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Chronic Diseases and Community Health

Learning Objectives

After reading this chapter, you should be able to:

• State a rationale for the role of lifestyle and behavior in health outcomes.

• Describe the health effects associated with tobacco and alcohol consumption.

• Describe policies and interventions for control of tobacco use.

• Define the term chronic disease and give examples of three major chronic diseases.

• Describe at least two programs for prevention of chronic diseases.

Chapter 8 Huntstock/Thinkstock

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CHAPTER 8Section 8.2 Epidemiology of Chronic Diseases

8.1 Introduction Chronic diseases cause 70% of deaths in the United States each year (CDC, 2012e). As defined in Chapter 6, the term chronic diseases refers to “non-communicable diseases that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely” (CDC, 2009b, para. 1). Also, according to the Centers for Disease Control and Preven- tion, “[c]hronic diseases—such as heart disease, stroke, cancer, diabetes, and arthritis—are the most common, costly, and preventable of all health conditions in the United States” (2012e). Fifty percent of deaths each year in this country are caused by stroke (caused by the stoppage of blood flow to the brain), heart disease (caused by buildup in the arteries of the heart), and cancer (caused by uncontrolled division of abnormal cells in the body) (Heron, 2009). As the leading sources of death and disability in this country, chronic dis- eases are extremely significant for community health (Remington & Brownson, 2011).

Chronic diseases share four common, modifiable risk factors that are associated with spe- cific lifestyle choices. These risk factors are being sedentary, consuming foods high in saturated fats and calories, smoking cigarettes and using other forms of tobacco, and con- suming excessive amounts of alcohol. In addition, physical inactivity and poor diet are associated with obesity, an increasingly prevalent long-lasting condition, which is a risk factor for other chronic conditions (Fine et al., 2001).

Chapter 8 covers the occurrence, distribution, and risk factors for five major chronic dis- eases: cardiovascular diseases, cancer, diabetes, chronic obstructive pulmonary disease (COPD), and arthritis.

8.2 Epidemiology of Chronic Diseases In 2011, six chronic diseases—diseases of the heart, malignant neoplasms, chronic lower res- piratory diseases, cerebrovascular diseases, Alzheimer’s disease, and diabetes mellitus— were among the leading causes of death in this country (Hoyert & Xu, 2012). Liver dis- ease, a disease which reduces, damages, or stops the function of the liver, is also a growing concern. During the 20th century and into the early 21st century, several of the chronic dis- eases that continue to be the leading killers of Americans have shown remarkable declines. Other chronic diseases have remained stable or increased with respect to their contribu- tions to the leading causes of death. During the same time span, disparities in chronic disease mortality rates by education, income, and racial/ethnic group have continued or increased.

Mortality Trends

Since 1935, cancer, stroke, and heart disease have continued to be among the five lead- ing causes of death. Coronary heart disease (CHD) and cancer have persisted as the top two causes of death over this 75-year period. Together they caused 47% of deaths in 2010, declining from a peak of 60% in 1983. Since 1979, chronic lower respiratory diseases have been among the five leading causes of death. Refer to Figure 8.1 for information on the percentage of deaths due to five leading causes over a 75-year time span.

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CHAPTER 8Section 8.2 Epidemiology of Chronic Diseases

Figure 8.1: Percentage of all deaths due to five leading causes of death by year, United States, 1935–2010

Source: Adapted from Hoyert, D. L. (2012). 75 years of mortality in the United States, 1935–2010. NCHS Data Brief (88), 2.

Heart disease was relatively nonexistent before the 1980s. What might account for this surge in heart disease–related deaths? What programs and policies might community and public health professionals take on to combat this? What other trends do you see?

The CDC states that

[s]ince 1960, death rates for chronic diseases have changed dramatically, especially reductions in deaths caused by heart disease and stroke . . . heart disease death rates have declined by almost two-thirds during the past 50 years, and stroke rates have declined by more than three quarters. (Rem- ington & Brownson, 2011, p. 72)

However, death rates for other chronic diseases have tended to remain stable or increase. Between 1960 and 2007, the death rate for cancer declined by only 8% (10% between 1960 and 2009). During the past 3 decades, chronic lower respiratory diseases increased by about 50%. Additional information on trends in the leading causes of chronic disease– related deaths in the United States is presented in Table 8.1.

P e rc

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ta g

100

1935 1940 1950 1960 1970 1980 1990 2000 2010

Year

All other causes

Influenza and pneumonia

Kidney disease

Stroke

Cancer

Heart disease

Accidents (unintentional injuries)

Certain diseases of early infancy

Chronic lower respiratory diseases

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CHAPTER 8Section 8.2 Epidemiology of Chronic Diseases

Table 8.1: Trends in the leading causes of chronic disease–related deaths, United States, 1960 and 2009

Rate,* by year Trends, 2009 vs. 1960

Disease 1960 2009 Percent Change

Rate difference*

Number of lives saved (lost)§

Heart disease 559 180 –68% –379 1,137,000

Cancer 194 174 –10% –20 60,000

Stroke 178 38.9 –78% –139 417,300

Diabetes 22.5 20.9 –7% –1.6 4,800

Liver disease 13.3 9.2 –31% –4.1 12,300

Pneumonia and influenza

53.7 16.2 –70% –38 112,500

Accidents 62.3 37 –41% –25 75,900

Suicide 12.5 11.7 –6% –0.8 2,400

Homicide 5.0 5.5 +10% +0.5 (1,500)

Source: Remington, P. L., & Brownson, R. C. (2011). Fifty years of progress in chronic disease epidemiology and control. MMWR, 60(supplement), 74. * Per 100,000 population (age adjusted to the 2000 U.S. population). † For chronic obstructive pulmonary disease, comparison is 1980 vs. 2009, as follows: 1980 rate—28.3; 2009 rate—42.2; percent

change, 2009 vs. 1980—+49%; rate difference—+14; number of lives saved: 41,700. § Estimated by multiplying the rate difference by the 2010 U.S. population (300 million persons) rounded to the nearest 1,000.

Sociodemographic Variations in Chronic Diseases

The prevalence of chronic diseases is associated with poverty, lower levels of education, and minority racial/ethnic group status. An example of the relationship between poverty and chronic diseases is the occurrence of multiple chronic health conditions (i.e., affliction with more than one chronic disease). Poverty is associated with the prevalence of multiple chronic health condi- tions (for example, heart disease and cancer). During 2009 and 2010, among persons who had multiple (two or more) chronic health conditions, about one-third were below the poverty level— more than twice the percentage among persons with the highest income levels (400% or more of the poverty level) (National Center for Health Sta- tistics, 2012). Refer to Figure 8.2 for more informa- tion. Possible reasons for this association include the inability of poorer individuals to afford nutri- tious food and access to health care—because they do not have health insurance.

iStockphoto/Thinkstock

With limited or no access to health care, those living below poverty run increased risk of chronic disease.

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CHAPTER 8Section 8.2 Epidemiology of Chronic Diseases

Figure 8.2: Two or more selected chronic conditions among adults 45 to 64 years of age, by percent of poverty level, United States, 1999–2000 and 2009–2010

Source: Hoyert, DL. 75 years of mortality in the United States, 1935-2010. NCHS Data Brief. 2012;88:2.

Chronic diseases have largely been connected with income level, indicating health disparities remain dominant among low-income groups. Within the two different time spans presented here, what can you infer about the disparity between the rich and poor? Does poverty cause poor health or does poor health cause poverty?

Level of education is also related to the occurrence of chronic diseases. Often, informa- tional interventions for chronic disease (e.g., smoking cessation interventions) are more effective among persons who have more education in comparison with less educated indi- viduals. Further studies have shown that health disparities have significantly contributed to different risks of chronic disease in the United States (Denny et al., 2005).

0% 10% 30% 50%40%20%

Percentage

1999–2000

2009–2010

Y e a r

Below 100%

100%–199%

200%–399%

400% or more

31% 24%

17% 12%

33% 30%

21% 16%

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CHAPTER 8Section 8.3 Cardiovascular Diseases

8.3 Cardiovascular Diseases Cardiovascular diseases are “a group of disorders of the heart and blood vessels” (WHO, n.d.a, para. 1). These include heart diseases and stroke. The toll of mortality from both heart

disease and stroke has declined greatly during the past half- decade (Remington & Brownson, 2011). Between 1960 and 2009, heart disease mortality declined by 68% and stroke mortality by 78%. These declines can be attrib- uted to reductions in smoking and improvements in screening for car- diovascular disease risk factors, as well as treatments for cardiovascu- lar disease. See Figure 8.3 for the distribution of heart disease death rates across the United States.

Voisin/Phanie/SuperStock

Heart disease mortality has declined in part due to new treatments that have been developed.

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CHAPTER 8Section 8.3 Cardiovascular Diseases

Figure 8.3: Heart disease death rates, 2007–2009, adults ages 35 and older, by county

Age Adjusted Average Annual Deaths per 100,000

109.8–315.2 399.8–458.2 458.38–750.8315.3–359.6 359.7–399.7

Source: CDC division for heart disease and stroke prevention. Heart disease fact sheet. Retrived from http://www.cdc.gov/dhdsp/data _statistics/fact_sheets/fs_heart_disease.htm

The Centers for Disease Control and Prevention states that heart disease is the leading cause of death for both men and women in the United States, with one in every four Americans dying from the disease each year. Based on the map, the Deep South has the highest number of deaths and the western states the lowest. What is the difference? What factors could be present in the Deep South that may point to higher numbers of heart disease deaths?

Further Definition of Cardiovascular Diseases

Some of the disorders that comprise cardiovascular diseases include:

• coronary heart disease (CHD): disease of the blood vessels supplying the heart muscle;

• cerebrovascular disease: disease of the blood vessels supplying the brain; • peripheral arterial disease: disease of the blood vessels supplying the arms

and legs; • rheumatic heart disease: damage to the heart muscle and heart cells (cardiac

tissue) from rheumatic fever caused by streptococcal bacteria; • congenital heart disease: malformations of the heart structure existing at birth

include the following conditions: atrial septal defect (ASD), coarctation of the aorta, patent ductus arteriosus (PDA), and ventricular septal defect (VSD);

• deep vein thrombosis (DVT) and pulmonary embolism: DVT involves the formation of a clot in a deep vein of the body, occurring most often in the femoral and ilia

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http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

CHAPTER 8Section 8.3 Cardiovascular Diseases

Health Care in Action: Selected Healthy People 2020 Objectives for the Topic Area of Heart Disease and Stroke

HDS–1: (Developmental) Increase overall cardiovascular health in the U.S. population.

HDS–2: Reduce coronary heart disease deaths.

Target: 100.8 deaths per 100,000 population.

Baseline: 126.0 coronary heart disease deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

HDS–3: Reduce stroke deaths.

Target: 33.8 deaths per 100,000 population.

Baseline: 42.2 stroke deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

HDS–4: Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high.

Target: 92.6 percent.

Baseline: 90.6 percent of adults aged 18 years and older had their blood pressure measured within the preceding 2 years and could state their blood pressure level in 2008 (age adjusted to the year 2000 standard population).

HDS–5: Reduce the proportion of persons in the population with hypertension.

HDS–5.1 Reduce the proportion of adults with hypertension.

Target: 26.9 percent.

Baseline: 29.9 percent of adults aged 18 years and older had high blood pressure/hypertension in 2005– 08 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

HDS–5.2 Reduce the proportion of children and adolescents with hypertension.

Target: 3.2 percent. (continued)

veins, and pulmonary embolism involves blood clots in the leg veins, which can dislodge and move to the heart and lungs (WHO, n.d.a).

Healthy People 2020 Objectives for Cardiovascular Health

In recognition of the significance of cardiovascular diseases as leading causes of mortal- ity, Healthy People 2020 developed 24 objectives for improvement of cardiovascular health. The goal of Healthy People 2020 with respect to this area is to “[i]mprove cardiovascular health and quality of life through prevention, detection, and treatment of risk factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; and prevention of repeat cardiovascular events” (USDHHS, n.d.a). See Health Care in Action: Selected Healthy People 2020 Objectives for the Topic Area of Heart Disease and Stroke for details on the first five objectives.

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CHAPTER 8Section 8.3 Cardiovascular Diseases

Heart Disease/Coronary Artery Disease As we noted in the introduction, heart disease is the leading cause of death in the United States for both men and women (CDC, 2011g). Figure 8.4 shows a picture of the architec- ture of the human heart with major arteries and veins. The most common of heart dis- ease in the United States is “coronary artery disease, which can cause heart attack, angina, heart failure, and arrhythmias” (CDC, 2009a, para. 1). Coronary heart disease (CAD) is the result of fatty buildup, or plaque, in the arteries that supply blood to the heart (see Figure 8.5 for an illustration). Table 8.2 defines important terms related to coronary artery disease.

Figure 8.4: Picture of the human heart showing major arteries and veins

Source: CDC. Heart disease. About heart disease. Retrieved from http://www.cdc.gov/heartdisease/about.htm

This drawing depicts the major arteries and veins that support the blood flow to and from the heart. With all of these arteries and veins, how could a heart attack be possible? What malfunctions would have to occur to cause the heart to fail? What factors can keep these arteries and veins functioning optimally?

Superior vena cava

Right auricle

Right coronary artery

Anterior cardia vein

Right marginal artery

Aortic arch

Left coronary artery

Anterior Interventricular

branch

Great cardiac

vein

Health Care in Action: Selected Healthy People 2020 Objectives for the Topic Area of Heart Disease and Stroke (continued)

Baseline: 3.5 percent of children and adolescents aged 8 to 17 years had high blood pressure/hyperten- sion in 2005–08.

Target setting method: 10 percent improvement.

Source: Adapted from Healthypeople.gov. Heart disease and stroke. Retrieved from http://www.healthypeople.gov/2020/topics objectives2020/overview.aspx?topicId=21

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http://www.cdc.gov/heartdisease/about.htm

http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=21

CHAPTER 8Section 8.3 Cardiovascular Diseases

Figure 8.5: Coronary artery disease: Buildup of plaque from cholesterol deposits in arteries

Source: CDC. Heart disease. Coronary artery disease (CAD). Retrieved from http://www.cdc.gov/heartdisease/about.htm

Cholesterol is a frequently used term in today’s world of health. What does it actually do? How can a person keep their heart arteries clean from fatty deposits?

Normal cross - section of artery

Tear in artery wall

Fatty material is deposited in vessel wall

Narrowed artery becomes blocked by a blood clot

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http://www.cdc.gov/heartdisease/about.htm

CHAPTER 8Section 8.3 Cardiovascular Diseases

Table 8.2: A glossary of terms related to coronary artery disease

Term Definition

Angina Chest pain or discomfort, which is a symptom of coronary artery disease; caused by insufficient blood circulation to the heart

Arrhythmia Abnormal heart rhythm

Atherosclerosis Narrowing of the arteries over time, caused by a buildup of plaque

Atrial fibrillation A type of arrhythmia that can cause rapid, irregular beating in the heart’s upper chambers

Coronary artery disease (CAD) The buildup of plaque in the arteries that supply blood to the heart (called coronary arteries); refer to Figure 8.5 for an illustration of CAD.

Heart failure Reduced ability of the heart to pump blood normally; sometimes called congestive heart failure

Ischemic heart disease Reduced blood supply to the heart caused by disease of the blood vessels that supply the heart muscles

Myocardial infarction Medical term for a heart attack

Plaque Accumulation of cholesterol deposits in the arteries

Sudden cardiac arrest Complete stopping of the heart

Source: Data from Centers for Disease Control and Prevention. (2009b). About heart disease. Retrieved February 11, 2013 from http:// www.cdc.gov/heartdisease/about.htm; American Heart Association. (2011). What is cardiovascular disease (heart disease)? Retrieved February 11, 2013 from http://www.heart.org/HEARTORG/Caregiver/Resources/WhatisCardiovascularDisease/What-is-Cardiovascular- Disease_UCM_301852_Article.jsp; Mathers, C., Truelsen, T., Begg, S., & Satoh, T. (2004). Global burden of ischemic heart disease in the year 2000. Global Burden of Disease 2000. Geneva, Switzerland.

Chest pain is the most frequent symptom of a heart attack, especially among males. Other symptoms, such as tiredness, shortness of breath, and weakness are more common symp- toms of heart attack than chest pain is among women, persons who have diabetes, and the elderly. Spotlight: Heart Disease Facts summarizes information relating to heart disease in the United States.

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http://www.cdc.gov/heartdisease/about.htm

http://www.heart.org/HEARTORG/Caregiver/Resources/WhatisCardiovascularDisease/What-is-Cardiovascular-Disease_UCM_301852_Article.jsp

CHAPTER 8Section 8.3 Cardiovascular Diseases

Mortality It has been estimated that nearly one-half of all middle-aged men and one-third of middle- aged women in the United States will develop some manifestation of coronary heart dis- ease. In 2009, heart disease caused 25% of all deaths among Americans. The condition is the leading cause of death among most racial/ethnic groups in the United States (CDC, 2011g, 2013f, 2012i). Heart disease mortality differs according to U.S. geographic location. Counties located in the southern United States had the highest heart disease death rates (from 2007 to 2009) among adults aged 35 years and older; western states had the lowest heart disease rates. While coronary heart disease mortality rates have declined over the past four decades, the disease remains responsible for approximately one out of every three deaths in individuals over the age of 35 (Rosamond, Flegal, & Furie, 2008).

Incidence and Prevalence According to information from the Behavioral Risk Factor Surveillance System (BRFSS), the prevalence of coronary heart disease was 6.0% in 2010 (Fang, Shaw, & Keenan, 2011). Age, sex, race/ethnicity, and education were among the demographic variables associated with the prevalence of coronary heart disease. The lifetime prevalence of heart disease by age groups from 1999–2000 through 2009–2010 is shown in Figure 8.6. Note the increasing prevalence across age groups and the differences between men and women.

Spotlight: Heart Disease Facts

• Heart disease is the leading cause of death for both men and women. Men made up more than half of the deaths due to heart disease in 2009.

• About 600,000 Americans die from heart disease each year—that’s 1 in every 4 total yearly deaths.

• Coronary heart disease is the most common type of heart disease, killing more than 385,000 people annually.

• In the United States, someone has a heart attack every 34 seconds. Each minute, someone in the United States dies from a heart disease-related event.

• Heart disease is the leading cause of death for people of most racial/ethnic groups in the United States, including African Americans, Hispanics, and Whites. For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer.

• Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity.

Source: Adapted from CDC. (2012i). Heart disease fact sheet. Division for Heart Disease and Stroke Prevention. Retrieved January 22, 2013 from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

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http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

CHAPTER 8Section 8.3 Cardiovascular Diseases

Figure 8.6: Respondent-reported lifetime heart disease prevalence among adults 19 years of age and older, by sex and age, United States, 1999–2000 through 2009–2010

Source: Health United States, 2011.

Income level is a known factor in overall health disparity, but what about gender? This graphic depicts the differences between men and women and their prevalence of heart disease over the first decade of the 21st century. What does this mean for women and men? What does this chart indicate about heart disease awareness programs?

Regarding data for 2010, the prevalence of heart disease by age group was 1.2% (18 to 44 years), 7.1% (15 to 64 years), and 19.8% (65 years and older). The prevalence was higher among men than among women (7.8% versus 4.6%). Persons with less than a high school education had approximately twice the prevalence as those with a college degree or higher level of education (9.2% versus 4.6%). Among ethnic/racial groups, Blacks had the highest prevalence (6.5%), and Asian/Pacific Islanders the lowest prevalence (3.9%).

Modifiable and Nonmodifiable Risk Factors As noted previously, many of the chronic diseases share common modifiable risk factors. For heart disease, these risk factors include diabetes, overweight and obesity, a high-fat diet, physical inactivity, and excessive alcohol consumption (CDC, 2012i). Other modifiable

P e rc

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ta g

Year

50.0%

45.0%

40.0%

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

1999– 2000

Men Women

18–44 years

45–54 years

55–64 years

65–74 years

75 years and over

18–44 years

45–54 years

55–64 years

65–74 years

75 years and over

2009– 2010

1999– 2000

2009– 2010

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CHAPTER 8Section 8.3 Cardiovascular Diseases

risk factors are cigarette smoking, high LDL cholesterol, and hypertension. Nonmodifiable risk factors, by definition, are those factors that are immutable—such as increasing age and male gender (American Heart Association, 2011). Individuals with the greatest risk for these disorders are those with a genetic susceptibility (Scheuner et al., 1997), and those with limited socioeconomic circumstances (e.g. limited access to healthful foods, medical care, and resources for exercise and healthy lifestyle choices).

Hypertension

Hypertension is a systolic blood pressure of 140 mmHg or higher and a diastolic pressure of 90 mmHg or higher (140/90) (CDC, 2013g). It is commonly referred to as high blood pressure. Prehyper- tension is a systolic blood pres- sure in the range of 120 through 139 mmHg and a diastolic pres- sure of 80 through 89 mmHg. Prehypertension is a risk factor for development of hypertension. Normal blood pressure is defined as a systolic blood pressure of less than 120 mmHg and a diastolic pressure of less than 80 mmHg.

Hypertension, which usually has no warning signs or symptoms, raises the probability of having heart disease and stroke. As the pressure increases, the arte- rial muscles constrict to stem the flow. This constant constriction and expansion increases the muscle thickness in the coronary arteries, which contributes to further blood-flow constriction. About one-third of U.S. adults have hypertension, a condition that causes nearly 1,000 deaths per day (CDC, 2013g). The medical costs attributed to hypertension are about $131 billion per year. During the past decade, the prevalence of hypertension in the United States has tended to remain constant. As Figure 8.7 illustrates, states with a high prevalence of hypertension are concentrated in the southern tier of the country.

Cusp/SuperStock

Hypertension can lead to heart attack or stroke; surprisingly, it affects about one-third of the U.S. population, many of whom may not be aware, as it often shows no symptoms.

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CHAPTER 8Section 8.3 Cardiovascular Diseases

Figure 8.7: Prevalence of hypertension among U.S. adults ages 20 and older, 2011 (percentage)

Source: CDC. Heart disease fact sheet. Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

Much like the map showing heart disease prevalence, this map shows that the Deep South has the high- est prevalence rates of hypertension as well. Furthermore, the western states have the lowest preva- lence. What constitutes a healthy state? What elements are present in the West that are likely missing in the southern portion of the United States?

The frequency of hypertension increases with age and varies among racial/ethnic groups. Almost 70% of persons aged 65 and older have hypertension. Non-Hispanic Blacks have a hypertension prevalence of 38.6%, which is more than twice the prevalence among Mexi- can Americans (17.3%). Among non-Hispanic Whites, the prevalence is 32.3%.

Although hypertension is a treatable condition, less than one half of individuals with hypertension have the condition under control, and a third of hypertensive persons are not receiving treatment. Persons who have the lowest frequency of control of hyperten- sion are adults younger than 39 years of age, Mexican Americans, and those without health insurance.

Age-Adjusted Prevalence (Percentage)

25.2–27.9 28.0-29.1 29.2-31.0 33.0-38.931.1-32.9

AZ NM OK

KS CO

MS AL GA

NC TN

IN OH PA

WV VA

MA NH

DE NJ CT

MEVT

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http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

CHAPTER 8Section 8.3 Cardiovascular Diseases

Stroke

As mentioned earlier in the chapter, stroke events reduce or stop the flow of blood to the brain. Other names for stroke are a cerebrovascular accident (CVA) and a brain attack. There are two major types of stroke, ischemic strokes and hemorrhagic strokes. Ischemic strokes, which account for 85% of all strokes, are further classified as embolic or throm- botic strokes. An embolic stroke happens when a blood clot that originates in the brain or some other part of the body dislodges and blocks one of the blood vessels in the brain while a thrombotic stroke is caused by the formation of a blood clot in an artery of the brain. The clot develops in an artery that has narrowed due to the accumulation of fat and cholesterol. A hemorrhagic stroke, caused by the bursting of a blood vessel in the brain, can be either from an intracerebral hemorrhage—the rupture of an artery inside the brain—or a subarachnoid hemorrhage—during which bleeding occurs between the covering of the brain and the brain itself.

Stroke was the fourth leading cause of death and the primary cause of long-term seri- ous disability in the United States in 2008 (Fang, Shaw, & George, 2012). Cerebrovascular diseases (strokes) were responsible for more than 128,000 deaths and represented slightly more than 5% of total deaths in 2009.

The risk factors for stroke are hypertension, atrial fibrillation, diabetes, family history, high cholesterol, increasing age, and being of Black ancestry. The prevalence of stroke among persons aged 65 years and older was 8.3% in 2010—almost three times higher than among persons aged 45 to 64 years.

In 2010, the prevalence of stroke as determined by the BRFSS was 2.6%. State-specific prevalence data for stroke show disparities by state of residence and demographic charac- teristics such as race and education. States with high prevalence of stroke in 2010 tended to be clustered in the South—for example, Alabama and Mississippi. The stroke belt is a collection of states that have higher than average mortality rates due to stroke, and include Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. The factors contributing to the stroke belt states’ high incidence of stroke deaths is not clearly understood yet. These states also had a high prevalence of hypertension, a major risk factor for stroke. American Indians/ Alaska natives and Blacks had a higher prevalence of stroke in comparison with other racial and ethnic groups. Persons who had less than a high school diploma had almost three times the prevalence of stroke (4.6%) than persons who had a college degree or higher level of education.

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CHAPTER 8Section 8.4 Cancer

8.4 Cancer Cancer is the leading cause of global mortality. In 2008, cancer was responsible for 7.6 million deaths worldwide and repre- sented about 13% of all deaths in that year (WHO, 2013a). As shown in Figure 8.8, cancer was the second leading cause of death in the United States in 2009 and was the cause of more than 23% of deaths. Among males, the three leading causes of cancer mortality were can- cer of the lung and bronchus, prostate cancer, and cancer of the colon and rectum. Among women, mortality was primar- ily due to cancer of the lung and bronchus, female breast cancer, and cancer of the colon and the

rectum. While cancer cannot typically be predicted in an individual, there are risk fac- tors that may increase the chance of developing cancer. The National Cancer Institute has identified the following as risk factors:

• Growing older • Tobacco • Sunlight • Ionizing radiation • Certain chemicals and other substances • Some viruses and bacteria • Certain hormones • Family history of cancer • Alcohol • Poor diet, lack of physical activity, or being overweight (2006).

The highest incidence rates of cancer among men and women were for prostate cancer and female breast cancer, respectively. For both genders, cancer of the lung and bronchus and cancer of the colon and rectum had the second and third highest incidence rates (CDC, 2013j, n.d.d). Cancer screening is important for the prevention of prostate and female breast cancer. Screening looks for cancer before a person has any symptoms—symptoms appear when the cancer cells have multiplied, grown, and spread, at which point the can- cer is likely to be harder to treat or cure.

B BOISSONNET/BSIP/SuperStock

Prostate cancer is one of the leading causes of death among men in the United States, in addition to having the top incidence rate of any other type of cancer among men.

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CHAPTER 8Section 8.4 Cancer

Figure 8.8: Cancer mortality and incidence for top 10 cancer sites, males and females, United States, 2009

Source: CDC. Cancer-United States cancer statistics (USCS) data-2009. Top ten cancers. Retrieved from http://apps.nccd.cdc.gov/uscs/ toptencancers.aspx

The World Health Organization found that cancer was responsible for 7.6 million deaths worldwide and represented 13% of all deaths on Earth. Shown here are the cancers that killed those 7.6 million people. While lung and bronchus cancers were the top killers, the most common incidences of cancers were breast in women and prostate in men. Why is there a different cancer at the top of each list? Wouldn’t reason suggest that the most common cancer would be the most fatal? What could be affecting the outcomes?

0% 25% 75%50%

Rates per 100,000

Lung and Bronchus

Prostate

Colon and Rectum

Pancreas

Leukemias

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Corpus and Uterus, NOS Brain and Other Nervous System Liver and Intrahepatic Bile Duct

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Top 10 Cancer Sites: 2009, Female, United States–All Races Mortality

0% 50% 100% 150%

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Lung and Bronchus

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0% 50% 150%100%

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10.3%

11.2%

11.8%

15.8%

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37.1%

54.1%

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http://apps.nccd.cdc.gov/uscs/toptencancers.aspx

CHAPTER 8Section 8.4 Cancer

Health Care in Action: Healthy People 2020 Objectives for the Topic Area of Cancer

C–1: Reduce the overall cancer death rate.

Target: 160.6 deaths per 100,000 population.

Baseline: 178.4 cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–2: Reduce the lung cancer death rate.

Target: 45.5 deaths per 100,000 population.

Baseline: 50.6 lung cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–3: Reduce the female breast cancer death rate.

Target: 20.6 deaths per 100,000 females.

Baseline: 22.9 female breast cancer deaths per 100,000 females occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–4: Reduce the death rate from cancer of the uterine cervix.

Target: 2.2 deaths per 100,000 females.

Baseline: 2.4 uterine cervix cancer deaths per 100,000 females occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–5: Reduce the colorectal cancer death rate.

Target: 14.5 deaths per 100,000 population.

Baseline: 17.0 colorectal cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

(continued)

Healthy People 2020 Objectives for Cancer

Healthy People 2020 has established 20 objectives for the topic area of cancer. The goal of Healthy People 2020 for cancer is to “[r]educe the number of new cancer cases, as well as the illness, disability, and death caused by cancer” (USDHHS, n.d.a, para. 1). Health Care in Action: Healthy People 2020 Objectives for the Topic Area of Cancer shows the first eight objectives for cancer mortality.

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CHAPTER 8Section 8.4 Cancer

Health Care in Action: Healthy People 2020 Objectives for the Topic Area of Cancer (continued)

C–6: Reduce the oropharyngeal cancer death rate.

Target: 2.3 deaths per 100,000 population.

Baseline: 2.5 oropharyngeal cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–7: Reduce the prostate cancer death rate.

Target: 21.2 deaths per 100,000 males.

Baseline: 23.5 prostate cancer deaths per 100,000 males occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

C–8: Reduce the melanoma cancer death rate.

Target: 2.4 deaths per 100,000 population.

Baseline: 2.7 melanoma cancer deaths per 100,000 population occurred in 2007 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

Source: (USDHHS, n.d.,b, para. 1) Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=21

Five-Year Cancer Survival

The percentage of persons surviving for 5 years following a diagnosis of cancer varies according to cancer site and race. Figure 8.9 shows the 5-year relative survival for cancer sites among White and Black patients. Among White patients, cancer diagnoses with 90% or higher 5-year survival are prostate cancer, thyroid cancer, testis cancer, melanoma of the skin, and female breast cancer. Among Black patients, 5-year relative survival percent- ages for cancer are lower than among White patients; among Blacks, 5-year survival rates are greater than 90% only for prostate cancer and thyroid cancer.

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http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=21

CHAPTER 8Section 8.4 Cancer

Figure 8.9: Five-year cancer survival (percent), both sexes, by race and cancer site, 2002–2008

Source: National Cancer Institute. SEER cancer statistics review, 1975-2009.

Health disparities are common between races, especially the comparison of Whites to Blacks. A review of this chart clearly depicts this disparity per cancer type. What can public health professionals do to improve the survival rates for Black patients?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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Thyroid

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Cervix Uteri

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Oral Cavity & Pharynx

Larynx

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Myeloma

Brain & ONS

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Esophagus

Lung & Bronchus

Liver & IBD

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Pancreas

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89% 95%

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81% 85%

59% 84%

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49% 74%

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59% 69%

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59% 66%

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42% 63%

54% 61%

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13% 16%

11% 15%

11% 7%

5% 6%

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White Patients

Black Patients

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CHAPTER 8Section 8.4 Cancer

Lung Cancer

Of the various types of cancer, lung cancer causes the greatest number of deaths among both men and women in the United States (CDC, 2011i). In fact, lung cancer is responsible for more deaths than the combined sum caused by breast cancer, prostate cancer, and colon cancer (CDC, 2013i). The age-adjusted rate of death for lung cancer, based on deaths between 2006 and 2010, is 49.5 per 100,000 men and women per year; a tally of 159,480 lung can- cer deaths in the United States is projected for 2013 (National Cancer Institute, n.d.d).

From 2005 to 2009, the age- adjusted lung cancer incidence rate was 62.6 per 100,000 men and women per year. Black men and White women had the highest incidence rates. The age-adjusted death rate for lung cancer was 50.6 per 100,000 per- sons, with the highest death rates among Black men and White women. The median ages of diagnosis and death were 70 years and 72 years, respectively. The 5-year survival for lung cancer depends on the stage in which the cancer is diagnosed. When it is diagnosed in a localized site, the 5-year relative survival is about 50% (National Cancer Institute, n.d.d).

For both men and women, lung cancer incidence is elevated in the southern states, as illustrated by Figure 8.10, which presents information on lung cancer incidence according to sex and U.S. Census region. The CDC states that “[n]early half of states with higher smoking prevalence for women and more than a third of states with higher lung cancer incidence [for all persons] are in the South” (Henley, Eheman, Richardson, & Plescia, 2011, p. 1244). The primary cause of lung cancer in the United States is cigarette smoking, which is believed to be responsible for about 90% of lung cancer cases in men and 80% in women (CDC, 2013i). Figure 8.10 demonstrates that in comparison with other U.S. regions, lung cancer incidence is declining most rapidly in the western states. This phenomenon reflects a lower prevalence of smoking and higher smoking quit rates in the western states.

iStockphoto/Thinkstock

Lung cancer rates are higher in the Southern United States, as smoking tends to be more prevalent in these states.

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CHAPTER 8Section 8.4 Cancer

Figure 8.10: Lung cancer incidence per 100,000 persons by sex and U.S. Census region, United States, 1999–2008

Source: CDC. MMWR. 2011; 60(36) p. 1244.

Lung cancer causes the greatest number of deaths among both men and women in the United States. Looking at this graph, men residing in the South have the highest incidence of lung cancer. It appears that women have nearly an equal incidence rate regardless of geographic region. What could be the possible cause for such a gender disparity? Why would southern men have a significantly higher inci- dence rate of lung cancer than their female counterparts?

Breast Cancer

Breast cancer is defined as

a cancer that starts in the tissues of the breast. There are two main types of breast cancer: ductile carcinoma [, which] starts in the tubes (ducts) that move milk from the breast and nipple. Most breast cancers are of this type. Lobular carcinoma starts in parts of the breast, called lobules, that [sic] produce milk. (United States National Library of Medicine, 2012, para. 1)

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CHAPTER 8Section 8.4 Cancer

Breast cancer among men is a rare occurrence (National Cancer Institute, n.d.a). In 2012, the estimated incidence and number of deaths among females were 226,870 and 39,510, respectively.

Breast cancer incidence increases with age and then declines after age 75 (National Cancer Institute, n.d.b). From 2005 to 2009, about one-fifth of the diagnosed breast cancer patients were between the ages of 35 and 44, one-fifth were 45 through 54, and another one-fifth were 55 through 64. About 15% and 6% of breast cancer patients were between the ages of 75 and 84 and 85 years of age and older, respectively. Other information regarding breast cancer incidence and mortality is as follows:

• Age-adjusted incidence rate: 124.3 per 100,000 women per year • Median age at diagnosis: 61 years • Age-adjusted mortality rate: 23.0 per 100,000 women per year • Median age at death: 68 years • Highest incidence: White women; lowest incidence: American Indian/Alaska

native women • Highest death rate: Black women; lowest death rate: Asian/Pacific Islander

women.

Colorectal Cancer

According to 2012 data from the Surveillance Epidemiology and End Results (SEER) pro- gram, the incidence of cancer of the colon and rectum was about 143,000 cases (almost equally divided among men and women) in that year. The prevalence, defined as the number of persons alive with cancer of the colon and rectum, was 1.1 million cases on January 1, 2009 (National Cancer Institute, n.d.c).

Mortality from colorectal cancer, approximately 52,000 deaths in 2012, increased with age. The median age at death was 74 years. Regarding the age distribution of deaths from 2005 to 2009, the greatest percentage of deaths—nearly one-third—was for persons between the ages of 75 and 84 years. For all racial/ethnic groups in the United States, the annual incidence of colorectal cancer from 2005 to 2009 was 54.0 per 100,000 men and 40.2 per 100,000 women. Among both men and women, the highest incidence was among Blacks (see Table 8.3). If diagnosed before it has spread, colorectal cancer has a high survival rate. When localized to a primary site, colorectal cancer has a 5-year relative survival percent- age of almost 90%.

Table 8.3: Incidence rates of colorectal cancer by race, 2005–2009 Race/Ethnicity Male Female

All Races 54.0 per 100,000 men 40.2 per 100,000 women

White 53.1 per 100,000 men 39.2 per 100,000 women

Black 66.9 per 100,000 men 50.3 per 100,000 women

Asian/Pacific Islander 44.9 per 100,000 men 34.2 per 100,000 women

American Indian/Alaska Native 45.2 per 100,000 men 38.0 per 100,000 women

Hispanic 45.2 per 100,000 men 31.5 per 100,000 women

Source: National Cancer Institute. (n.d.c); Surveillance Epidemiology and End Results. Cancer of the colon and rectum. Retrieved February 16, 2013 from http://seer.cancer.gov/statfacts/html/colorect.html

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http://seer.cancer.gov/statfacts/html/colorect.html

CHAPTER 8Section 8.4 Cancer

Prostate Cancer

The CDC states that

[n]ot counting some forms of skin cancer, prostate cancer is the most com- mon cancer in American men, and second only to lung cancer in the num- ber of cancer deaths. Every year, more than 200,000 men are diagnosed with prostate cancer and more than 25,000 men die from it. (2013k , para. 2)

The lifetime prevalence of prostate cancer was estimated to be 2.5 million men on January 1, 2009.

The prostate-specific antigen (PSA) test is used to screen for prostate cancer. At the writing of this text, the United States Preventive Services Task Force recommends against screen- ing with the PSA screening test because the risks of the screening procedure are believed to outweigh the benefits. The benefits of screening can include early detection with more effective treatment. However, these benefits are exceeded by the PSA test’s risks, which include false positive results, side effects of prostate cancer treatment, and unnecessary treatment of prostate cancers that are not significant for health.

Incidence of prostate cancer is associated with age and race (National Cancer Institute, n.d.e). The incidence of prostate cancer increases with increasing age until the age group of 75 years and older. From 2005 to 2009, approximately one-third of men diagnosed with prostate cancer were between the ages of 55 and 64 years and one-third between the ages of 65 and 74 years. Then the incidence declined to slightly fewer than 20% between the ages of 75 and 84 years and even lower (less than 4%) among persons 85 years of age and older. The median age of diagnosis was 67 years. Using data collected from 2007 to 2009, statisticians estimate that the lifetime risk of a man developing prostate cancer is approxi- mately one in six.

From 2005 to 2009, the age-adjusted incidence rate of prostate cancer was 154.8 per 100,000 men; the age-adjusted death rate was 23.6 per 100,000 men (refer to Table 8.4). Of the five racial/ethnic groups shown in Table 8.4, Blacks had the highest incidence of prostate can- cer, followed by Whites and Hispanics. Also, Blacks had the highest mortality rate from prostate cancer.

Survival rates from prostate cancer are high. Data from the National Cancer Institute’s SEER demonstrated that “[t]he overall five-year relative survival for 2002–2008 from 18 SEER geographic areas was 99.2%. Five-year relative survival by race was: 99.6% for white men; 96.2% for black men” (National Cancer Institute, n.d.e).

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CHAPTER 8Section 8.5 Diabetes

Table 8.4: Incidence and mortality rates of prostate cancer by race

Race/Ethnicity Incidence Mortality

All Races 154.8 per 100,000 men 23.6 per 100,000 men

White 146.9 per 100,000 men 21.7 per 100,000 men

Black 236.0 per 100,000 men 53.1 per 100,000 men

Asian/Pacific Islander 85.4 per 100,000 men 10.0 per 100,000 men

American Indian/Alaska Native 78.4 per 100,000 men 19.7 per 100,000 men

Hispanic 125.9 per 100,000 men 17.8 per 100,000 men

Source: National Cancer Institute. (n.d.e). Surveillance Epidemiology and End Results. SEER stat fact sheets: Prostate cancer. Retrieved February 16, 2013 from http://seer.cancer.gov/statfacts/html/prost.html

8.5 Diabetes Diabetes is a prevalent chronic disease that affects 347 million people in the world (WHO, 2013b). About 3.4 million people globally died from the effects of high blood sugar in 2004. Estimates suggest that from 2008 to 2030, deaths from diabetes will increase by two- thirds. In the United States, diabetes affects about one-twelfth of the population and is the seventh leading cause of death. See Spotlight: 2010 U.S. Fast Facts on Diabetes Among Persons of All Ages for more facts on diabetes in the United States.

Spotlight: 2010 U.S. Fast Facts on Diabetes Among Persons of All Ages

• Diabetes is the seventh leading cause of death in the United States.

• Diabetes affects 25.8 million people—8.3% of the U.S. population.

• A total of 18.8 million people have been diag- nosed with diabetes, and 7.0 million people are undiagnosed.

• Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States.

• Diabetes is a major cause of heart disease and stroke.

Source: Adapted from Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation. (2011e). National diabetes fact sheet.

BELMONTE/BSIP/SuperStock

Not only is diabetes dangerous on its own, but it can also cause blindness and lead to heart disease or amputations.

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http://seer.cancer.gov/statfacts/html/prost.html

CHAPTER 8Section 8.5 Diabetes

Description of Diabetes

Diabetes is a group of diseases associated with high blood glucose levels related to defi- ciencies in the production of insulin and the action of insulin. At present diabetes is incur- able but can be controlled by medications, diet, and exercise.

The three common forms of diabetes—type 1, type 2, and gestational diabetes—are defined below. Prediabetes refers to elevated blood glucose levels (and other indices) that are not sufficiently high to be classified as diabetes but increase the future risk of diabetes and cardiovascular diseases.

• Type 1 diabetes was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. Type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose. To survive, people with type 1 diabetes must have insulin deliv- ered by injection or a pump. This form of diabetes usually strikes children and young adults, although disease onset can occur at any age. In adults, type 1 diabetes accounts for approximately 5% of all diagnosed cases of diabetes. Risk factors for type 1 diabetes may be auto- immune, genetic, or environmental.

• Type 2 diabetes was previously called non-insulin-dependent diabetes mel- litus (NIDDM) or adult-onset diabetes. In adults, type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity.

• Gestational diabetes is a form of glucose intolerance [that affects women] . . . during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes. (CDC, 2011e, p. 11)

CDC/Amanda Mills

At present, diabetes is an incurable disease, but it can be controlled with diet, exercise, and medications.

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CHAPTER 8Section 8.5 Diabetes

Epidemiology of Diabetes

The prevalence of diabetes (percentage and total number of cases) has demonstrated an increasing trend over the past half century (CDC, n.d.c). Between 1958 and 2010, the per- centage of persons with diabetes in the United States increased from slightly less than 1% to more than 8% (according to some estimates) in 2010. Figure 8.11 shows time trends in the prevalence of diagnosed diabetes between 1958 and 2010. About 1.9 million Ameri- cans aged 20 years or older were newly diagnosed with diabetes in 2010 (CDC, 2012b).

Figure 8.11: Number and percentage of U.S. population with diagnosed diabetes, 1958–2010

Source: CDC. Division of diabetes translation. National diabetes Surveillance System. Long-term trends in diagnosed diabetes, October 2011. Retrieved from http://www.cdc.gov/diabetes/statistics.

The prevalence of diabetes has risen steadily from the middle to the end of the 20th century, yet it has sharply increased since 2000. What factors have contributed to this incline? Why has the disease rapidly increased over the last 10 years versus its slower ascent prior to 2000?

The prevalence of diabetes varies by race/ethnicity and increases with age. In 2010, the prevalence of diabetes was highest among American Indians and Alaska natives (16.3%) in comparison with Whites (8.2%), Blacks (12.9%), Asians (9.1%), and Hispanics/Latinos (13.2%), who had the second highest prevalence among the five groups (CDC, 2012h, 2013b). With respect to the association of age with diabetes, the prevalence of both diag- nosed and undiagnosed diabetes increased by age group. For example, the prevalence of diabetes according to 2005 through 2008 estimates was:

• about 0.26% (215,000 cases) among persons younger than 20 years of age, for both (type 1 and type 2 diabetes) in 2010;

• 3.7% among persons aged 20 to 44 years;

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http://www.cdc.gov/diabetes/statistics

CHAPTER 8Section 8.6 Chronic Obstructive Pulmonary Disease

• 13.7% among persons aged 45 to 64 years; and • 26.9% (10.9 million cases) among persons who were 65 years of age and older.

8.6 Chronic Obstructive Pulmonary Disease Worldwide, chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality and a growing pub- lic health problem. COPD, which refers to diseases characterized by airflow obstruction, affected approximately 64 million people globally in 2004 and was the cause of 3 million deaths in 2005 (about 5% of all deaths in the world) (WHO, 2012).

In 2009, COPD (also called chronic lower respiratory disease [CLRD]) was the third leading cause of mortality in the United States and the cause of more than 137,000 deaths. The economic costs of

COPD for the American society are high, resulting in medical expenditures of about $6,000 annually for each person affected by COPD. Data indicate that about 12 million Americans have been diagnosed with COPD. In addition, estimates suggest that at least this number of persons are affected with COPD but have not yet been diagnosed (CDC, 2011h).

Definition

The coding category “chronic obstructive pulmonary diseases,” which was changed to “chronic lower respiratory diseases” in the Tenth Revision of the International Classifica- tion of Diseases (ICD-10), was applied to the classification of deaths that occurred after 1999 (Anderson, Miniño, Hoyert, & Rosenberg, 2001). CLRD is a category that includes chronic bronchitis, emphysema, asthma, and several other lower respiratory conditions (American Lung Association, 2011). COPD includes chronic bronchitis and emphysema (United States National Library of Medicine, 2011) and is a “heterogeneous group of slowly progressive diseases characterized by airflow obstruction that interferes with nor- mal breathing” (Brown, Croft, Greenlund, & Giles, 2008, p. 1229). COPD can be a life- threatening condition, is among the leading causes of death in the United States, and is expected to become the third leading cause of death globally by 2030.

The symptoms of COPD include cough (productive or nonproductive of mucus), breath- ing difficulties and shortness of breath, tiredness, wheezing, and proneness to respiratory infections. Fortunately, COPD is a treatable condition for which early diagnosis should be sought.

Ton Koene/age fotostock/SuperStock

A significant proportion (15%) of COPD cases can be linked to occupational exposures like breathing in certain gases.

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CHAPTER 8Section 8.6 Chronic Obstructive Pulmonary Disease

Mortality

Death rates from COPD are higher among men than among women and higher among Whites than among Blacks and other racial and ethnic groups. In the United States during 2005, COPD was the underlying cause of about 1 in 20 deaths. Between 1980 and 2000, COPD mortality rates increased for both men and women. From 2000 to 2005, mortality from this cause tended to remain stable. Figure 8.12 presents age-standardized death rates by sex from COPD from 2000 to 2005. During this period, death rates were higher among men than among women.

Figure 8.12: Age-standardized death rate from chronic obstructive pulmonary disease among adults aged 25 years and older, by sex, United States, 2000–2005

Source: CDC. Deaths from chronic obstructive pulmonary disease-United States, 2000–2005. MMWR. 2008; 57 (45): p. 1230.

COPD was the underlying cause of 1 in 20 deaths in 2005. Prior to that year, what trends do you see in the death rates from COPD? What was the turning point after 2004 that caused the slope to rise again?

Causes/Risk Factors

Smoking is the leading cause of COPD and accounts for about three-quarters of the cases. Other causes of COPD are the following:

• Occupational exposures (e.g., to certain gases and fumes in the work environ- ment), which cause about 15% of cases of COPD

• Secondhand cigarette smoke exposure • High levels of outdoor air pollution • Unventilated indoor cooking fires

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CHAPTER 8Section 8.7 Arthritis

• Frequent lower respiratory infections during childhood • Possible influence of genetic factors.

8.7 Arthritis The term arthritis refers to joint inflammation, which often involves pain and stiffness in or around the joints of the body. In the public health field, arthritis is used “to describe more than 100 rheumatic diseases and conditions that affect joints, the tissues which sur- round joints and other connective tissue” (CDC, 2011b, para. 1). Some of the common types of arthritis are childhood arthritis, fibromyalgia, gout, osteoarthritis, rheumatoid arthritis, and systematic lupus erythematosus (CDC, 2011c).

Arthritis is an extensive and increas ing public health prob- lem in this country (Cheng, Hootman, Murphy, Langmaid, & Helmick, 2010). Arthritis (that is, self-reported doctor-diagnosed arthritis) is a very common dis- ease that affects slightly more than one-fifth of adults in the United States. In addition, esti- mates indicate that almost 300,000 children under the age of 18 have arthritis. The most com- mon cause of disability in this country, arthritis causes activ- ity limitations among one-tenth of the U.S. population. In 2003, the medical costs associated with arthritis totaled $128 billion (CDC, 2011a, 2011d).

Prevalence of Arthritis

The prevalence of arthritis varies by age, gender, race/ethnicity, and several other impor- tant characteristics (CDC, 2011d). From 2007 to 2009, the prevalence data were as follows:

• Age—arthritis was more common among older adults than among younger adults and increased with age. For persons aged 18 to 44 years, 45 to 64 years, and 65 years and older, the prevalence of arthritis was 7.6%, 29.8%, and 50.0%, respectively.

• Gender—the prevalence of arthritis was higher among men than among women: 25.9% versus 18.3%.

• Race/ethnicity—the prevalence among non-Hispanic Whites (22.3%), Blacks (21.8%), and American Indian/Alaska natives (28.6%) exceeded the prevalence among Hispanics (15.6%) and Asian/Pacific Islanders (10.6%).

AbleStock.com/Thinkstock

Physical and occupational therapy can help those suffering from arthritis to carry out daily activities.

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CHAPTER 8Section 8.7 Arthritis

• Obesity—obese and overweight persons had a higher prevalence than people who were of normal weight; the prevalence of arthritis among obese persons (about 30%) was nearly twice the prevalence among persons of normal weight (about 17%).

• Physical inactivity was associated with arthritis. • Education—lower-educated persons were affected more frequently by arthritis

than higher-educated individuals. • Smoking—arthritis was more common among current or former smokers than

among persons who had never smoked.

Time Trends in the Future Prevalence of Arthritis

In future decades, with the numbers of elderly persons in the population increasing, the prevalence of arthritis is expected to increase correspondingly. As illustrated by Figure 8.13, the CDC predicts that one-quarter of the U.S. population will have doctor-diagnosed arthritis by the year 2030 (2010b). Also, the prevalence of arthritis-attributable activity limitation is projected to increase.

Figure 8.13: Projected prevalence of doctor-diagnosed arthritis among U.S. adults ages 18 years and older, 2005–2030

Source: CDC. NHIS arthritis surveillance. Retrieved from http://www.cdc.gov/arthritis/data_statistics/national_nhis.htm

The Centers for Disease Control and Prevention predicts that 25% of the U.S. population will have doctor-diagnosed arthritis by 2030. By looking at the projected rates in this chart, what can you deduce about the illness?

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Women

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http://www.cdc.gov/arthritis/data_statistics/national_nhis.htm

CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

8.8 Behavioral Risk Factors for Chronic Diseases As was noted in the introduction, four common risk factors that are dimensions of lifestyle and behavior have some degree of association with all of the chronic diseases discussed in the present chapter (CDC, 2012e). Known as modifiable behavioral risk factors, they include cigarette smoking, excessive alcohol consumption, sedentary lifestyle, and diet. In the CDC’s influential report, the organization stated that tobacco, poor diet and physi- cal inactivity, and alcohol consumption accounted for 18.1%, 15.2%, and 3.5% of deaths in 2000, respectively (CDC, 2012e). Other leading behavioral risk factors cited in the report were exposures to microbial and toxic agents, motor vehicle crashes, firearm-associated violence, risky sexual behavior, and illicit drug use (CDC, 2012e). Despite the fact that chronic diseases are highly preventable, a substantial number of Americans exhibit behav- iors that place them at risk of chronic diseases. Figure 8.14 shows the prevalence of adults who had at least one of three modifiable risk factors for chronic disease—smoking, uncon- trolled hypertension, and uncontrolled high levels of cholesterol—between 1999 and 2008. The percentage was over 50% (about 107.3 million Americans) in 2008. For other examples of Americans’ status with respect to risk factors see Spotlight: Risk Behaviors: The Facts.

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Figure 8.14: Age-standardized prevalence* and estimated number of adults aged ≥20 years† who currently smoke,§ or have uncontrolled hypertension,¶ or have uncontrolled high levels of cholesterol**—National Health and Nutrition Examination Survey, United States, 1999–2008

* Weighted prevalence estimates, directly standardized to the 2000 U.S. standard population, based on the following age groups: 20–39, 40–59, and ≥60 years. † Numbers were calculated using Current Population Survey data and weighted, unstandardized prevalence estimates. Additional information available at http://www.cdc.gov/nchs/tutorials/nhanes/faqs.htm. § Defined as 1) a “Yes” response to the question, “Have you smoked at least 100 cigarettes in your entire life?” plus a response of “Every day” or “Some days” to the question, “Do you now smoke cigarettes . . . ?” or 2) a measured serum cotinine level of >10 ng/mL. ¶ Average systolic blood pressure ≥140 mm Hg or average diastolic pressure ≥90 mm Hg. ** Low-density lipoprotein cholesterol (LDL-C) level above the treatment goals established by the National Cholesterol Education Program Adult Treatment Panel-III guidelines: <160 mg/dL, <130 mg/dL, and <100 mg/dL for low-, intermediate-, and high-risk groups, respectively. †† 95% confidence interval. §§ Linear trend in prevalence shows significant decline (p<0.01) from 1999–2000 to 2007–2008 after adjustment for sex, age group, race/ethnicity, and poverty-income ratio. Source: CDC. Million hearts: strategies to reduce the prevalence of leading cardiovascular disease risk factors-United States, 2011. MMWR. 2011; 60(36):1249.

Although chronic diseases are preventable, millions of Americans still partake in at least one of three risk factors for chronic disease. The linear trend line shows a decline; yet chronic disease remains among the largest concerns of public health. What can community and public health professionals do to pro- mote healthier behaviors to prevent chronic disease?

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Spotlight: Risk Behaviors: The Facts

• More than 43 million (about 1 in 5) U.S. adults smoke. • About 1 in 5 U.S. high school students are current smokers. • More than one-third of all U.S. adults fail to meet minimum recommendations for aerobic

physical activity. In an analysis of a CDC 2011 survey of nearly half a million Americans, 20% were getting at least 150 minutes of moderate, or at least 75 minutes of vigorous, aerobic activity a week, as well as doing muscle-strengthening exercises at least twice a week. Those cardio-plus-strength guidelines were set by the CDC in 2008.

• Only 1 in 3 U.S. high school students participate in daily physical education classes. • More than 60% of U.S. children and adolescents eat more than the recommended daily

amounts of saturated fat. • Only 24% of U.S. adults and 20% of U.S. high school students eat five or more servings of

fruits and vegetables per day. • About 1 in 6 Americans aged 18 years and older engaged in binge drinking (5 or more drinks

for men and 4 or more drinks for women during a single occasion) in the past 30 days. • Nearly 45% of U.S. high school students reported having had at least one drink of alcohol in

the past 30 days.

Source: Adapted from Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. (2009b). Chronic diseases: The power to prevent, the call to control. At a Glance (p. 2).

Tobacco Use

The World Health Organization states that “[t]obacco use is the leading cause of prevent- able death. It kills nearly 6 million people and causes hundreds of billions of dollars of economic damage worldwide each year” (2011, p. 8). The number of deaths from tobacco- related causes is projected to climb to 8 million annually by the year 2030 (CDC, 2013e). Smokers die up to 14 years sooner than nonsmokers (refer to Figure 8.15). Also, nonsmok- ers’ exposure to secondhand cigarette smoke increases their risk of lung cancer and other adverse health outcomes. In the United States, approximately 443,000 deaths were attrib- utable to cigarette smoking each year between 2000 and 2004 (CDC, 2012c). Other deaths associated with smoking-related causes include those due to lung cancer, ischemic heart disease, and COPD.

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Figure 8.15: Annual deaths attributable to cigarette smoking, United States, 2000–2004

Adapted from: CDC. Smoking and Tobacco Use. Retrieved from http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/

Smokers die up to 14 years sooner than nonsmokers. How many years of life could have been saved if just one-quarter of the 443,000 people represented in this chart had quit smoking? What about half of them? All of them?

Prevalence of Cigarette Smoking According 2009 data from WHO, more than half of males 15 years of age and older in the WHO Western Pacific Region (a vast area composed of 37 countries including Cambodia, China, and Japan) smoked some form of tobacco (n.d.b). The WHO European Region had the highest percentage of women who smoked: 22%. With the exception of the European Region, a higher percentage of girls between the ages of 13 and 15 years used tobacco than females 15 years of age and older.

The prevalence of smoking among American adults was 19.0% in 2010 and varied by racial/ethnic group (CDC, 2013c). The prevalence was highest among non-Hispanic American Indians/Alaska natives (31.5%) and lowest among Asian Americans (9.9%).

About 443,000 U.S. Deaths Attributable Each Year to Cigarette Smoking*

*Average annual number of deaths 2000–2004

Lung Cancer 128,900 (29%)

Ischemic Heart Disease 126,000 (28%)

Chronic Obstructive Pulmonary Disease

92,900 (21%)

Other Diagnoses

44,000 (10%)

Stroke 15,900 (4%)

Other Cancers 35,300 (8%)

iStockphoto/Thinkstock

Tobacco takes on many forms. As the leading factor related to preventable death, tobacco is harmful in any form.

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Policy interventions to control tobacco use have led to lower smoking rates in the United States in comparison with other coun- tries that do not have such policies in place. Examples of successful U.S. policy interventions are high tobacco taxes and smoke-free pub- lic establishments.

Other Forms of Tobacco In addition to cigarettes, tobacco is available in many other forms, and its use is hazardous no matter what kind is used. Also, the use—par- ticularly by youth—of other forms of tobacco such as chewing tobacco

can be associated with the uptake of smoking. The following list describes some other types of tobacco products.

• Hookahs (called water pipes) are used to smoke flavored tobacco (CDC, 2013h). • Cigars are a roll of tobacco wrapped in leaf tobacco (CDC, 2013a).

• Bidis are thin, small hand-rolled cigarettes; kreteks are sometimes referred to as clove cigarettes (CDC, 2012d).

• Gutka is a combination of betel quid and tobacco. Betel quid is composed of betel leaf, areca nut, and slaked lime (CDC, 2013l).

Youth Tobacco Use Tobacco use becomes established during youth, particularly before 18 years of age. The CDC states that “[t]obacco use during adolescence is associated with . . . health risk behav- iors [such as] [h]igh risk sexual behavior[,] . . . use of alcohol[,] . . . and use of other drugs” (2013m). Causes of youth tobacco use include low self-esteem, inability to resist influences to initiate tobacco use, and peer-group approval and use. In 2009, approximately 20% of high school students and 5% of middle school students had smoked one or more ciga- rettes in the previous month.

Alcohol Consumption

Alcohol use was linked with an annual average of 80,374 alcohol-attributable deaths between 2001 and 2005 in the United States (CDC, n.d.b). Table 8.5 presents data on selected chronic and acute causes of alcohol-attributable deaths, including liver disease, cardiovas- cular disease, and stroke. Somewhat more of these deaths were due to acute causes than to chronic causes. Examples of chronic causes were alcoholic liver disease (12,219 deaths), liver cirrhosis (7,055 deaths), and cardiovascular effects such as stroke (1,847) and hyper- tension (1,544). One of the most frequent acute causes of alcohol-attributable death was motor-vehicle traffic crashes, which accounted for over 13,000 cases.

Figure 8.15: Annual deaths attributable to cigarette smoking, United States, 2000–2004

Adapted from: CDC. Smoking and Tobacco Use. Retrieved from http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/

About 443,000 U.S. Deaths Attributable Each Year to Cigarette Smoking*

*Average annual number of deaths 2000–2004

Lung Cancer 128,900 (29%)

Ischemic Heart Disease 126,000 (28%)

Chronic Obstructive Pulmonary Disease

92,900 (21%)

Other Diagnoses

44,000 (10%)

Stroke 15,900 (4%)

Other Cancers 35,300 (8%)

iStockphoto/Thinkstock

Tobacco takes on many forms. As the leading factor related to preventable death, tobacco is harmful in any form.

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Other health effects risks associ- ated with excessive alcohol use are adverse neurological out- comes such as dementia, and negative social consequences such as social dysfunction and family discord (CDC, n.d.a). Excessive alcohol consumption increases the possibility of risky sexual behavior, child abuse, and family violence (CDC, 2012f). Other issues related to excessive alcohol use are the enormous costs incurred for treatment of injuries and dis- eases causes by drinking to excess (CDC, 2011f); the popu- larity of alcohol as the drug of choice for abuse among under- age drinkers (CDC, 2012g); the growing phenomenon of binge drinking (CDC, 2012J); and the increasing availability of potent caffeinated alcoholic beverages (CDC, 2010a). Underage drinking and excessive drinking among college students are serious public health issues for institutions of higher education (NIAAA, n.d.). Alcohol consumption by pregnant women can harm the fetus— for example, by causing the fetal alcohol spectrum disorders (CDC, 2013d).

Table 8.5: Alcohol-attributable deaths (average number per year) due to excessive alcohol use, all ages, United States, 2001–2005

Cause Overall Males Females

Chronic causes 36,643 25,693 10,950

Acute causes 43,731 32,159 11,572

Total for All Causes 80,374 57,852 22,522

Chronic Causes

Liver Disease

Alcoholic liver disease 12,219 8,938 3,281

Liver cirrhosis, unspecified 7,055 4,134 2,921

Total 19,274 13,072 6,202

Cardiovascular Disease

Alcohol cardiomyopathy 448 389 59

Hypertension 1,544 836 708

Stroke, hemorrhagic 1,847 1,520 327

Stroke, ischemic 715 519 196

Total 4,554 3,264 1,290

Binge drinking and mixing energy drinks with alcoholic beverages is a growing health concern on America’s college campuses.

(continued)

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Cause Overall Males Females

Cancer

Breast cancer (females only) 417 0 417

Esophageal cancer 525 466 59

Laryngeal cancer 267 231 35

Liver cancer 893 671 222

Oropharyngeal cancer 406 345 61

Prostate cancer (males only) 241 241 0

Total 2,749 1,954 794

Acute Causes

Drowning 868 716 152

Fall injuries 5,532 2,888 2,644

Fire injuries 1,158 692 466

Homicide 7,787 6,174 1,613

Motor-vehicle traffic crashes 13,819 10,802 3,016

Poisoning (not alcohol) 5,416 3,669 1,747

Suicide 7,235 5,778 1,457

Total 41,815 30,719 11,095

Source: Centers for Disease Control and Prevention. (2012a). Alcohol Related Disease Impact (ARDI) application. Retrieved from http://apps.nccd.cdc.gov/DACH_ARDI/default/default.aspx

Sedentary Lifestyle

Sedentary lifestyle (being physically inac- tive) is one of the major risk factors for chronic diseases, including obesity and a range of other adverse health outcomes. The 1996 report of the Surgeon General titled Physical Activity and Health states that “[p]hysical inactivity is a serious, nation- wide problem. Its scope poses a public health challenge for reducing the national burden of unnecessary illness and pre- mature death” (USDHHS, 1996, para. 3). Among children, in particular, excessive amounts of screen time (watching TV and playing games on a computer) reduce physical activity levels.

Tetra Images/SuperStock

Americans spend large amounts of time being inactive, in part due to the demands of their jobs.

Table 8.5: Alcohol-attributable deaths (average number per year) due to excessive alcohol use, all ages, United States, 2001–2005 (continued)

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

In addition to lowering the risk of death from the major chronic diseases, the health ben- efits of regular physical activity include the following (CDC, 2011j):

• Controlling weight • Reducing the risk of cardiovascular disease and type 2 diabetes • Reducing the risk of some forms of cancer (e.g., colon cancer and female breast

cancer) • Reducing blood pressure among persons who have hypertension • Strengthening bones and muscles • Preventing falls among older persons.

According to data from the CDC, for 2010, “50% of adults 18 years of age and over met neither the aerobic activity nor the muscle-strengthening physical activity federal guide- lines. This percentage increased with age, rising from 39% of adults 18–24 years of age to 70% of adults 75 years and over” (National Center for Health Statistics, 2012). In 2010, the percentage of women who did not meet guidelines for physical activity was higher than the percentage of men; among racial and ethnic groups, the category of Hispanic or Latino was the group with the highest percentage of persons who did not meet guidelines; with respect to level of education, the percentage was highest among persons without a high school diploma. Table 8.6 gives data on physical activity levels of Americans for four time periods between 1998 and 2010.

Table 8.6: Selected characteristics (percent) of adults not meeting both of the 2008 federal Physical Activity Guidelines for aerobic activity and muscle strengthening

Characteristic 1998 2000 2009 2010

18–44 50.7 49.1 43.6 43.1

45–64 58.8 57.6 51.8 51.0

65+ 71.0 67.0 62.2 64.6

Male 50.8 49.6 45.0 43.8

Female 61.9 59.4 53.2 54.0

Hispanic or Latino 67.7 66.5 59.0 60.2

Non-Hispanic White 53.6 51.4 45.6 45.0

Non-Hispanic Black 65.8 64.6 56.5 58.4

No high school diploma 76.3 74.0 69.1 69.8

High school diploma 64.6 61.7 59.6 59.0

Some college or more 48.0 47.1 42.1 42.1

Source: National Center for Health Statistics. (2012). Health, United States, 2011: With special feature on socioeconomic status and health (p. 252). Hyattsville, MD: Author.

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CHAPTER 8Section 8.8 Behavioral Risk Factors for Chronic Diseases

Dietary Factors

The USDA emphasizes the functions of dietary choices and physical activity in maintain- ing a healthy weight, minimizing the risk of chronic disease, and general health promo- tion (2010). A balanced and nutritious diet lowers the risk of chronic disease and helps to prevent a variety of adverse health conditions—for example, obesity, dental problems, constipation, heart disease, type 2 diabetes, hypertension, osteoporosis, and anemia. The Healthy People 2020 goal for nutrition and weight status is to “[p]romote health and reduce chronic disease risk through the consumption of healthful diets and achievement and mainte- nance of healthy body weights” (Healthypeople.gov, n.d. para. 1). In order to develop a healthy weight, one needs to couple adequate exercise levels with a good diet—for most people, either one by itself is not suffi- cient for maintaining a healthy body weight.

Consumers who eat meals in restaurants frequently and pur- chase prepared meals from gro- cery stores are contributing to an unhealthful diet if the meals that they select are high in satu- rated fats and other undesirable nutritional components. Many of the snack foods such as chips and sodas available in con- venience stores located in inner cities, where alternative sources of groceries may not be available, contain excessive amounts of saturated fats, sodium, and sugar. A high-fat diet can contribute to a condition known as dyslipidemia (undesirable blood lipid profiles, for example, as in elevated total cholesterol levels). The USDA releases Dietary Guidelines for Americans every 5 years. The recommendations for 2010 focus on one’s balancing caloric intake with caloric expenditure (keeping levels of food intake in line with calories used) and consuming nutrient-dense foods and beverages. Examples of specific recommenda- tions (modified for brevity) from the USDA are the following:

• Reduce intake of sodium • Reduce consumption of saturated fat and cholesterol • Reduce consumption of refined grains, particularly if they contain solid fats

(trans fats), added sugars, and sodium • Increase consumption of fruits and vegetables • Increase consumption of whole grains • Increase consumption of the amount and variety of seafood.

Jeff Greenberg/age fotostock/SuperStock

Nutritional choices tend to be more limited in disadvantaged neighborhoods.

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CHAPTER 8Summary

Summary This chapter described the characteristics and determinants of five major chronic diseases and illustrated the role of lifestyle and personal behaviors in their occurrence. Chronic diseases are the leading causes of morbidity and mortality in the United States. Epidemio- logically significant chronic diseases covered in the chapter are cardiovascular diseases, cancer, diabetes, COPD, and arthritis.

Cardiovascular diseases encompass several conditions that include heart disease, hyper- tension, and stroke. In first and fourth place as leading causes of death in 2009 were heart disease and stroke, which together were responsible for almost a third of deaths annually in the United States. The second leading cause of death in 2009 was cancer in its various forms (e.g., lung cancer, breast cancer, prostate cancer, and colorectal cancer). In 2007, diabetes was the seventh leading cause of death. More than one-quarter of the popula- tion over the age of 65 has diabetes. This potentially devastating condition is associated with neurological damage, amputations, kidney disease, and visual problems. Chronic obstructive pulmonary disease (chronic lower respiratory disease) was the third leading cause of death in 2009. Arthritis, a very prevalent condition, is the leading cause of dis- ability in the United States and is projected to affect one-quarter of U.S. adults by 2030.

Chronic diseases share common and modifiable behavioral risk factors (e.g., tobacco use, alcohol consumption, physical inactivity, and poor diet), which are a function of personal behaviors associated with lifestyle choices. Lifestyle is related to social–environmental influences that originate in the community and is an indirect determinant of community morbidity and mortality patterns.

Study Questions and Exercises

1. State why the chronic diseases are often referred to as diseases of lifestyle and explain your answer.

2. Based on your reading of the material in this chapter, what aspects of your cur- rent lifestyle might put you more or less at risk?

3. Select an issue related to tobacco use, alcohol consumption, or chronic diseases. Identify one community health resource and one website that addresses this issue.

4. Cancer risk is hypothesized to result from a combination of genetic, environmen- tal, and behavioral factors. Gives two examples of behavioral risk factors that may put one at an increased risk of cancer.

5. Go to the Healthy People 2020 (www.healthypeople.gov) website. Find and list at least five objectives related to tobacco use. How would public health interven- tions reduce tobacco use?

6. Research the World Wide Web for five media articles that describe the issue of binge drinking among college students. Summarize these articles in a two-page report, giving the sources of the information.

7. Select one the following governmental health agencies: Centers for Disease Con- trol and Prevention, National Institutes of Health, or the World Health Organiza- tion. Go to the website and find the mission of the agency. Identify one example of a policy or initiative that is currently being proposed to improve the health of a community.

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CHAPTER 8Key Terms

Key Terms

arthritis Joint inflammation, which often involves pain and stiffness in or around the joints of the body. Some of the common types of arthritis are childhood arthritis, fibromyalgia, gout, osteoarthritis, rheu- matoid arthritis, and systematic lupus erythematosus.

cancer A disease in the body where abnor- mal cells divide uncontrollably possibly causing a malignant growth or tumor.

cardiovascular diseases A group of disor- ders of the heart and blood vessels. These include heart diseases and stroke.

chronic obstructive pulmonary disease (COPD) Includes chronic bronchitis and emphysema and is a heterogeneous group of slowly progressive diseases character- ized by airflow obstruction that interferes with normal breathing.

coronary artery disease (CAD) The buildup of plaque in the arteries that supply blood to the heart (called coronary arteries).

diabetes A group of diseases associated with high blood glucose levels related to deficiencies in the production of insulin and the action of insulin. At present dia- betes is incurable but can be controlled by medications, diet, and exercise.

gestational diabetes A form of glucose intolerance that affects women during pregnancy.

heart disease The result of fatty buildup, or plaque, in the arteries of the heart.

hypertension A systolic blood pressure of 140 mmHg or higher, and a diastolic pressure of 90 mmHg or higher (140/90). It is commonly referred to as high blood pressure.

liver disease A disease which reduces, damages, or stops the function of the liver.

plaque Accumulation of (fatty) choles- terol deposits in the arteries.

sedentary lifestyle Being physically inactive. A sedentary lifestyle is one of the major risk factors for chronic diseases, including obesity and a range of other adverse health outcomes.

stroke An event caused by the stoppage of blood flow to the brain.

type 1 diabetes Develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose.

type 2 diabetes Begins as insulin resis- tance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it.

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