1 figure, 2 tables omitted
Heart disease and stroke are the first and third leading causes of death,
respectively, in the United States.1 Certain
modifiable risk factors, including high blood pressure, high cholesterol,
diabetes, tobacco use, obesity, and lack of exercise, are the main targets
for primary and secondary prevention of heart disease and stroke. A substantial
proportion of the population has multiple risk factors, increasing their likelihood
of cardiovascular disease.2,3 To
assess the prevalence of multiple risk factors for heart disease and stroke
and to identify disparities in risk status among population subgroups, CDC
analyzed data from the 2003 Behavioral Risk Factor Surveillance System (BRFSS)
survey. This report summarizes the results of that analysis, which indicated
that approximately 37% of the survey population had two or more risk factors
for heart disease and stroke and that considerable disparities in risk factors
existed among socioeconomic groups and racial/ethnic populations. To decrease
morbidity and mortality from heart disease and stroke, public health programs
should improve identification of persons with multiple risk factors and focus
interventions on those populations disproportionately affected.
BRFSS is a state-based, random-digit–dialed telephone survey of
the noninstitutionalized, U.S. civilian population aged ≥18 years. CDC
analyzed self-reported data from the 2003 BRFSS survey, which included 256,155
participants from 50 states, the District of Columbia, Puerto Rico, Guam,
and the U.S. Virgin Islands. In 2003, the median CASRO response rate among
states/territories was 53.2% (range: 34.4% [New Jersey] to 80.5% [Puerto Rico]).
These rates reflect both telephone sampling efficiency and the degree of participation
among eligible respondents who were contacted.
This analysis examined six risk factors for heart disease and stroke:
high blood pressure, high cholesterol, diabetes, current smoking, physical
inactivity, and obesity. Persons reported whether they were ever told by a
doctor or other health professional that they had high blood pressure, high
cholesterol, or diabetes. Current smoking was defined as having smoked at
least 100 cigarettes during one’s lifetime and still smoking by the
date of the survey. Physical inactivity was assessed by a “no”
response to the question, “During the past month, other than your regular
job, did you participate in any physical activities or exercises, such as
running, calisthenics, golf, gardening, or walking for exercise?” Obesity
was defined as having a body mass index ≥30.0 kg/m2 on the basis
of self-reported height and weight.4 Multiple-risk–factor
status was defined as having two or more of the six risk factors. Differences
in the prevalence of multiple risk factors were examined by age, sex, race/ethnicity,
education, income, and employment status; pregnant women were excluded from
analysis. Data were weighted to reflect the noninstitutionalized, civilian
population of each state/territory. Statistical software was used to account
for the complex sampling design. Data were age-standardized to the 2000 U.S.
standard population. Age-specific and age-adjusted prevalences are reported.
For this report, references to white and black populations mean non-Hispanic
whites and non-Hispanic blacks, respectively.
In 2003, 25.6% (95% confidence interval [CI] = ±0.3)
of respondents reported having high blood pressure, 25.3% (CI = ±0.3)
reported having high blood cholesterol, 25.0% (CI = ±0.3)
were obese, 24.1% (CI = ±0.3) were physically inactive, 22.6%
(CI = ±0.3) were current smokers, and 7.4% (CI = ±0.2)
reported having diabetes. Overall, 29.8% (CI = ±0.4) reported
having no risk factors, 33.1% (CI = ±0.4) reported one risk
factor, and 37.2% (CI = ±0.3) reported two or more risk factors.
The percentage of respondents reporting two or more risk factors increased
among successive age groups. The prevalence of having two or more risk factors
was highest among blacks (48.7%) and American Indians/Alaska Natives (46.7%)
and lowest among Asians (25.9%); prevalences were similar in women (36.4%)
and men (37.8%). The prevalence of multiple risk factors ranged from 25.9%
among those who graduated from college to 52.5% among those with less than
a high school diploma (or equivalent). Household income followed a similar
pattern, with persons reporting ≥$50,000 annual income having the lowest
prevalence (28.8%) and those reporting <$10,000 having the highest prevalence
(52.5%) of two or more risk factors. Household income was not provided by
12.3% of respondents; these persons reported a 36.9% prevalence of multiple
risk factors. The occurrence of two or more risk factors also varied by employment
status. Adults who reported being unable to work had the highest prevalence
(69.3%) of two or more risk factors, followed by retired persons (45.1%),
adults who reported being unemployed (43.4%), homemakers (34.3%), and employed
The prevalence of two or more heart disease and stroke risk factors
also varied by state/territory and ranged from 27.0% (Hawaii) to 46.2% (Kentucky).
Twelve states and two territories had a multiple-risk–factor prevalence
of ≥40% (Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi,
North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto
DK Hayes, MD, KJ Greenlund, PhD, CH Denny, PhD, JB Croft, PhD, NL Keenan,
PhD, Div of Adult and Community Health, National Center for Chronic Disease
Prevention and Health Promotion, CDC.
This report indicates that, in 2003, a high proportion of the U.S. population
had multiple risk factors for heart disease and stroke, particularly certain
population subgroups defined by race/ethnicity and socioeconomic status (i.e.,
education, family income, and employment). Prevalence of multiple risk factors
also varied considerably by state/territory. A better understanding of the
reasons for these differences could guide public health prevention programs.
Furthermore, the small proportion of the population that reports no risk factors
demonstrates the substantial public health burden of heart disease and stroke.
In this study, 37.2% of respondents reported having two or more of the
six heart disease and stroke risk factors examined. A previous study that
used BRFSS examined five risk factors and observed an 18% increase in the
prevalence of multiple risk factors from 1991 to 1999, with 27.9% of the population
reporting two or more risk factors in 1999.5 If
physical inactivity is excluded from the 2003 BRFSS survey analysis, the prevalence
of multiple risk factors is 28.8%; thus, the greater prevalence determined
by the current study is probably attributable to the inclusion of physical
inactivity as an additional risk factor.
Changes in self-reported risk-factor status might also be attributable
either to an increasing prevalence of risk factors overall or to better detection
and awareness of certain risk factors. For example, in a study using data
from the National Health and Nutrition Examination Survey, hypertension based
on actual blood pressure measurements increased from 24.5% during 1988-1994
to 28.4% during 1999-2000,6 suggesting an increase
in prevalence. High blood pressure based on self-reports (i.e., BRFSS survey)
also increased, from 23.8% in 1991 to 25.4% in 1999,5 suggesting
a greater awareness of the risk factor. However, for the same period, self-reports
of high blood cholesterol increased,5 whereas
the prevalence based on actual measurement of blood cholesterol changed minimally.7 Regardless of the differences between actual measurements
and self-reports, the results indicate that a substantial proportion of the
adult population has multiple risk factors for heart disease and stroke.
The findings in this report are subject to at least five limitations.
First, BRFSS data are based on self-reported information and are subject to
recall and social desirability bias (e.g., underreporting of actual weight).8 Second, this study did not examine the degree of individual
cardiovascular risk factors nor their control through lifestyle, behavioral,
or pharmacologic means. Third, those respondents who had not been screened
for high cholesterol, diabetes, or high blood pressure might not have been
aware they had these risk factors, an obstacle possibly attributable to unequal
access to health-care services. Fourth, the low response rate might have influenced
the results; however, when compared with other surveys, data from BRFSS have
been demonstrated to be reliable and valid.9 Finally,
this study only examined modifiable risk factors and did not include other
established risk factors (e.g., family history of premature coronary heart
Many modifiable risk factors for heart disease and stroke can be addressed
through prevention, early recognition, and treatment. Policy and environmental
changes (e.g., workplace smoking cessation programs and health-care provider
adherence to primary care guidelines) also are essential in influencing persons
to live heart-healthy and stroke-free lives. CDC has formed multiple local,
national, and global partnerships to address the burden of heart disease and
stroke. One example is the Public Health Action Plan to Prevent Heart Disease
and Stroke, which is being implemented by the National Forum for Heart Disease
and Stroke Prevention.10 Through one of its
eight task groups, this forum is assessing existing research agendas and gaps
in policy development for preventing heart disease, stroke, and associated
risk factors. Another task group is examining current data systems and identifying
gaps in surveillance, including incidence of risk factors for heart disease
and stroke, incidence and case fatality of acute events, and disability among
CDC funds health departments in 32 states and the District of Columbia
to promote heart-healthy and stroke-free communities. These programs emphasize
the use of education, environmental strategies, and system changes to address
heart disease and stroke among diverse populations. For example, Oregon’s
program uses population-based public health approaches to raise public awareness
of the urgency of addressing cardiovascular disease, the symptoms of heart
disease and stroke, and the need to call 911. To decrease the disproportionate
burden of multiple risk factors on minority populations, public health programs
should focus on improving identification and treatment of affected persons
and promoting policy and lifestyle changes conducive to cardiovascular health.
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