 at 13%, which was above the national average. Percentage Oral Conditions Trends, BRFSS, Have not had a Teeth Cleaning in 5 or More Years or Not at All National Nevada Note: National median percentage is the median percentage of all the states including DC. 24 The Burden of Chronic Disease in Nevada 2013

30 Adults in Nevada Ages Who Reported Having Had Permanent Teeth Removed, BRFSS, 2010 National Overall Adults Males Females White Black Hispanic Other Race <HS Education HS / GED Some post HS College Graduate <$15,000 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000+ Clark County Washoe County Balance of the State 43.6% 57.3% 57.4% 57.2% 57.1% 66.4% 58.6% 54.8% 73.0% 67.9% 56.9% 44.6% 64.8% 78.5% 71.0% 64.3% 56.9% 39.4% 58.7% 50.6% 58.6% [Education and income level greatly influence access to consistent oral health care] 15% of Nevadans ages reported having all of their permanent teeth removed. 35% of Nevadans aged years who had all of their permanent teeth removed also reported having less than a high school education, and a household income of less than $15, % of Nevadans aged years who had all their permanent teeth removed live in the rural and frontier territories. [Appendix II, Table 17] Note: National median percentage is the median percentage of all the states including DC. 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% [Appendix II, Table 16] Note: National median percentage is the median percentage of all the states including DC. 57% of Nevadans ages reported having had some permanent teeth removed. 66% of Nevadans aged years who had some permanent teeth removed were Black. 73% of Nevadans ages who had some permanent teeth removed had less than a high school education. 78% of Nevadans ages who had at least one permanent tooth removed earned a household income between $15,000 and $24, % of Nevadans ages who had at least one permanent tooth removed lived in either Clark County or the rural/frontier territories. 25 The Burden of Chronic Disease in Nevada 2013

31 Prevalence 13% of Nevadans had not had a teeth cleaning in five or more years or not at all. Those with the highest prevalence of not receiving a teeth cleaning in the past five years or not at all were: o Males (15%) o Blacks (16%) followed by other races (14%) Oral Conditions Continued How long has it been since you had your teeth cleaned by a dentist or dental hygienist *Taken BRFSS (2010) Oral health conditions are only assessed every two years BFRSS (2010) 7.3 o o o o Ages years (16%) followed by ages years (15%) Those with less than a high school education (28%) Those with a household income less than $15,000 (28%) Those who live in rural or frontier areas (17%) Those with less educational attainment and income were less inclined to obtain regular oral health cleanings. [Appendix II, Table 18] Note: National median percentage is the median percentage of all the states including DC. 26 The Burden of Chronic Disease in Nevada 2013

32 Risk Factors Associated With Chronic Disease According to the World Health Organization (2005), if the majority of risk factors associated with chronic disease were eliminated: 80% of all heart disease, stroke, and type 2 diabetes would be prevented 40% of cancer cases would be prevented CDC states that the most common risk factors associated with the top chronic diseases are a lack of physical activity, poor nutrition, tobacco use and excessive alcohol use (CDC, 2009b). Lack of Physical Activity Regular physical activity is one of the most important preventive measures an individual can take to safeguard their own health. Regular physical activity can improve quality of life, strengthen bones and muscles, help one maintain a healthy weight, increase life expectancy and most of all reduce the chances or severity of many chronic diseases (CDC, 2011h). A lack of physical activity can put an individual at risk for negative health outcomes such as obesity, cardiovascular disease, type-2 diabetes, some cancers, poor mental health and reduced life expectancy. According to CDC, less than half (48%) of adults meet the 2008 Physical Activity Guidelines while less than 3 in 10 high school students get at least 60-minutes of physical activity every day (CDC, 2008d). In 2010, Americans were asked if they participated in any physical activities in the past 30-days; a quarter of Americans polled said they did not (CDC, 2011h). Healthy People 2020 objectives are to reduce the proportion of individuals who in engage in no leisure-time physical activity, increase the proportion of individuals who meet current Federal physical activity guidelines for aerobic physical activity and increase the proportion of the nation s public and private schools that require daily physical education for all students (Healthy People, 2012e). Poor Nutrition Nutrition is a cornerstone of health. According to the Dietary Guidelines for Americans (2010), a diet based on conscious calorie consumption and food choices can help an individual maintain a healthy weight, improve quality of life, and reduce the risk of chronic disease (U.S. Department of Health and Human Services, 2010). Conscious calorie consumption is relative to body mass index (BMI), and conscious food choices that promote healthy well-being include consuming foods high in nutrients such as vegetables, fruits, whole grains and steering away from foods high in saturated and trans fats, high in sugar and high in sodium. Poor nutrition can increase the risk of heart disease, stroke, some cancers, diabetes and osteoporosis and can add to the difficulty of maintaining a healthy weight (CDC, 2009b). According to CDC, more than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are considered obese (Ogden, Carroll & Flegal, 2007, 2008). Since 1980, obesity rates have doubled and in some cases tripled (Ogden, Carroll & Flegal, 2007, 2008). In 2008, overall medical care costs related to obesity was estimated to be as high as $147 billion. Healthy People 27 The Burden of Chronic Disease in Nevada 2013