Healthy People 2020. Leading Health Indicators (LHI).

Healthy People 2020. Leading Health Indicators.

Healthy People 2020 provides a comprehensive set of 10-year, national goals and objectives for improving the health of all Americans. Healthy People 2020 contains 42 topic areas with nearly 600 objectives (with others still evolving), which encompass 1,200 measures. A smaller set of Healthy People 2020 objectives, called Leading Health Indicators, has been selected to communicate high-priority health issues and actions that can be taken to address them.

Great strides have been made over the past decade: life expectancy at birth increased; rates of death from coronary heart disease and stroke decreased. Nonetheless, public health challenges remain, and significant health disparities persist.

The Healthy People 2020 Leading Health Indicators place renewed emphasis on overcoming these challenges as we track progress over the course of the decade. The indicators will be used to assess the health of the Nation, facilitate collaboration across sectors, and motivate action at the national, State, and community levels to improve the health of the U.S. population.

The Leading Health Indicators are composed of 26 indicators organized under 12 topics. The Healthy People 2020 Leading Health Indicators are:

Access to Health Services

• Persons with medical insurance (AHS-1.1)
• Persons with a usual primary care provider (AHS-3)

Clinical Preventive Services

• Adults who receive a colorectal cancer screening based on the most recent guidelines (C-16)
• Adults with hypertension whose blood pressure is under control (HDS-12)
• Adult diabetic population with an A1c value greater than 9 percent (D-5.1)
• Children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines (IID-8)

Environmental Quality

• Air Quality Index (AQI) exceeding 100 (EH-1)
• Children aged 3 to 11 years exposed to secondhand smoke (TU-11.1)

Injury and Violence

• Fatal injuries (IVP-1.1)
• Homicides (IVP-29)

Maternal, Infant, and Child Health

• Infant deaths (MICH-1.3)
• Preterm births (MICH-9.1)

Mental Health

• Suicides (MHMD-1)
• Adolescents who experience major depressive episodes (MDE) (MHMD-4.1)

Nutrition, Physical Activity, and Obesity

• Adults who meet current Federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity (PA-2.4)
• Adults who are obese (NWS-9)
• Children and adolescents who are considered obese (NWS-10.4)
• Total vegetable intake for persons aged 2 years and older (NWS-15.1)

Oral Health

• Persons aged 2 years and older who used the oral health care system in past 12 months (OH-7)

Reproductive and Sexual Health

• Sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months (FP-7.1)
• Persons living with HIV who know their serostatus (HIV-13)

Social Determinants

• Students who graduate with a regular diploma 4 years after starting 9th grade (AH-5.1)

Substance Abuse

• Adolescents using alcohol or any illicit drugs during the past 30 days (SA-13.1)
• Adults engaging in binge drinking during the past 30 days (SA-14.3)

Tobacco

• Adults who are current cigarette smokers (TU-1.1)
• Adolescents who smoked cigarettes in the past 30 days (TU-2.2)

Each of the 26 indicators listed under the 12 topics above will be tracked, measured, and reported on regularly throughout the decade.(1)

Learn more about the Leading Health Indicators development and framework

Create a Healthy People 2020 Leading Health Indicators app

The U.S. Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion (ODPHP) and Office of the National Coordinator for Health IT (ONC) are challenging teams of developers and health professionals to co-design an application that will be used to help solve one or more of our Nation’s high-priority health problems.

(1) Footnote – Preparedness measures were not selected as Leading Health Indicators because of the newness of the topic to Healthy People 2020 and the lack of historical data. However, because of their importance to the health and safety of the Nation, HHS will continue to closely monitor the Healthy People 2020 Preparedness measures and, if necessary, elevate them to an LHI.

---

>> Leading Health Indicators. Development and Framework.

Leading Health Indicators Development and Selection Process 

The process of selecting the Leading Health Indicators (LHIs) mirrored the extensive collaborative efforts undertaken to develop Healthy People 2020. The process was led by the Healthy People 2020 Federal Interagency Workgroup, with approximately 50 members from across the U.S. Department of Health and Human Services (HHS) and other Federal departments.

Reports by the Institute of Medicine of the National Academy of Sciences and the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 provided several recommendations for HHS to consider in developing the final set of LHIs. In addition, consideration was given to other indicator sets, such as the National Prevention Strategy mandated by the Affordable Care Act, as well as key priorities of the Secretary and the Assistant Secretary for Health, to ensure alignment among the various prevention initiatives within HHS and across the Federal Government.

Leading Health Indicators Framework

The Healthy People 2020 LHIs were selected and organized using a Health Determinants and Health Outcomes by Life Stages conceptual framework. This approach is intended to draw attention to both individual and societal determinants that affect the public’s health and contribute to health disparities from infancy through old age, thereby highlighting strategic opportunities to promote health and improve quality of life for all Americans.

• Determinants of Health and Health Disparities
  Biological, social, economic, and environmental factors—and their interrelationships—influence the ability of individuals and communities to make progress on these indicators. Addressing these determinants is key to improving population health, eliminating health disparities, and meeting the overarching goals of Healthy People 2020.
• Health Across the Life Stages
  The LHIs will be examined using a life stages perspective. This approach recognizes that specific risk factors and determinants of health vary across the life span. Health and disease result from the accumulation (over time) of the effects of risk factors and determinants. Intervening at specific points in the life course can help reduce risk factors and promote health. The life stages perspective addresses one of the four overarching goals of Healthy People 2020: “Promote quality life, healthy development, and health behaviors across all life stages.”

 

---

 

>> Leading Health Indicators. Access to Health Services

A person’s ability to access health services has a profound effect on every aspect of his or her health, yet at the start of the decade, almost 1 in 4 Americans do not have a primary care provider (PCP) or health center where they can receive regular medical services. Approximately 1 in 5 Americans (children and adults) do not have medical insurance. People without medical insurance are more likely to lack a usual source of medical care, such as a PCP, and are more likely to skip routine medical care due to costs, increasing their risk for serious and disabling health conditions. When they do access health services, they are often burdened with large medical bills and out-of-pocket expenses.

Increasing access to both routine medical care and medical insurance are vital steps in improving the health of all Americans.

The Access to Health Services Leading Health Indicators are:

• Persons with medical insurance (AHS-1.1)
• Persons with a usual primary care provider (AHS-3)

>>> Health Impact of Access to Health Services

Access to health services affects a person’s health and well-being. Regular and reliable access to health services can:

• Prevent disease and disability
• Detect and treat illnesses or other health conditions
• Increase quality of life
• Reduce the likelihood of premature (early) death
• Increase life expectancy

Primary care providers (PCPs) play an important role in protecting the health and safety of the communities they serve. PCPs can develop meaningful and sustained relationships with patients and provide integrated services while practicing in the context of family and community. Having a usual PCP is associated with:

• Greater patient trust in the provider
• Good patient-provider communication
• Increased likelihood that patients will receive appropriate care

>>> Access to Health Services Across the Life Stages

Access to health services is important at every age. Having both a PCP and medical insurance can prevent illness by improving access to a range of recommended preventive services across the lifespan, from childhood vaccinations to screening tests for cancer and chronic diseases, such as diabetes and heart disease. Having a PCP and medical insurance also plays a vital role in finding health problems in their earliest, most treatable stages, and managing a person through the course of the disease. Lacking access to health services—even for just a short period—can lead to poor health outcomes over time.

For example:

Children and Adolescents

About the Disparities Data

• All disparities described are statistically significant at the 0.05 level of significance. To maintain comparability across indicators, disparities are computed using adverse events.
• Data for these measures are available annually.
• Medical Insurance (AHS-1.1) data come from the National Health Interview Survey, Centers for Disease Control and Prevention, National Center for Health Statistics.
• Usual Source of Care (AHS-3) data come from the Medical Panel Expenditure Survey, Agency for Healthcare Research and Quality.

---

>> Leading Health Indicators. Clinical Preventive Services.

Clinical preventive services, such as routine disease screening and scheduled immunizations, are key to reducing death and disability and improving the Nation’s health. These services both prevent and detect illnesses and diseases—from flu to cancer—in their earlier, more treatable stages, significantly reducing the risk of illness, disability, early death, and medical care costs. Yet, despite the fact that these services are covered by Medicare, Medicaid, and many private insurance plans under the Affordable Care Act, millions of children, adolescents, and adults go without clinical preventive services that could protect them from developing a number of serious diseases or help them treat certain health conditions before they worsen.

For example, regular colorectal cancer screening beginning at age 50 is the most effective way to reduce a person’s risk of getting the disease.(1) Despite the potentially life-saving effectiveness of this screening test, only 25% of adults age 50 to 64 in the United States, and fewer than 40% of adults age 65 and older in the United States are up to date on colorectal cancer screening and other recommended clinical preventive services.(2) Increasing the number of people who take advantage of and have access to clinical preventive services continues to be a major public health challenge.

The Clinical Preventive Services Leading Health Indicators are:

• Adults who receive a colorectal cancer screening based on the most recent guidelines (C-16)
• Adults with hypertension whose blood pressure is under control (HDS-12)
• Adult diabetic population with an A1c value greater than 9 percent (D-5.1)
• Children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines (IID-8)

>>> Health Impact of Clinical Preventive Services

Clinical preventive services offer tremendous opportunity to save years of life and to help people live better during those years. Moreover, science-based prevention can save money—and provide high-quality care—by helping people avoid unnecessary tests and procedures. Evidence-based preventive services are effective in reducing death, disability, and disease, including:

• Certain cancers, such as colorectal cancer, breast cancer, and cervical cancer
• Chronic diseases, such as heart disease and diabetes
• Infectious diseases, such as influenza, chicken pox, and pneumonia
• Mental health conditions and substance abuse
• Vision disorders

For example:

• Clinical preventive services to prevent cardiovascular disease alone could save tens of thousands of lives each year.(3)
• On average, 42,000 deaths per year are prevented among children who receive recommended childhood vaccines.(3)
• Blood pressure screening and control is one of the most effective ways to prevent heart disease and stroke. Among people with diabetes, blood pressure control reduces the risk of cardiovascular disease by 33 to 50%.(3)
• Water fluoridation reduces tooth decay by 25% in children and adults.(3)

>>> Clinical Preventive Services Across the Life Stages

The U.S. Preventive Services Task Force releases recommendations for preventive services based on rigorous review of the evidence. These recommendations, in combination with the Centers for Disease Control and Prevention’s (CDC’s) recommended immunization schedules and the Bright Futures guidelines for children and adolescents, provide a comprehensive set of recommendations for primary and secondary preventive services for all Americans—from infancy through old age.

Children and Adolescents

• Immunizations can protect children and adolescents from serious and potentially fatal diseases, including mumps, tetanus, and chicken pox.
• Early screening can detect vision and hearing problems in young children.
• Screening children and adolescents for overweight and obesity can protect them from adverse health outcomes later in life.

Adults

• Regular checkups that measure weight, blood pressure, and cholesterol levels can protect men and women from chronic diseases, such as heart disease and diabetes.
• A Pap test at least every 3 years beginning at age 21 or approximately 3 years after becoming sexually active can protect women from cervical cancer.
• A mammogram every 2 years beginning at age 50 can detect early signs of breast cancer in women.
• Colorectal cancer screening beginning at age 50 can protect both men and women from colorectal cancer.
• “Booster” immunizations can protect both adult men and women against tetanus, diphtheria, and whooping cough.

>>> Determinants of Clinical Preventive Services

Many of the strongest predictors of health and well-being fall outside of the medical care setting. Social, economic, and physical environmental factors all influence health. For example, educational attainment, stable employment, safe homes and neighborhoods, and access to appropriate clinical preventive services tend to affect health positively.Access to clinical preventive services in various medical care and community settings must also address logistic factors, such as adequate transportation and time off for workers, to help them get the care they need. Addressing these determinants is key in reducing health disparities and improving the health of all Americans.

>>> Disparities in Clinical Preventive Services

Significant health disparities in access to clinical preventive services exist and are closely linked with social, economic, and environmental factors. For example:

• In 2008, a greater proportion of people who are white non-Hispanic received recommended colorectal cancer screenings (57.2%) than any other racial or ethnic group. In fact, the proportion of people from other racial or ethnic groups who had not received colorectal cancer screening is 15% to 56% higher than the white non-Hispanic population.
• In 2008, the proportion of people with advanced educational degrees who received recommended colorectal cancer screenings was almost twice as high (70.4%, age adjusted) as for people with less than a high school education (36.8%, age adjusted).
• In 2005 to 2008, people age 65 and older with diabetes had the lowest rate of uncontrolled hyper- and/or hypoglycemia (5.0%), compared to adults age 45 to 64 (14.4%) and 18 to 44 (26.8%).
• In 2009, the rate of incomplete childhood vaccination is 18% higher among children without medical insurance than for children with private medical insurance.
• In 2005 to 2008, females (52.0%, age adjusted) had a higher (better) rate of hypertension control than males (38.6%, age adjusted).
• In 2005 to 2008, the rate of uncontrolled blood pressure among adults with hypertension was 27% and 10% higher among people who are Mexican American and black non-Hispanic, respectively, than people who are white non-Hispanic.
• A lesser proportion of people who live in rural areas receive recommended preventive services (e.g., cancer screening and management of cardiovascular disease) in part because of lack of access to physicians and medical care delivery sites.(4)

About the Disparities Data

All disparities described are statistically significant at the 0.05 level of significance.Colorectal Cancer Screening (C-16)

• Data for this measure are available periodically and come from the National Health Interview Survey, CDC, National Center for Health Statistics (NCHS).
• See the Health Indicators Warehouse for all age adjustment information for this indicator.

Blood Pressure Control (HDS-12)

• Data for this measure are from the National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
• See the Health Indicators Warehouse for all age adjustment information for this indicator.

Uncontrolled Glycemia in Persons With Diabetes (D-5.1)

• Data are from the NHANES, CDC, NCHS.

Complete Vaccination Among Children (IID-8)

• Data for this measure are available annually and come from the National Immunization Survey, CDC, National Center for Immunization and Respiratory Diseases, and NCHS.
• Complete vaccination is defined as receipt of the following doses of each of the following vaccines: 4 DTap, 3 polio, 1 MMR, 3 or 4 Hib (depending on product type received, including primary series plus the booster dose), 3 Hep B, 1 varicella, and 4 PCV.
• Public and private insurance are not mutually exclusive. About 5% of children with medical insurance are included in both categories. “Other” types of insurance (e.g., military insurance, Indian Health Services coverage) are not included.

References

(1) Frequently Asked Questions About Colorectal Cancer. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services (HHS), 2011. Available from http://www.cdc.gov/cancer/colorectal/basic_info/faq.htm#6

(2) Clinical Preventive Services. Healthy Aging, CDC, HHS, 2011. Available from http://www.cdc.gov/aging/services/index.htm

(3) National Prevention Strategy. HHS, 2011. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(4) National Prevention Strategy. HHS, 2011. p.25. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

---

>> Leading Health Indicators. Evironmental Quality.

The environment directly affects health status and plays a major role in quality of life, years of healthy life lived, and health disparities. Poor air quality is linked to premature death, cancer, and long-term damage to respiratory and cardiovascular systems. Secondhand smoke containing toxic and cancer-causing chemicals contributes to heart disease and lung cancer in nonsmoking adults. Globally, nearly 25% of all deaths and the total disease burden can be attributed to environmental factors.(1)

Poor environmental quality has its greatest impact on people whose health status is already at risk. For example, nearly 1 in 10 children and 1 in 12 adults in the United States have asthma, which is caused, triggered, and exacerbated by environmental factors such as air pollution and secondhand smoke. Yet:

• Approximately 127 million people in the United States live in counties that exceed national air quality standards.(2)
• 88 million nonsmokers are exposed to secondhand smoke each year.(3)

Safe air, land, and water are fundamental to a healthy community environment. An environment free of hazards, such as secondhand smoke, carbon monoxide, allergens, lead, and toxic chemicals, helps prevent disease and other health problems. Implementing and enforcing environmental standards and regulations, monitoring pollution levels and human exposures, building environments that support healthy lifestyles, and considering the risks of pollution in decision-making can improve health and quality of life for all Americans.

The Environmental Quality Leading Health Indicators are:

• Air Quality Index (AQI) exceeding 100 (EH-1)
• Children aged 3 to 11 years exposed to secondhand smoke (TU-11.1)

>>> Health Impact of Environmental Quality

Poor air quality contributes to cancers, cardiovascular disease, asthma, and other illnesses. Poor water quality can lead to gastrointestinal illness and a range of other conditions, including neurological problems and cancer. Some chemicals in and around homes and workplaces can contribute to acute poisonings and other toxic effects.The built environment (such as schools, parks, greenways, and transportation systems) affects both individual health and environmental quality. For example, supporting bicycling as a primary mode of transportation increases physical activity and reduces pollution and accidents from motor vehicles.(4)

>>> Environmental Quality Across the Life Stages

Living environments, including housing and institutional settings, can support health across the life span, from infancy through old age.

Infants and Children

• Exposures to environmental and occupational hazards before and during pregnancy can increase the risk of subsequent health problems for infants and children. These problems include birth defects, developmental disabilities, and childhood cancer.(5),(6)
• Children may be more vulnerable to environmental exposures than adults because their bodily systems are still developing and their behavior can expose them more to chemicals and organisms.(6)
• Asthma is the third ranking cause of non-injury-related hospitalization among children age 14 and younger.
• Childhood lead poisoning reduces IQ, which can never be regained. Recent studies suggest that children with blood lead levels well below the Federal standard (10 ug/dl) can suffer from diminished IQ and effects on behavior.(5)

Adults

• Work-related factors, including occupational exposures to chemicals, excessive heat or cold, and noise, can create or worsen a variety of health problems, including cancer, chronic obstructive pulmonary disease (COPD), asthma, and heart disease.

Older Adults

• Environmental hazards, including extreme temperatures, air quality, and pollution, can pose a significant risk to older adults, especially those with COPD or asthma.

>>> Determinants of Environmental Quality

Many environments in which people live, work, and play expose them to pollution and hazards. Fortunately, homes, communities, workplaces, and schools can be designed to promote healthy choices and improve safety. Healthy community design can improve people’s health and safety by:

• Improving air and water quality
• Decreasing mental health stresses
• Strengthening the social fabric of a community
• Providing fair access to employment opportunities, education, and resources
• Increasing options for physical activity and healthful diets
• Decreasing injuries and accidents

The ability to live in an area with high environmental quality is associated with gender, age, education level, income, race and ethnicity, and geographic location. Many health-related hazards (like mold, allergens, poor indoor air quality, structural deficiencies, and lead) are disproportionately found in low-income housing. Addressing these determinants is key in reducing health disparities and improving the health of all Americans. Efforts are needed to overcome barriers to improving environmental quality.

>>> Disparities and Environmental Quality

Some populations are disproportionately exposed to environmental hazards. As a result, health disparities exist.

• In 2005 to 2008, children age 3 to 11 with private medical insurance had the lowest (best) rate of exposure to secondhand smoke (43.1%). Children with public medical insurance had an exposure rate of 66.4% and children with no medical insurance had a rate of 55.3%.
• In 2005 to 2008, children age 3 to 11 who were not obese had a lower (better) rate of exposure to secondhand smoke than children who were obese (50.4% versus 62.1%).
• In 2010, non-Hispanic black children were more likely to have asthma (16%) than Hispanic children (8%) or non-Hispanic white children (8%).(—-(7))

References

(1) World Health Organization (WHO). Preventing disease through healthy environments. Geneva, Switzerland: WHO; 2006. Available from http://www.who.int/quantifying_ehimpacts/publications/preventingdisease.pdf

(2) US Environmental Protection Agency (EPA), Office of Air Quality Planning and Standards. Our Nation’s air: Status and trends through 2008. Washington: EPA; 2010. Available from http://www.epa.gov/airtrends/2010

(3) Centers for Disease Control and Prevention. Tobacco Use: Smoking and Secondhand Smoke. CDC Vital Signs, September 2010. Available from http://www.cdc.gov/vitalsigns/pdf/2010-09-vitalsigns.pdf

(4) CDC. CDC Transportation Recommendations, 2010. Available from http://www.cdc.gov/transportation

(5)EPA. Fast Facts on Children’s Environmental Health, 2008. Available from http://yosemite.epa.gov/ochp/ochpweb.nsf/content/fastfacts.htm

(6) US Department of Health and Human Services, Office on Women’s Health. The Environment and Women’s Health Fact Sheet, 2009. Available from http://womenshealth.gov/publications/our-publications/fact-sheet/environment-womens-health.cfm

(7) CDC, National Center for Health Statistics. Summary Health Statistics for US Children: National Health Interview Survey, 2010. Vital Health and Statistics, Series 10, Number 250, 2011: p. 16. Available from http://www.cdc.gov/nchs/data/series/sr_10/sr10_250.pdf

---

>> Leading Health Indicators. Injury and Violence.

Motor vehicle crashes, homicide, domestic and school violence, child abuse and neglect, suicide, and unintentional drug overdoses have become widespread occurrences in the United States. In addition to their immediate health impact, the effects of injuries and violence extend well beyond the injured person or victim of violence, affecting family members, friends, coworkers, employers, and communities. Witnessing or being a victim of violence is linked to lifelong negative physical, emotional, and social consequences.

Both unintentional injuries and those caused by acts of violence are among the top 15 killers of Americans of all ages. Injuries are the leading cause of death for Americans age 1 to 44, and a leading cause of disability for all ages, regardless of sex, race and ethnicity, or socioeconomic status. Each year, more than 29 million people suffer an injury severe enough that emergency department treatment is needed. More than 180,000 people each year die from these injuries, with approximately 51,000 of these deaths resulting from a violent event. Many unintentional injuries are preventable.

The Injury and Violence Leading Health Indicators are:

• Fatal injuries (IVP-1.1)
• Homicides (IVP-29)

>>> Health Impact of Injury and Violence

Unintentional injuries and violence-related injuries can be caused by a number of events, from motor vehicle accidents to physical assault, and can occur virtually anywhere. No matter what the circumstances of the event are, injuries can have serious, painful, and debilitating physical and emotional health consequences, many of which are long term or permanent, including:

• Hospitalization
• Brain injury
• Poor mental health
• Disability
• Premature death

While their extent, severity, and impact may vary, injuries from any cause can significantly influence the physical, mental, and economic well-being of individuals, families, and communities nationwide.

>>> Injury and Violence Across the Life Stages

Injury and violence are pressing public health concerns at every stage of life. While older adults and children are most vulnerable to sustaining an injury that requires medical attention, Americans of all ages are susceptible to injury and violence.

Children

• Injuries resulting from motor vehicle accidents are the leading cause of death for children age 0 to 19.(1)
• Each year, approximately 2.8 million children go to the hospital emergency department for injuries caused by falling.(1)
• Suffocation is the leading cause of injury death for infants age 1 and younger, and drowning is the leading cause of injury death for children age 1 to 4. (1)
• A history of exposure to adverse experiences in childhood, including exposure to violence and maltreatment, is associated with health risk behaviors such as smoking, alcohol and drug use, and risky sexual behavior, as well as obesity, diabetes, sexually transmitted diseases, attempted suicide, and other health problems.(2)

Adolescents and Young Adults

• Approximately 72% of all deaths among adolescents age 10 to 24 are attributed to injuries from 4 causes: motor vehicle crashes (30%), all other unintentional injuries (15%), homicide (15%), and suicide (12%).(3)
• More than 1 million serious sports-related injuries occur each year among adolescents age 10 to 17.(3)

Adults

• More than 2.3 million adult drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle crashes in 2009.(4)
• Each year, women experience about 4.8 million intimate partner-related physical assaults and rapes. Men are the victims of about 2.9 million intimate partner-related physical assaults.(5)
• Every day on average, 12 working men and women are killed on the job.(6) In 2009, more than 4.1 million workers across all industries had work-related injuries and illnesses that were reported by employers.

Older Adults

• Each year, about one-third of men and women age 65 and older experience a fall, and 20% to 30% of them suffer a moderate to severe injury, such as a hip fracture or head injury.(2)
• Injuries can make it more difficult for older adults to live independently, and injuries increase older adults’ risk of early death.

>>> Determinants of Injury and Violence

An individual’s risk of injury and violence is determined by many social, economic, and environmental factors. These include gender, age, race and ethnicity, income level, education level, and geographic location . For example, interpersonal and family dynamics influence an individual’s risk of injury or violence. Similarly, the physical environment, both in the home and community, can affect the rate of injuries related to falls, fires, burns, road traffic incidents, drowning, and violence.

Understanding these factors and how they overlap to create disparities in injury and violence is key to improving the health and safety of all Americans. For example:

• Communities and streets can be designed to reduce pedestrian, bicyclist, and motor vehicle-related injuries.
• Exercise programs, medication review, home modifications, and vision screening can prevent falls among older adults.
• Housing, economic development, and education initiatives show promise in reducing rates of crime and violence.

>>> Disparities and Injury and Violence

Some populations are more likely to experience injury or violence than others. Data from 2007 show:

• People who are Asian or Pacific Islander had a lower injury death rate (26.0 deaths per 100,000 population, age adjusted) than any other racial or ethnic group.
• Females had a lower injury death rate (34.3 deaths per 100,000 population, age adjusted) than males (85.7 deaths per 100,000 population, age adjusted).
• People who lived in cities or urban areas had a lower injury death rate (56.1 deaths per 100,000 population, age adjusted) than people who lived in rural or nonurban areas (75.0 deaths per 100,000 population, age adjusted).
• People who were married had a lower injury death rate (47.5 deaths per 100,000 population, age adjusted) than people who were never married, widowed, or divorced (124.4, 129.8, and 142.2 deaths per 100,000 population, age adjusted, respectively).
• People who are black non-Hispanic had a higher homicide rate (21.8 deaths per 100,000, age adjusted) than any other racial or ethnic group. In 2007, the death rate from homicide among black non-Hispanic people was more than 9 times higher than that of people who are Asian or Pacific Islander (2.3 deaths per 100,000 population, age adjusted)—the population with the lowest homicide death rate.
• The homicide rate for males (9.6 deaths per 100,000 population, age adjusted) was nearly 4 times as high as the rate for females (2.5 deaths per 100,000 population, age adjusted).

>>> About the Disparities Data

• All disparities described are statistically significant at the 0.05 level of significance.
• Data for this measure are available annually and come from the National Vital Statistics System–Mortality, Centers for Disease Control and Prevention, National Center for Health Statistics.
• Data (except those by foreign born status and age group) are age adjusted to the 2000 standard population using the age groups: less than 1; 1 to 4; 5 to 14; 15 to 24; 25 to 34; 35 to 44; 45 to 54; 55 to 64; 65 to 74; 75 to 84; and 85 and over. Data by foreign born status are adjusted using the age groups: less than 5; 5 to 17; 18 to 24; 25 to 34; 35 to 44; 45 to 54; 55 to 64; 65 to 74; and 75 and over. Data by age group are not age adjusted. Age-adjusted rates are weighted sums of age-specific rates.

References

(1) Borse N, Gilchrist J, Dellinger A, et al. CDC childhood injury report: patterns of unintentional injuries among 0 to 19 year olds in the United States, 2000–2006. Atlanta, GA: Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control; 2008. Available from: http://www.cdc.gov/safechild/images/CDC-childhoodinjury.pdf

(2) National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(3) CDC, National Center for Chronic Disease Prevention and Health Promotion. Healthy youth: injury and violence. Atlanta, GA; 2010. Available from http://www.cdc.gov/healthyyouth/injury

(4) CDC. Injury prevention and control: motor vehicle safety. Atlanta, GA; 2011. Available from http://www.cdc.gov/motorvehiclesafety/index.html

(5) CDC. Understanding intimate partner violence. Atlanta, GA; 2011. Available from http://www.cdc.gov/violenceprevention/pdf/IPV_factsheet-a.pdf

(6) American Federation of Labor and Congress of Industrial Organizations. Death on the Job: the toll of neglect: a national state-by-state profile of worker safety and health in the United States. Washington, DC; 2011. Available from http://www.aflcio.org/issues/safety/memorial/upload/dotj_2011.pdf

---

>> Leading Health Indicators. Injury and Violence. Maternal, Infant, and Child Health.

The well-being of mothers, infants, and children determines the health of the next generation and can help predict future public health challenges for families, communities, and the medical care system. Moreover, healthy birth outcomes and early identification and treatment of health conditions among infants can prevent death or disability and enable children to reach their full potential.

Despite major advances in medical care, critical threats to maternal, infant, and child health exist in the United States. Among the Nation’s most pressing challenges are reducing the rate of preterm births, which has risen by more than 20% from 1990 to 2006,(1) and reducing the infant death rate, which in 2011 remained higher than the infant death rate in 46 other countries.(2)

The Maternal, Infant, and Child Health Leading Health Indicators are:

• Infant deaths (MICH-1.3)
• Preterm births (MICH-9.1)

>>> Health Impact of Maternal, Infant, and Child Health

More than 80% of women in the United States will become pregnant and give birth to one or more children.(3) 31% of these women suffer pregnancy complications, ranging from depression to the need for a cesarean delivery.(4) Many of these complications are associated with obesity during pregnancy. Although rare, the risk of death during pregnancy has declined little over the last 20 years.

Each year, 12% of infants are born preterm and 8.2% of infants are born with low birth weight.(5) In addition to increasing the infant’s risk of death in its first few days of life, preterm birth and low birth weight can lead to devastating and lifelong disabilities for the child. Primary among these are visual and hearing impairments, developmental delays, and behavioral and emotional problems that range from mild to severe.

Preconception (before pregnancy) and interconception (between pregnancies) care provide an opportunity to identify existing health risks and to prevent future health problems for women and their children. These problems include heart disease, diabetes, genetic conditions, sexually transmitted diseases, and unhealthy weight.

>>> Maternal, Infant, and Child Health Across the Life Stages

A life stages approach to maternal, infant, and child health aims to improve the health of a woman before she becomes pregnant. The risk of pregnancy-related complications and maternal and infant disability and death can be reduced by improving access to quality care before, during, and after pregnancy.

Adults

• 1 in 5 women are obese at the beginning of their pregnancy, placing them at increased risk of complications, including high blood pressure and diabetes, during pregnancy.(6)
• Approximately 12% of pregnant women in the United States smoke during pregnancy,(7) and another 12% of pregnant women in the United States have consumed alcohol in the past 30 days.(8) These behaviors not only negatively affect women’s health and safety, but significantly increase their infants’ risk of serious health problems—including premature birth and severe birth defects—and death.
• Of women who could get pregnant, 69% do not take recommended folic acid supplements, 31% are obese, and about 3% take prescription or over-the-counter drugs that are known to cause birth defects.(9)
• Approximately 1 in 10 women are depressed during any trimester of pregnancy, or any month within the first year after delivery.(3) Depression can inhibit a woman’s ability to perform daily activities, bond with her infant, and relate to her family.

Infants and Children

• Birth defects are one of the leading causes of infant deaths, accounting for more than 20% of all infant deaths.(10) Some of these birth defects can be prevented and, with proper prenatal care, many can be detected before birth, enabling better care during and after birth.
• Infants born to obese women are twice as likely to be obese and to develop type 2 diabetes later in life.(6)
• Newborn health screenings and wellness visits can detect and sometimes prevent diseases and serious health disorders, such as sickle cell disease or hearing loss, that can have profound effects on a child’s health throughout his or her lifetime.
• Scheduled immunizations can protect infants and children from 14 vaccine-preventable diseases, including chickenpox, measles, and mumps. Scheduled immunizations are especially important for children age 2 and younger, who are at the highest risk for infectious diseases like pneumonia, sepsis, and meningitis.

>>> Determinants of Maternal, Infant, and Child Health

A range of biological, social, environmental, and physical factors have been linked to maternal, infant, and child health outcomes. These include race and ethnicity, age, and socioeconomic factors, such as income level, educational attainment, medical insurance coverage, access to medical care, prepregnancy health, and general health status. For example, children reared in safe and nurturing families and neighborhoods, free from maltreatment and other social problems, are more likely to have better outcomes as adults.

Prepregnancy health behaviors and health status are influenced by a variety of environmental and social factors, such as access to medical care and chronic stress. Some of these factors can affect and compound others, creating a rippling effect. For instance, factors ranging from age to medical insurance coverage affect a woman’s general health status; a woman’s health status, in turn, directly influences her risk of pregnancy complications and her child’s cognitive and physical development.

Understanding the many factors that affect women, infants, and children—both negatively and positively—is key to improving the health of all Americans, particularly the next generation.

>>> Disparities in Maternal, Infant, and Child Health

Disparities in maternal, infant, and child health persist, including racial and ethnic disparities in mortality and morbidity for mothers and children. Data show that:

• In 2006, females who were Asian or Pacific Islander had the best infant mortality rate (4.6 per 1,000 live births), while females who were black non-Hispanic had the worst infant mortality rate (13.4 per 1,000 live births).
• In 2006, females who were married experienced lower infant mortality rates (5.1 deaths per 1,000 live births) than females who were not married (9.2 deaths per 1,000 live births).
• In 2006, females age 30 to 34 experienced the lowest infant mortality rate (5.3 per 1,000 live births) compared with:
• Females age 15 or younger (18.1 infant deaths per 1,000 live births)
• Females age 15 to 19 (9.7 infant deaths per 1,000 live births)
• Females age 20 to 24 (7.5 infant deaths per 1,000 live births)
• Females age 25 to 29 (6.0 infant deaths per 1,000 live births)
• Females age 35 and older (6.4 infant deaths per 1,000 live births)
• In 2007, a lesser proportion of Asian or Pacific Islander women delivered preterm live infants (10.9%) than black non-Hispanic women (18.3%), American Indian or Alaska Native women (13.9%), Hispanic women (12.3%), or white non-Hispanic women (11.5%).
• In 2007, a lesser proportion of females who were married delivered preterm live births than females who were not married (11.4% versus 14.6%).
• In 2007, a lesser proportion of females age 25 to 29 experienced preterm live births (11.6%) than:
• Females age 15 or younger (22.1%)
• Females age 15 to 19 (14.5%)
• Females age 35 or older (14.5%)
• Females age 20 to 24 (12.6%)
• Females age 30 to 34 (12.0%)

>>> About the Disparities Data

• All disparities described are statistically significant at the 0.05 level of significance. To maintain comparability across indicators, disparities are computed using adverse events.
• Data for both objectives are available annually from the National Vital Statistics System, Centers for Disease Control and Prevention, National Center for Health Statistics.

References

(1) Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2006. National Vital Statistics Reports. vol 57 no 7. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention (CDC); 2009. Available from http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf 

(2) Central Intelligence Agency. Country comparisons: infant mortality rate. The World Factbook. Available from https://cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

(3) CDC. Maternal and Infant Health Research: Pregnancy Complications. Atlanta GA; 2010. Available from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/

(4) National Center on Birth Defects and Developmental Disabilities (NCBDDD), CDC. Preconception Health and Care, 2006. Atlanta, GA; 2006. Available from http://www.cdc.gov/ncbddd/preconception/documents/At-a-glance-4-11-06.pdf

(5) National Center for Health Statistics, CDC. Births and natality. FastStats. Atlanta, GA; 2010. Available from http://www.cdc.gov/nchs/fastats/births.htm

(6) CDC. Obesity. Maternal and Infant Health Research: Pregnancy Complications. Atlanta GA; 2010. Available from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/

(7) CDC. Pregnancy and smoking. Resources for Entertainment Education Content Developers. Atlanta, GA; 2011. Available from http://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/

(8) CDC. Data and statistics. Fetal Alcohol Spectrum Disorders (FASD). Atlanta, GA; 2011. Available from http://www.cdc.gov/ncbddd/fasd/data.html

(9) NCBDDD, CDC. Preconception Care. Atlanta, GA; 2006. Available from http://www.cdc.gov/ncbddd/preconception/whypreconception.htm

(10) NCBDDD, CDC. Birth Defects. Atlanta, GA; 2011. Available from http://www.cdc.gov/ncbddd/birthdefects/data.html

>> Leading Health Indicators. Mental Health.

The burden of mental illness in the United States is among the highest of all diseases, and mental disorders are among the most common causes of disability. Recent figures suggest that, in 2004, approximately 1 in 4 adults in the United States had a mental health disorder in the past year (1)—most commonly anxiety or depression—and 1 in 17 had a serious mental illness. Mental health disorders also affect children and adolescents at an increasingly alarming rate; in 2010, 1 in 5 children in the United States had a mental health disorder, most commonly attention deficit hyperactivity disorder (ADHD). It is not unusual for either adults or children to have more than one mental health disorder.

Mental health is essential to a person’s well-being, healthy family and interpersonal relationships, and the ability to live a full and productive life. People, including children and adolescents, with untreated mental health disorders are at high risk for many unhealthy and unsafe behaviors, including alcohol or drug abuse, violent or self-destructive behavior, and suicide—the 11th leading cause of death in the United States for all age groups and the second leading cause of death among people age 25 to 34.

Mental health disorders also have a serious impact on physical health and are associated with the prevalence, progression, and outcome of some of today’s most pressing chronic diseases, including diabetes, heart disease, and cancer. Mental health disorders can have harmful and long-lasting effects—including high psychosocial and economic costs—not only for people living with the disorder, but also for their families, schools, workplaces, and communities.

Fortunately, a number of mental health disorders can be treated effectively, and prevention of mental health disorders is a growing area of research and practice. Early diagnosis and treatment can decrease the disease burden of mental health disorders as well as associated chronic diseases. Assessing and addressing mental health remains important to ensure that all Americans lead longer, healthier lives.

The Mental Health Leading Health Indicators are:

• Suicides (MHMD-1)
• Adolescents who experience major depressive episodes (MDE) (MHMD-4.1)

>>> Health Impact of Mental Health

Mental health and physical health are inextricably linked. Evidence has shown that mental health disorders—most often depression—are strongly associated with the risk, occurrence, management, progression, and outcome of serious chronic diseases and health conditions, including diabetes, hypertension, stroke, heart disease,(2),(3) and cancer.(4), (5) This association appears to be caused by mental health disorders that precede chronic disease; chronic disease can intensify the symptoms of mental health disorders—in effect creating a cycle of poor health.(5) This cycle decreases a person’s ability to participate in the treatment of and recovery from mental health disorders and chronic disease. Therefore, while efforts are underway to reduce the burden of death and disability caused by chronic disease in the United States, simultaneously improving mental health nationwide is critical to improving the health of all Americans.

>>> Mental Health Across the Life Stages

Mental health disorders are a concern for people of all ages, from early childhood through old age.

Children and Adolescents

• Approximately 20% of U.S. children and adolescents are affected by mental health disorders during their lifetime. Often, symptoms of anxiety disorders emerge by age 6, behavior disorders by age 11, mood disorders by age 13, and substance use disorders by age 15.(6)
• 15% of high school students have seriously considered suicide, and 7% have attempted to take their own life.(7)
• Mental health disorders among children and adolescents can lead to school failure, alcohol or other drug abuse, family discord, violence, and suicide.(8)

Adults

• It is estimated that only about 17% of U.S. adults are considered to be in a state of optimal mental health.(1)
• An estimated 26% of Americans age 18 and older are living with a mental health disorder in any given year, and 46% will have a mental health disorder over the course of their lifetime.(1)
• Almost 15% of women who recently gave birth reported symptoms of postpartum depression.(1)

Older Adults

• Alzheimer’s disease is among the 10 leading causes of death in the United States. It is the 6th leading cause of death among American adults and the 5th leading cause of death for adults age 65 years and older.(9)
• Among nursing home residents, 18.7% of people age 65 to 74, and 23.5% of people age 85 and older have reported mental illness.(1)

>>> Determinants of Mental Health

Several factors have been linked to mental health, including race and ethnicity, gender, age, income level, education level, sexual orientation, and geographic location. Other social conditions—such as interpersonal, family, and community dynamics, housing quality, social support, employment opportunities, and work and school conditions—can also influence mental health risk and outcomes, both positively and negatively. For example, safe shared places for people to interact, such as parks and churches, can support positive mental health. A better understanding of these factors, how they interact, and their impact is key to improving and maintaining the mental health of all Americans.

>>> Disparities in Mental Health

Disparities in mental health, particularly those based on age, gender, and race and ethnicity, have been observed for a number of populations.

• In 2007, people who were black non-Hispanic had the lowest suicide rate (5.1 per 100,000 population, age adjusted), while people who were white non-Hispanic had the highest suicide rate (13.6 per 100,000 population, age adjusted).
• Females had a lower suicide rate (4.7 per 100,000 population, age adjusted) than males (18.4 per 100,000 population, age adjusted) in 2007.
• In 2007, people who were born in the United States had a higher suicide rate (12.1 per 100,000 population, age adjusted) than people who were born outside of the United States (6.6 per 100,000 population, age adjusted).
• In 2007, people age 12 to 17 had the lowest suicide rate (3.2 per 100,000 population, age adjusted), while people age 45 to 64 had the highest suicide rate (16.8 per 100,000 population, age adjusted).
• In 2008, a lesser proportion of adolescents who were black non-Hispanic experienced a major depressive episode (7.0%) than adolescents who were white non-Hispanic (8.7%) or adolescents of two or more races (11.9%).
• A lesser proportion of adolescent males experienced a major depressive episode (4.3%) compared to adolescent females (12.4%) in 2008.
• In 2008, adolescents age 12 to 13 had the lowest (best) proportion experiencing a major depressive episode (4.8%), compared to adolescents age 14 to 15 (8.4%) or adolescents age 16 to 17 (11.1%).
• In 2008, a greater proportion of adolescents who were born in the United States had a major depressive episode (8.4%) than adolescents born outside of the United States (6.4%).

>>> About the Disparities Data

• All disparities described are statistically significant at the 0.05 level of significance. To maintain comparability across indicators, disparities are computed using adverse events.
• See the Health Indicators Warehouse for all age adjustment information for this indicator
• Data for suicides (MHMD-1) are available annually from the National Vital Statistics System, Centers for Disease Control and Prevention, National Center for Health Statistics.
• Data for major depressive episode among adolescents (MHMD-4.1) are available annually from the National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.

References

(1) Reeves WC, Strine TW, Pratt LA, et al. Mental illness surveillance among adults in the United States.Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention (CDC); 2011. Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm?s_cid=su6003a1_w

(2) Jonas BS, Franks P, Ingram DD. Are symptoms of anxiety and depression risk factors for hypertension?Arch Fam Med, 6:43-49; 1997.

(3) Jonas BS, Mussolino ME. Symptoms of depression as a prospective risk factor for stroke. Psychosomatic Medicine, 62: 463-71, 2000.

(4) CDC. Public Health Action Plan To Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011–2015. Atlanta, GA; 2011. Available from http://www.cdc.gov/mentalhealth/docs/11_220990

(5) Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders.Preventing Chronic Disease. 2005 Jan. Atlanta, GA: CDC. Available from: http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm

(6) Merikangas KR, He J, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry. 2010 Oct. 49(10):980-989.

(7) Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2007. Surveillance summaries, June 6. Morbidity and Mortality Weekly Report. 2008; 57(No. SS-4). Atlanta, GA: CDC. Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm

(8) MedlinePlus, National Library of Medicine, National Institutes of Health. Child Mental Health. Bethesda, MD; 2011. Available from http://www.nlm.nih.gov/medlineplus/childmentalhealth.html

(9) CDC. Healthy Aging: Alzheimer’s Disease. Atlanta, GA; 2011. Available from http://www.cdc.gov/aging/aginginfo/alzheimers.htm

---

>> Leading Health Indicators. Nutrition, Physical Activity, and Obesity.

Good nutrition, physical activity, and a healthy body weight are essential parts of a person’s overall health and well-being. Together, these can help decrease a person’s risk of developing serious health conditions, such as high blood pressure, high cholesterol, diabetes, heart disease, stroke, and cancer. A healthful diet, regular physical activity, and achieving and maintaining a healthy weight also are paramount to managing health conditions so they do not worsen over time.

Most Americans, however, do not eat a healthful diet and are not physically active at levels needed to maintain proper health. Fewer than 1 in 3 adults and an even lower proportion of adolescents eat the recommended amount of vegetables each day.(1) Compounding this is the fact that a majority of adults (81.6%) and adolescents (81.8%) do not get the recommended amount of physical activity.(2)

As a result of these behaviors, the Nation has experienced a dramatic increase in obesity. Today, approximately 1 in 3 adults (34.0%) and 1 in 6 children and adolescents (16.2%) are obese. Obesity-related conditions include heart disease, stroke, and type 2 diabetes, which are among the leading causes of death. In addition to grave health consequences, overweight and obesity significantly increase medical costs and pose a staggering burden on the U.S. medical care delivery system.

Ensuring that all Americans eat a healthful diet, participate in regular physical activity, and achieve and maintain a healthy body weight is critical to improving the health of Americans at every age.

The Nutrition, Physical Activity, and Obesity Leading Health Indicators are:

• Adults who meet current Federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (PA-2.4)
• Adults who are obese (NWS-9)
• Children and adolescents who are considered obese (NWS-10.4)
• Total vegetable intake for persons aged 2 years and older (NWS-15.1)

>>> Health Impact of Nutrition, Physical Activity, and Obesity

The health impact of eating a healthful diet and being physically active cannot be understated. Together, a healthful diet and regular physical activity can help people:

• Achieve and maintain a healthy weight
• Reduce the risk of heart disease and stroke
• Reduce the risk of certain forms of cancer
• Strengthen muscles, bones, and joints
• Improve mood and energy level

Chief among the benefits of a healthful diet and physical activity is a reduction in the risk of obesity. Obesity is a major risk factor for several of today’s most serious health conditions and chronic diseases, including high blood pressure, high cholesterol, diabetes, heart disease and stroke, and osteoarthritis. Obesity also has been linked to many forms of cancer.

>>> Nutrition, Physical Activity, and Obesity Across the Life Stages

Good nutrition, regular physical activity, and achieving and maintaining a healthy body weight are cornerstones of health at every stage of life:

Children

• Children and adolescents who eat a healthful diet are more likely to reach and maintain a healthy weight, achieve normal growth and development, and have strong immune systems.
• Children and adolescents who get regular physical activity have improved muscle development, bone health, and heart health.
• Children and adolescents who are overweight or obese are at increased risk for developing diabetes and heart disease; they are also likely to stay overweight or obese into adulthood, placing them at increased risk for serious chronic diseases.

Adults

• Adults who eat a healthful diet and stay physically active can decrease their risk of a number of adult-onset health conditions and diseases, including heart disease and diabetes.
• Regular physical activity can lower an adult’s risk of depression.
• Adults who maintain a healthy weight are less likely to die prematurely.

Pregnant Women

• Good nutrition helps pregnant women support the healthy development of their infants.
• Regular physical activity throughout pregnancy can help women control their weight, make labor more comfortable, and reduce their risk of postpartum depression.(3)
• Staying at a healthy body weight can

>>> Determinants of Nutrition, Physical Activity, and Obesity

A number of factors affect a person’s ability to eat a healthful diet, stay physically active, and achieve or maintain a healthy weight. The built environment has a critical impact on behaviors that influence health. For example, in many communities, there is nowhere to buy fresh fruit and vegetables, and no safe or appealing place to play or be active. These environmental factors are compounded by social and individual factors—gender, age, race and ethnicity, education level, socioeconomic status, and disability status—that influence nutrition, physical activity, and obesity. Addressing these factors is critically important to improving the nutrition and activity levels of all Americans; only then will progress be made against the Nation’s obesity epidemic and its cascading impact on health.

>>> Disparities in Nutrition, Physical Activity, and Obesity

Some populations are more likely to eat a healthful diet and be physically active, while others are more likely to be obese. As a result, health disparities exist.

Nutrition

In 2004:

>> Leading Health Indicators. Oral Health.

Oral diseases ranging from dental caries (cavities) to oral cancers cause pain and disability for millions of Americans. The impact of these diseases does not stop at the mouth and teeth. A growing body of evidence has linked oral health, particularly periodontal (gum) disease, to several chronic diseases, including diabetes, heart disease, and stroke. In pregnant women, poor oral health has also been associated with premature births and low birth weight.(1), (2), (3), (4), (5) These conditions may be prevented in part with regular visits to the dentist. In 2007, however, only 44.5% (age adjusted) of people age 2 and older had a dental visit in the past 12 months, a rate that has remained essentially unchanged over the past decade.

The Oral Health Leading Health Indicator is:

• Persons aged 2 years and older who used the oral health care system in the past 12 months(OH-7)

>>> Health Impact of Oral Health

Oral health is an essential part of staying healthy. Good oral health allows a person to speak, smile, smell, taste, touch, chew, swallow, and make facial expressions to show feelings and emotions.(6), (7) Poor oral health has serious consequences, including painful, disabling, and costly oral diseases. Millions of Americans are living with one or more oral diseases, including:

• Dental caries (cavities)
• Periodontal (gum) disease
• Cleft lip and palate
• Oral and facial pain
• Oral and pharyngeal (mouth and throat) cancers

Gum disease, in particular, is associated with diabetes, heart disease, and stroke. In pregnant women, gum disease is also associated with premature births and low birth weight.(6), (7)

Many of these oral diseases may be prevented with regular dental care.

>>> Oral Health Across the Life Stages

Poor oral health affects Americans at all life stages, from infancy through older adulthood. For example:

Children and Adolescents

• Tooth decay affects more than 1 in 4 U.S. children age 2 to 5.
• Tooth decay affects 1 in 2 U.S. adolescents age 12 to 15.

Adults

• 1 in 7 adults age 35 to 44 has gum disease; after age 65, the rate increases to 1 in 4.

Older Adults

• 1 in 4 U.S. adults age 65 or older have lost all of their teeth.
• More than 7,800 people, mostly older Americans, die from oral and pharyngeal (mouth and throat) cancers each year.(8)

>>> Determinants of Oral Health

The ability to access oral health care is associated with gender, age, education level, income, race and ethnicity, access to medical insurance, and geographic location. Addressing these determinants is key in reducing health disparities and improving the health of all Americans. Efforts are needed to overcome barriers to access to oral health care caused by geographic isolation, poverty, insufficient education, and lack of communication skills.

>>> Disparities and Oral Health

Some populations are less likely than others to access oral health care. As a result, health disparities exist.

• In 2008, a greater proportion of white non-Hispanic people age 2 and older (48.6%, age adjusted) had gone to the dentist in the last 12 months than any other race or ethnic group.
• In 2008, people in families with higher incomes were more likely to visit the dentist than people in families with lower incomes.
• In 2008, a greater proportion of females (46.5%, age adjusted) went to the dentist than males (39.3%, age adjusted).
• In 2008, a greater proportion of people who have attended at least some college (57.4%, age adjusted) went to the dentist than people who have graduated high school (38.2%, age adjusted) or have less than a high school education (18.5%, age adjusted).
• In 2008, a greater proportion of people without disabilities (44.3%, age adjusted) went to the dentist than people with disabilities (38.0%, age adjusted).
• In 2007, a greater proportion of people age 64 and younger with private medical insurance (52.2%, age adjusted) went to the dentist than people with public insurance (31.1%, age adjusted) and people with no insurance (22.6%, age adjusted).
• In 2007, a greater proportion of people living in metropolitan areas (cities and suburbs) (45.3%, age adjusted) went to the dentist than people living in rural areas (41.8%, age adjusted).

>>> About the Disparities Data

• See the Health Indicators Warehouse for all age adjustment information for this indicator.
• All disparities described are statistically significant at the 0.05 level of significance.
• Data for this measure are available annually and come from the Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality.

References

(1) Bensley L, VanEenwyk J, Ossiander EM. Associations of self-reported periodontal disease with metabolic syndrome and number of self-reported chronic conditions. Preventing Chronic Disease, 2011;8(3):A50. Available from http://www.cdc.gov/pcd/issues/2011/may/10_0087.htm

(2) Journal of the American Dental Association, October 1, 2006; vol. 137 ( no. suppl 2). Available fromhttp://jada.ada.org/content/137/suppl_2.toc

(3) The oral-systemic disease connection. Journal of the American Dental Association October 1, 2006; vol. 137 (no. suppl 2) 5S-6S. Available from http://jada.ada.org/content/137/suppl_2/5S.full

(4) Public Health Implications of Chronic Periodontal Infections in Adults. Division of Oral Health. Centers for Disease Control and Prevention. Available from http://www.cdc.gov/OralHealth/publications/library/conferences/

(5) Periodontal Disease and Adverse Pregnancy Outcomes. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research; 2000. Available from http://www2.nidcr.nih.gov/sgr/sgrohweb/chap5.htm#pregnancy

(6) Oral Health in America: A Report of the Surgeon General. pp. 33-59. Available from http://www2.nidcr.nih.gov/sgr/sgrohweb/home.htm

(7) Oral Health in America: A Report of the Surgeon General. pp. 155-88. Available from http://www2.nidcr.nih.gov/sgr/sgrohweb/home.htm

(8) Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers: At A Glance 2011. Oral Health, Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Available from http://www.cdc.gov/chronicdisease/resources/publications/aag/doh.htm

---

>> Leading Health Indicators. Reproductive and Sexual Health.

An estimated 19 million new cases of sexually transmitted diseases (STDs) are diagnosed each year in the United States—almost half of them among young people age 15 to 24. An estimated 1.1 million Americans are living with the human immunodeficiency virus (HIV), and 1 out of 5 people with HIV do not know they have it. Untreated STDs can lead to serious long-term health consequences, especially for adolescent girls and young women, including reproductive health problems and infertility, fetal and perinatal health problems, cancer, and further sexual transmission of HIV.

For many, reproductive and sexual health services are the entry point into the medical care system. These services improve health and reduce costs by not only covering pregnancy prevention, HIV and STD testing and treatment, and prenatal care, but also by screening for intimate partner violence and reproductive cancers, providing substance abuse treatment referrals, and counseling on nutrition and physical activity. Each year, publicly funded family planning services help prevent 1.94 million unintended pregnancies, including 400,000 teen pregnancies.(1) For every $1 spent on these services, nearly $4 in Medicaid expenditures for pregnancy-related care is saved.(2), (3)

Improving reproductive and sexual health is crucial to eliminating health disparities, reducing rates of infectious diseases and infertility, and increasing educational attainment, career opportunities, and financial stability.

The Reproductive and Sexual Health Leading Health Indicators are:

• Sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months (FP-7.1)
• Persons living with HIV who know their serostatus (HIV-13)

>>> Health Impact of Reproductive and Sexual Health

Reproductive and sexual health is a key component to the overall health and quality of life for both men and women. Reproductive and sexual health services can:

• Prevent unintended pregnancies. Nearly half of all pregnancies are unintended. Risks associated with unintended pregnancy include low birth weight, postpartum depression, delays in receiving prenatal care, and family stress.
• Prevent adolescent pregnancies. More than 400,000 teen girls age 15 to 19 give birth each year in the United States.(4)
• Detect health conditions early. Prenatal care can detect gestational diabetes or preeclampsia before it causes problems, and taking prenatal vitamins can prevent birth defects of the brain and spinal cord.
• Increase the detection and treatment of STDs. Untreated STDs can lead to serious long-term health consequences, especially for adolescent girls and young women.
• Decrease rates of infertility. The Centers for Disease Control and Prevention (CDC) estimates that undiagnosed and untreated STDs cause at least 24,000 women in the United States each year to become infertile.
• Slow the transmission of HIV through testing and treatment.(5) People living with HIV who receive antiretroviral therapy are 92% less likely to transmit HIV to others.(6)

>>> Reproductive and Sexual Health Across the Life Stages

Reproductive and sexual health is an important part of an individual’s overall health, particularly during childbearing years.

Infants

• Babies of mothers who do not get prenatal care are 3 times more likely to have a low birth weight and 5 times more likely to die than those born to mothers who do get prenatal care.(7)

Adolescents

• STDs are a risk to adolescents’ health and fertility. Nearly half of new STD infections are among young people age 15 to 24.(8)
• Adolescents who become pregnant are much less likely to complete their education. About 50% of teen mothers get a high school diploma by age 22, compared with 90% of teen girls who do not give birth.(4) Only 50% of teen fathers who have children before age 18 finish high school or get their GED by age 22.(9)

Older Adults (10)

Older adults are a traditionally overlooked population in reproductive and sexual health; this situation is changing, however, as the U.S. population ages. Consider the following:

• 29% of people living with AIDS are over age 50.
• Older women may be especially at risk of contracting HIV and other STDs because age-related vaginal thinning and dryness can cause tears in the vaginal area.
• Some older adults, compared with those who are younger, may be less knowledgeable about HIV/AIDS and therefore less likely to protect themselves. Many do not perceive themselves as at risk for HIV, do not use condoms, and do not get tested for HIV.

>>> Determinants of Reproductive and Sexual Health

Reproductive and sexual health, particularly the spread of STDs including HIV and the prevalence of unintended pregnancy, are determined in part by social, economic, and behavioral factors. Stigma is still a major barrier to people accessing reproductive and sexual health services. For example, the continued stigma around HIV and its association with men who have sex with men can prevent people from getting tested and knowing their serostatus.

Many other factors affect an individual’s reproductive and sexual health decision-making, including access to medical care, social norms, educational attainment, age, income, geographic location, insurance status, sexual orientation, and dependency on alcohol or other drugs. Addressing these determinants is key to reducing health disparities and improving the health of all Americans.

>>> Disparities and Reproductive and Sexual Health

Some populations are at increased risk for certain reproductive health problems. These disparities can be because of anatomical and biological differences, behavioral risks, social determinants, or a combination of these factors. As a result, health disparities exist.

Data from 2006 to 2008 found:

• Among racial and ethnic groups, the black non-Hispanic population had the highest proportion of sexually active females who received reproductive health services in the past 12 months (83.3%), while Hispanics had the lowest proportion (72.2%).
• Among sexually active females age 22 to 44, those with advanced degrees had the highest (best) proportion who received reproductive health services in the past 12 months (83.4%), compared to those with less than a high school education (72.6%) or those with a high school education (75.2%).
• A higher (better) proportion of sexually active females with family income at 500% or more of the Federal Poverty Level (FPL) (90.4%) received reproductive health services than those in lower income groups: less than 100% FPL (75.2%); 100% to 199% FPL (72.9%); and 200% to 399% FPL (77.9%).
• Sexually active females with public medical insurance reported receiving the highest (best) proportion of reproductive health services in the last 12 months (85.3%) whereas those who are uninsured reported receiving the lowest proportion of services (65.4%).

Data from 2006 found:

• 81.2% of white non-Hispanic people with HIV were aware of their HIV infection in 2006, compared to 70.5% of Asians and Pacific Islanders with HIV.
• Among people with HIV infection, 80.9% of females were aware of their HIV infection, compared to 78.3% of males.
• HIV infection awareness varied by age group, from 83.9% for people age 45 to 54 to 19.1% for people age 55 and older.

>>> About the Disparities Data

• Disparities for females who receive reproductive services (FP-7.1) are statistically significant at the 0.05 level of significance. Statistical significance of awareness of HIV status (HIV-13) could not be assessed because of lack of standard errors.
• To maintain comparability across indicators, all disparities are computed using adverse events.
• Data for females who receive reproductive services (FP-7.1) are available periodically from the National Survey of Family Growth, CDC, National Center for Health Statistics.
• Data for awareness of HIV status (HIV-13) are available annually from the HIV Surveillance System, CDC, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Data in the HIV Surveillance System, formerly HIV/AIDS Surveillance System, are continually updated, and new records are added as they are reported. For this reason, data for any given year may be revised, and data points are updated annually.

References

(1) Guttmacher Institute. In Brief: Facts on Publicly Funded Contraceptive Services in the United States. New York; 2011. Available from: http://www.guttmacher.org/pubs/fb_contraceptive_serv.pdf

(2) Gold RB, Sonfield A, Richards CL, et al. Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System. New York: Guttmacher Institute; 2009. Available from: http://www.guttmacher.org/pubs/NextSteps.pdf

(3) Frost J, Finer L, Tapales A. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. Journal of Health Care for the Poor and Underserved. 2008 Aug;19(3):778-96.

(4) Centers for Disease Control and Prevention (CDC). Preventing teen pregnancy in the U.S. CDC Vital Signs. Atlanta, GA; April 2011. Available from http://www.cdc.gov/VitalSigns/pdf/2011-04-vitalsigns.pdf

(5) Centers for Disease Control and Prevention (CDC). HIV testing in the U.S. CDC Vital Signs. Atlanta, GA; December 2010. Available from http://www.cdc.gov/VitalSigns/pdf/2010-11-30-vitalsigns.pdf

(6) National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services (HHS), Office of the Surgeon General; 2011: p.45. Available fromhttp://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(7) Office on Women’s Health, HHS. Prenatal Care Fact Sheet. Washington, DC; 2009. Available from http://womenshealth.gov/publications/our-publications/fact-sheet/prenatal-care.cfm

(8) National Prevention Information Network, CDC. STDs Today. Atlanta, GA; 2011. Available from http://www.cdcnpin.org/scripts/std/std.asp

(9) U.S. Department of Labor. National Longitudinal Survey of Youth 1997. Available from http://www.bls.gov/nls/nlsy97.htm

(10) CDC. HIV/AIDS Among Persons Aged 50 and Older. Atlanta, GA; 2008. Available fromhttp://www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm

---

>> Leading Health Indicators. Social Determinants.

A range of personal, social, economic, and environmental factors contribute to individual and population health. For example, people with a quality education, stable employment, safe homes and neighborhoods, and access to preventive services tend to be healthier throughout their lives.(1) Conversely, poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.

Social determinants are in part responsible for the unequal and avoidable differences in health status within and between communities. The selection of Social Determinants as a Leading Health Topic recognizes the critical role of home, school, workplace, neighborhood, and community in improving health.

The Social Determinants Leading Health Indicator is:

• Students who graduate with a regular diploma 4 years after starting 9th grade (AH-5.1)

Although education is the Leading Health Indicator for this topic, many of the Healthy People 2020 objectives address social determinants as a means to improve population health.

>>> Health Impact of Social Determinants

Social and physical determinants affect a wide range of health, functioning, and quality of life outcomes. For example:

• Access to parks and safe sidewalks for walking is associated with physical activity in adults.(2)
• Education is associated with:
• Longer life expectancy
• Improved health and quality of life
• Health-promoting behaviors like getting regular physical activity, not smoking, and going for routine checkups and recommended screenings.(3)
• Discrimination, stigma, or unfair treatment in the workplace can have a profound impact on health; discrimination can increase blood pressure, heart rate, and stress, as well as undermine self-esteem and self-efficacy.(3)
• Family and community rejection, including bullying, of lesbian, gay, bisexual, and transgender youth can have serious and long-term health impacts including depression, use of illegal drugs, and suicidal behavior.(4)
• Places where people live and eat affect their diet. More than 23 million people, including 6.5 million children, live in “food deserts”—neighborhoods that lack access to stores where affordable, healthy food is readily available (such as full-service supermarkets and grocery stores).(5)

>>> Social Determinants Across the Life Stages

From infancy through old age, the conditions in the social and physical environments in which people are born, live, work, and age can have a significant influence on health outcomes.

Children

• Early and middle childhood provide the physical, cognitive, and social-emotional foundation for lifelong health, learning, and well-being. A history of exposure to adverse experiences in childhood, including exposure to violence and maltreatment, is associated with health risk behaviors such as smoking, alcohol and drug use, and risky sexual behavior, as well as health problems such as obesity, diabetes, heart disease, sexually transmitted diseases, and attempted suicide.(6)
• Features of the built environment, such as exposure to lead-based paint hazards and pests, negatively affect the health and development of young children.

Adolescents

• Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people’s health and well-being. Addressing young people’s positive development facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population.
• Adolescents who grow up in neighborhoods characterized by poverty are more likely to be victims of violence; use tobacco, alcohol, and other substances; become obese; and engage in risky sexual behavior.(7)

Adults

• Access to and availability of healthier foods can help adults follow healthful diets. For example, better access to retail venues that sell healthier options may have a positive impact on a person’s diet. These venues may be less available in low-income or rural neighborhoods.
• Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the modern workplace and are increasingly affecting the health and lives of U.S. adults. Research has shown that workers experiencing these stressors are at higher risk of injuries, heart disease, and digestive disorders.(8)

Older Adults

• Availability of community-based resources and transportation options for older adults can positively affect health status. Studies have shown that increased levels of social support are associated with a lower risk for physical disease, mental illness, and death.(9), (10)

 

Race and ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations. Social determinants are often a strong predictor of health disparities. For example:

• In 2007 to 2008, the Asian or Pacific Islander population had the highest rate of high school graduation among racial and ethnic groups, with 91.4% of students attending public schools graduating with a diploma 4 years after starting 9th grade compared to rates among non-Hispanic white (81.0%), American Indian or Alaska Native (64.2%), Hispanic (63.5%), and non-Hispanic black (61.5%) populations.
• According to the National Assessment of Adult Literacy, African American, Hispanic, and American Indian or Alaska Native adults were significantly more likely to have below basic health literacy compared to their white and Asian or Pacific Islander counterparts. Hispanic adults had the lowest average health literacy score compared to adults in other racial and ethnic groups.(11)
• In 2007, African Americans and Hispanics were more likely to be unemployed compared to their white counterparts. Further, adults with less than a high school education were 3 times more likely to be unemployed than those with a bachelor’s degree.(12)
• Low socioeconomic status is associated with an increased risk for many diseases, including cardiovascular disease, arthritis, diabetes, chronic respiratory diseases, and cervical cancer as well as for frequent mental distress.(12)
• Low-income minorities spend more time traveling to work and other daily destinations than do low-income whites because they have fewer private vehicles and use public transit and car pools more frequently.(12)

>>> About the Disparities Data

• Standard errors are not available, so the statistical significance of stated disparities could not be assessed.
• Data for this measure are available annually and come from the Common Core of Data, U.S. Department of Education, National Center for Education Statistics. National data include data from 49 states and Washington, DC. Data by race and ethnicity include data from 48 states and Washington, DC. See the annual publication Public School Graduates and Dropouts From the Common Core of Datafor more information and data years not currently included in Healthy People: http://nces.ed.gov/ccd/pub_dropouts.asp

References

(1) National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services (HHS), Office of the Surgeon General; 2011: p.6. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(2)Booth ML, Owen N, Bauman A, et al. Social-cognitive and perceived environment influences associated with physical activity in older Australians. Prev Med 2000;31:15–22.

(3) National Prevention Strategy. p.22. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(4) National Prevention Strategy. p.48. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(5) National Prevention Strategy. p.34. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(6) National Prevention Strategy. p.41. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(7) National Prevention Strategy. p.25. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

(8) Rosa RR, Colligan MJ. Plain Language About Shiftwork. Cincinnati, OH: HHS, National Institute for Occupational Safety and Health; 1997. Available from http://www.cdc.gov/niosh/pdfs/97-145.pdf

(9) Seeman TE. Health promoting effects of friends and family on health outcomes in older adults. Am J Health Promot 2000;14:362–70.

(10) Stroebe W. Moderators of the stress-health relationship. In: Stroebe W. Social psychology and health. Philadelphia, PA: Open University Press; 2000:236–73.

(11) Kutner M, Greenberg E, Jin Y, et al The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.

(12) Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta, GA: Centers for Disease Control and Prevention; 2008. Available from http://www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf

---

>> Leading Health Indicators. Substance Abuse.

Although progress has been made in substantially lowering rates of substance abuse in the United States, the use of mind- and behavior-altering substances continues to take a major toll on the health of individuals, families, and communities nationwide. In 2005, an estimated 22 million Americans struggled with a drug or alcohol problem.

Substance abuse—involving drugs, alcohol, or both—is associated with a range of destructive social conditions, including family disruptions, financial problems, lost productivity, failure in school, domestic violence, child abuse, and crime. Moreover, both social attitudes and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public health issues. Estimates of the total overall costs of substance abuse in the United States, including lost productivity and health- and crime-related costs, exceed $600 billion annually.(1)

The Substance Abuse Leading Health Indicators are:

• Adolescents using alcohol or any illicit drugs during the past 30 days (SA-13.1)
• Adults engaging in binge drinking during the past 30 days (SA-14.3)

>>> Health Impact of Substance Abuse

Substance abuse contributes to a number of negative health outcomes and public health problems, including:

• Cardiovascular conditions
• Pregnancy complications
• Teenage pregnancy
• Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)
• Sexually transmitted diseases (STDs)
• Domestic violence
• Child abuse
• Motor vehicle crashes
• Homicide
• Suicide

For example, data show that:

• The use of cocaine, MDMA (ecstasy), amphetamines, and steroids have been linked to abnormal cardiovascular functioning, ranging from abnormal heart rate to heart attacks.(2)
• Approximately one-fourth of AIDS cases in the United States have resulted from injection drug use.(3)
• More than half of all people arrested in the United States, including for homicide, assault, and theft, test positive for illicit drugs.(4)
• In 2009, an estimated 10.5 million people age 12 or older reported driving under the influence of illicit drugs in the previous year.(5) In 2009, among fatally injured drivers, 18 percent tested positive for at least one drug.(6)
• Prenatal drug exposure can result in premature birth, miscarriage, low birth weight, and a variety of behavioral and cognitive problems.(7)

>>>> Substance Abuse Across the Life Stages

Substance abuse remains a serious concern for Americans of all ages.

Children and Adolescents

• On an average day in 2006, youth used the following substances for the first time: 7,970 drank alcohol; 4,348 used an illicit drug; 4,082 smoked cigarettes; and 2,517 used pain relievers nonmedically.(8)
• Daily marijuana use increased among students in 8th, 10th, and 12th grades from 2009 to 2010. Among 12th graders, marijuana use was at its highest point since the early 1980s, with 6.1 percent of all high school seniors reporting marijuana use.(8)
• Prescription medications, such as painkillers, and over-the-counter cough and cold medicines are some of the most abused drugs among high school seniors.(8)
• 13.8% of students in 8th grade, 28.9% of students in 10th grade, and 41.2% of students in 12th grade consumed at least 1 drink in the past 30 days. Youth who used alcohol in the past month drank an average of 4.7 drinks per day on the days they drank.

Adults

• In 2009, people age 18 to 25 had the highest rates of current drug use of any age group, at 21.2%. This is largely driven by the widespread use of marijuana among this age group (18.1%).(5)
• 41.7% of young adults age 18 to 25, 36.3% of adults age 26 to 34, and 19.2% of people age 35 or older reported binge drinking in 2009.(5)
• Adults dependent on alcohol report higher rates of illicit drug use and nonmedical use of prescription drugs compared with the general population.(9)

Several biological, social, environmental, psychological, and genetic factors are associated with substance abuse. These factors can include gender, race and ethnicity, age, income level, educational attainment, and sexual orientation.(10 )Substance abuse is also strongly influenced by interpersonal, household, and community dynamics.

Family, social networks, and peer pressure are key influencers of substance abuse among adolescents. For example, research suggests that marijuana exposure through friends and siblings was a primary determinant of adolescents’ current marijuana use.(11) Understanding these factors is key to reducing the number of people who abuse drugs and alcohol and improving the health and safety of all Americans.

>> Leading Health Indicators. Tobacco.

Tobacco use is the single most preventable cause of disease, disability, and death in the United States, yet more deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. (1), (2)

In 2009, an estimated 20.6% of all American adults age 18 and older—46.6 million people—smoked,(3) and every day another 850 young people age 12 to 17 began smoking on a daily basis.(4) As a result of widespread tobacco use, approximately 443,000 Americans die from tobacco-related illnesses, such as cancer and heart disease, each year. An estimated 49,000 of these deaths are the result of secondhand smoke exposure.(1) For every person who dies from tobacco use, another 20 suffer from at least one serious tobacco-related illness.(5)

Tobacco use poses a heavy burden on the U.S. economy and medical care system. Each year, cigarette smoking costs more than $193 billion in medical care costs, while secondhand smoke costs an additional $10 million.(1), (6) Tobacco use is thus one of the Nation’s deadliest and most costly public health challenges.

The Tobacco Use Leading Health Indicators are: 

• Adults who are current cigarette smokers (TU-1.1)
• Adolescents who smoked cigarettes in the past 30 days (TU-2.2)

>>> Health Impact of Tobacco Use

Tobacco use in any form—even occasional smoking—causes serious diseases and health problems, including:

• Several forms of cancer, including cancers of the lung, bladder, kidney, pancreas, mouth, and throat
• Heart disease and stroke
• Lung diseases, including emphysema, bronchitis, and chronic obstructive pulmonary disease (COPD)
• Pregnancy complications, including preterm birth, low birth weight, and birth defects
• Gum disease
• Vision problems

Secondhand smoke from cigarettes and cigars also causes heart disease and lung cancer in adults and a number of health problems in infants and children, including:

• Asthma
• Respiratory infections
• Ear infections
• Sudden infant death syndrome (SIDS)

Smokeless tobacco causes a number of serious oral health problems, including cancer of the mouth and gums, periodontal disease, and tooth loss.

>>> Tobacco Use Across the Life Stages

Preventing tobacco use and helping people who use tobacco quit can improve the health and quality of life for Americans of all ages. People who stop smoking greatly reduce their risk of disease and premature death. Benefits are greater for people who stop at earlier ages, but quitting tobacco use is beneficial at any age.

Children

• Secondhand smoke can trigger an asthma attack in a child who previously had not exhibited symptoms of asthma. Children with asthma who are around secondhand smoke have more severe and frequent asthma attacks.(7)
• Infants and children younger than 6 who are regularly exposed to secondhand smoke are at increased risk of lower respiratory tract infections, such as pneumonia and bronchitis.(7)
• Children who regularly breathe secondhand smoke are at increased risk for middle ear infections.(7)
• Infants who are exposed to secondhand smoke after birth are at greater risk of sudden infant death syndrome (SIDS).(7)

Adolescents

• Each day in the United States, approximately 3,450 young people age 12 to 17 smoke their first cigarette.(4)
• Adolescents who use smokeless tobacco are more likely than those who do not use smokeless tobacco to smoke cigarettes as adults.(8),(9), (10) Smoking during adolescence is associated with other health risks, including high-risk sexual behavior and alcohol and substance use.(8), (11)

Adults

• The risk of developing lung cancer is approximately 23 times higher among men who smoke and 13 times higher among women who smoke compared with people who have never smoked. Smoking causes an estimated 90% of all lung cancer deaths in men and 80% of all lung cancer deaths in women.(12)
• Men and women who smoke are 2 to 4 times more likely to develop coronary heart disease than people who do not smoke.(12)
• People who are exposed to secondhand smoke increase their heart disease risk by 25% to 30% and their lung cancer risk by 20% to 30%.(7)
• Smoking during pregnancy causes health problems for both women and infants, including pregnancy complications, premature birth, low birth weight, stillbirth, and sudden infant death syndrome (SIDS). Approximately 1 in 8 women in the United States smoke during pregnancy.
• People who smoke die approximately 13 to 14 years earlier than people who do not smoke.(13)

>>> Determinants of Tobacco Use

A broad range of social, environmental, psychological, and genetic factors have been associated with tobacco use, including gender, race and ethnicity, age, income level, educational attainment, and geographic location. Motivation to begin and to continue smoking is strongly influenced by the social environment, although genetic factors are also known to play a role. Smoke-free protections, tobacco prices and taxes, and the implementation of effective tobacco prevention programs all influence tobacco use.

Among adolescents and young adults, in particular, tobacco use is influenced by:

• The use of tobacco and approval of tobacco use by peers or siblings
• Smoking by parents or guardians
• Accessibility of tobacco products
• Exposure to tobacco use promotional campaigns
• Low self-image or self-esteem

Understanding and addressing these factors is key to reducing the number of Americans who use tobacco or are exposed to secondhand smoke.

>>> Disparities in Tobacco Use

Disparities in tobacco use persist. For example in 2008:

• The rate of current smoking among adults varied among race and ethnicity groups. The lowest rates were seen among people who identified as Asian (9.7%, age adjusted) and as Hispanic or Latino (14.9%, age adjusted). The age adjusted prevalence observed for other race and ethnicity groups were as follows:
• Non-Hispanic black: 20.7%
• Non-Hispanic white: 22.6%
• Native Hawaiian or Other Pacific Islander: 22.6%
• American Indian or Alaska Native: 23.7%
• More men were current smokers than women (22.8% and 18.5%, age adjusted, respectively).
• Among adults age 25 and over, prevalence of current smoking was lower among groups with higher education, with the lowest rates seen among those who have completed an advanced degree beyond college (5.5%, age adjusted).
• Prevalence of current smoking was lower among groups with higher family income levels. Prevalence of current smoking for adults in families living below the poverty threshold (<100%) was more than 2½ times the prevalence for adults in families living at 600% or more above the poverty limit (31.9% versus 11.8%, age adjusted, respectively).

In 2009:

• For students in grades 9 to 12, the prevalence of smoking cigarettes in the past 30 days varied among race and ethnicity groups. The lowest rates were seen for those who identified as Asian (9.1%) and non-Hispanic black (9.5%). The rates observed for other race and ethnicity groups were as follows:
• Hispanic or Latino: 18.0%
• Native Hawaiian or Other Pacific Islander: 20.8%
• Non-Hispanic white: 22.5%
• American Indian or Alaska Native: 25.8%
• Students who were obese had a higher prevalence of smoking cigarettes in the past 30 days than students who were not obese (22.1% and 18.8%, respectively).

>>> About the Disparities Data

All disparities described are statistically significant at the 0.05 level of significance.

Notes for Cigarette Smoking among Adults (TU-1.1):

• Data are available annually and come from the National Health Interview Survey, Centers for Disease Control and Prevention (CDC), National Center for Health Statistics.
• People are considered as current smokers if they report that they smoked at least 100 cigarettes in their lifetime and now report smoking cigarettes every day or some days.
• See the Health Indicators Warehouse for all age adjustment information for this indicator.

Notes for Cigarette Smoking among Adolescents (TU-2.2):

• Data are available biennially and come from the Youth Risk Behavior Surveillance System, CDC, National Center for Chronic Disease Prevention and Health Promotion.
• Students are classified as using cigarettes if they report smoking one or more cigarettes in the 30 days preceding the survey.

 

###

* The above information is adapted from materials provided by USA Department of Health and Human Services (HHS)
** More information at USA Department of Health and Human Services (HHS)