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

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

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

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

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

PROBLEM: Chronic diseases (e.g., heart disease, stroke, cancer, and diabetes) are the leading causes of morbidity and mortality in the United States. Engaging in healthy behaviors (e.g., quitting smoking and tobacco use, being more physically active, and eating a nutritious diet) and accessing preventive health-care services (e.g., routine physical checkups, screening for cancer, checking blood pressure, testing blood cholesterol, and receiving recommended vaccinations) can reduce morbidity and mortality from chronic and infectious disease and lower medical costs. Monitoring and evaluating health-risk behaviors and the use of health services is essential to developing intervention programs, promotion strategies, and health policies that address public health at multiple levels, including state, territory, metropolitan and micropolitan statistical area (MMSA), and county. REPORTING PERIOD: January-December 2010. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disabilities in the United States. This report presents results for 2010 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 192 MMSAs, and 302 counties. RESULTS: In 2010, the estimated prevalence of high-risk health behaviors, chronic diseases and conditions, access to health care, and use of preventive health services varied substantially by state and territory, MMSA, and county. In the following summary of results, each set of proportions refers to the range of estimated prevalence for the disease, condition, or behaviors, as reported by survey respondents. Adults reporting good or better health: 67.9%-89.3% for states and territories, 72.2%-92.1% for MMSAs, and 72.8%-95.8% for counties. Adults with health-care coverage: 69.4%-95.7% for states and territories, 45.7%-97.0% for MMSAs, and 45.7%-97.2% for counties. Adults who had a dental visit in the past year: 57.2%-81.7% for states and territories, 47.1%-83.5% for MMSAs, and 47.1%-88.2% for counties. Adults aged ≥65 years having had all their natural teeth extracted (edentulism): 7.4%-36.0% for states and territories, 4.8%-34.8% for MMSAs, and 2.4%-39.3% for counties. A routine physical checkup during the preceding 12 months: 53.8%-80.0% for states and territories, 49.5%-82.6% for MMSAs, and 49.5%-85.3% for counties. Influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 26.9%-73.4% for states and territories, 51.7%-77.1% for MMSAs, and 49.3%-87.8% for counties. Pneumococcal vaccination ever received among adults aged ≥65 years: 24.7%-74.0% for states and territories, 48.6%-79.9% for MMSAs, and 47.6%-83.1% for counties. Sigmoidoscopy or colonoscopy ever received among adults aged ≥50 years: 37.8%-75.7% for states and territories, 37.3%-79.9% for MMSAs, and 37.3%-82.5% for counties. Blood stool test received during the preceding 2 years among adults aged ≥50 years: 8.5%-27.0% for states and territories, 6.7%-51.3% for MMSAs, and 6.8%-57.2% for counties. Women who reported having had a Papanicolaou test during the preceding 3 years: 67.8%-88.9% for states and territories, 63.3%-91.2% for MMSAs, and 63.2%-95.7% for counties. Women aged ≥40 years who had a mammogram during the preceding 2 years: 63.8%-83.6% for states and territories, 60.3%-86.2% for MMSAs, and 59.3%-89.7% for counties. Current cigarette smokers: 5.8%-26.8% for states and territories, 5.8%-28.5% for MMSAs, and 5.9%-29.8% for counties. Binge drinking during the preceding month: 6.6%-21.6% for states and territories, 3.6%-23.0% for MMSAs, and 3.8%-24.0% for counties. Heavy drinking during the preceding month: 2.0%-7.2% for states and territories, 1.0%-10.0% for MMSAs, and 1.0%-14.2% for counties. Adults reporting no leisure-time physical activity: 17.5%-42.3% for states and territories, 13.1%-37.6% for MMSAs, and 8.5%-39.0% for counties. Adults who were overweight: 32.6%-40.7% for states and territories, 28.5%-42.5% for MMSAs, and 27.2%-46.4% for counties. Adults aged ≥20 years who were obese: 22.1%-35.0% for states and territories, 17.1%-42.1% for MMSAs, and 13.3%-42.1% for counties. Adults with current asthma: 5.2%-11.1% for states and territories, 3.4%-14.5% for MMSAs, and 3.3%-14.6% for counties. Adults with diagnosed diabetes: 5.3%-13.2% for states and territories, 4.6%-15.4% for MMSAs, and 2.6%-18.8% for counties. Adults with limited activities because of physical, mental or emotional problems: 10.8%-28.2% for states and territories, 13.5%-38.3% for MMSAs, and 11.7%-32.0% for counties. Adults using special equipment because of any health problem: 2.8%-10.6% for states and territories, 4.5%-15.5% for MMSAs, and 1.3%-15.5% for counties. Adults aged ≥45 years who have had coronary heart disease: 5.3%-16.7% for states and territories, 6.5%-19.6% for MMSAs, and 4.9%-19.6% for counties. Adults aged ≥45 years who have had a stroke: 2.4%-7.1% for states and territories, 2.3%-8.8% for MSMAs, and 1.7%-8.8% for counties. INTERPRETATION: The findings in this report indicate substantial variations in the health-risk behaviors, chronic diseases and conditions, access to health-care services, and the use of the preventive health services among U.S. adults at the state and territory, MMSA, and county levels. Healthy People 2010 (HP 2010) objectives were established to monitor health behaviors, conditions, and the use of preventive health services for the first decade of the 2000s. The findings in this report indicate that many of the HP 2010 objectives were not achieved by 2010. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases, and conditions and of the use of preventive health-care services. PUBLIC HEALTH ACTION: Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health-risk behaviors, chronic diseases, and conditions and to evaluate the use of preventive health-care services. BRFSS data also are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality from chronic conditions and corresponding health-risk behaviors.

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

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

PURPOSE: Physical activity confers multiple health benefits in the general population. This study examined the associations of physical activity with serious psychological distress (SPD) and receipt of mental healthcare services among U.S. adult cancer survivors. METHODS: We analyzed data from 4,797 cancer survivors (aged ≥18 years) and 38,571 adults without cancer who participated in the 2009 Behavioral Risk Factor Surveillance System. SPD was assessed using the Kessler-6 questionnaire. Adjusted prevalence and prevalence ratios were estimated by conducting log-linear regression analysis while controlling for potential confounders. RESULTS: Overall, 6.6 % of cancer survivors (vs. 3.7 % of adults without cancer, P < 0.001) reported having SPD, and 14.0 % of cancer survivors (vs. 10.0 % of adults without cancer, P < 0.001) reported receiving mental healthcare services; the percentages decreased with increasing physical activity levels. After multivariate adjustment, compared to cancer survivors who were physically inactive, cancer survivors who engaged in physical activity >0 to <150 min/week and ≥150 min/week were 62 % and 61 % (P < 0.001 for both) less likely to report SPD, respectively; cancer survivors who engaged in physical activity ≥150 min/week were 33 % (P < 0.05) less likely to report receiving mental healthcare services. Additionally, the inverse association between physical activity and receiving mental healthcare services persisted among women with breast or reproductive cancers and among men and women with gastrointestinal cancers. CONCLUSION: The inverse associations between physical activity and SPD or receiving mental healthcare services suggest that physical activity may play a role in improving mental health among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Healthcare clinicians may consider routinely monitoring and assessing the psychological well-being of cancer survivors and educate them about the potential benefits of physical activity in improving their mental health.

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

Obesity is associated with increased risks for mental disorders. This study examined associations of obesity indicators including body mass index (BMI), waist circumference, and waist-height ratio with suicidal ideation among U.S. women. We analyzed data from 3,732 nonpregnant women aged ≥20 years who participated in the 2005-2008 National Health and Nutrition Examination Survey. We used anthropometric measures of weight, height, and waist circumference to calculate BMI and waist-height ratio. Suicidal ideation was assessed using the Item 9 of the Patient Health Questionnaire-9. Odds ratios with 95% conference intervals were estimated using logistic regression analyses after controlling for potential confounders. The age-adjusted prevalence of suicidal ideation was 3.0%; the prevalence increased linearly across quartiles of BMI, waist circumference, and waist-height ratio (P for linear trend <0.01 for all). The positive associations of waist circumference and waist-height ratio with suicidal ideation remained significant (P < 0.05) after adjustment for sociodemographics, lifestyle-related behavioral factors, and having either chronic conditions or current depression. However, these associations were attenuated after both chronic conditions and depression were entered into the models. Thus, the previously reported association between obesity and suicidal ideation appears to be confounded by coexistence of chronic conditions and current depression among women of the United States.

OBJECTIVE: To compare the prevalence estimates of selected health indicators and chronic diseases or conditions among three national health surveys in the United States. METHODS: Data from adults aged 18years or older who participated in the Behavioral Risk Factor Surveillance System (BRFSS) in 2007 and 2008 (n=807,524), the National Health Interview Survey (NHIS) in 2007 and 2008 (n=44,262), and the National Health and Nutrition Examination Survey (NHANES) during 2007 and 2008 (n=5871) were analyzed. RESULTS: After adjustment for demographic characteristics, the prevalence estimates of current smoking, obesity, hypertension, and no health insurance were similar across the three surveys, with absolute differences ranging from 0.7% to 3.9% (relative differences: 2.3% to 20.2%). The prevalence estimate of poor or fair health from BRFSS was similar to that from NHANES, but higher than that from NHIS. The prevalence estimates of diabetes, coronary heart disease, and stroke were similar across the three surveys, with absolute differences ranging from 0.0% to 0.8% (relative differences: 0.2% to 17.1%). CONCLUSION: While the BRFSS continues to provide invaluable health information at state and local level, it is reassuring to observe consistency in prevalence estimates of key health indicators of similar caliber between BRFSS and other national surveys.

INTRODUCTION: Binge drinking (men, ≥5 drinks, women, ≥4 on an occasion) accounts for more than half of the 79,000 annual deaths due to excessive alcohol use in the United States. The frequency of binge drinking is associated with poor health-related quality of life (HRQOL), but the association between binge drinking intensity and HRQOL is unknown. Our objective was to examine this association. METHODS: We used 2008-2010 Behavioral Risk Factor Surveillance System data and multivariate linear regression models to examine the association between binge drinking intensity (largest number of drinks consumed on any occasion) among US adult binge drinkers and 2 HRQOL indicators: number of physically and mentally unhealthy days. RESULTS: Among binge drinkers, the highest-intensity binge drinkers (women consuming ≥7 drinks and men consuming ≥8 drinks on any occasion) were more likely to report poor HRQOL than binge drinkers who reported lower levels of intensity (women who consumed 4 drinks and men who consumed 5 drinks on any occasion). On average, female binge drinkers reported more physically and mentally unhealthy days (2.8 d and 5.1 d, respectively) than male binge drinkers (2.5 d and 3.6 d, respectively). After adjustment for confounding factors, women who consumed ≥7 drinks on any occasion reported more mentally unhealthy days (6.3 d) than women who consumed 4 drinks (4.6 d). Compared with male binge drinkers across the age groups, female binge drinkers had a significantly higher mean number of mentally unhealthy days. CONCLUSION: Our findings underscore the importance of implementing effective population-level strategies to prevent binge drinking and improve HRQOL.

OBJECTIVE: People with type 2 diabetes may need insulin therapy to compensate for their underlying pathogenic abnormalities and to improve glycemic control. We examined trends of insulin use among US adults aged ≥40 years with type 2 diabetes. METHODS: We analyzed data from the Behavioral Risk Factor Surveillance System collected annually during 1995-2007. Insulin use was assessed by self-report. Log-linear regression analyses with a robust error variance estimator were performed to estimate the prevalence, prevalence ratios, and their 95% confidence intervals. RESULTS: The overall crude and age-standardized proportion of insulin use decreased from 35% and 36% in 1995 to 23% and 22% in 2007, respectively. After adjustments for age, sex, race/ethnicity, education attainment, body mass index, and diabetes duration, the overall prevalence decreased from 33% to 22% (P<.0001 for linear trend). The decreasing rates were similar across sex (P=.23 for interaction between sex and survey year) and race/ethnicity (P=.35 for interaction between race/ethnicity and survey year). CONCLUSION: The proportion of insulin use decreased from 1995 to 2007 among US adults aged ≥40 years. Continuing efforts may be needed to properly identify those who may need to initiate and maintain insulin therapy among patients with type 2 diabetes as medically indicated.

PROBLEM: Chronic diseases and conditions (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors and conditions (e.g., smoking, physical inactivity, poor diet, excessive drinking, and obesity) and using preventive health-care services (e.g., physical examination, vaccination, screening for high blood pressure and high cholesterol, consumption of fruits and vegetables, and participation in regular leisure-time physical activity) can reduce morbidity and mortality from chronic diseases. REPORTING PERIOD: January 2009--December 2009. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based random-digit--dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors and conditions, chronic diseases and conditions, access to health care, and use of preventative health services and practices related to the leading causes of death and disabilities in the United States. This report presents results for 2009 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, 180 metropolitan and micropolitan statistical areas (MMSAs), and 283 selected counties. RESULTS: In 2009, the estimated prevalence of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairments and disabilities varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topics. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior, as reported by the survey respondent. Adults who reported having fair or poor health: 10.1%--30.9% for states and territories, 7.9%--25.8% for MMSAs, and 4.5%--26.1% for counties. Adults with health-care coverage: 71.4%--94.7% for states and territories, 52.7%--96.3% for MMSAs, and 52.7%--97.6% for counties. Annual routine physical checkup among adults aged ≥18 years: 55.8%--79.3% for states and territories, 51.8%--80.7% for MMSAs, and 49.2%--83.5% for counties. Annual influenza vaccination among adults aged ≥65 years: 26.8%--76.8% for states and territories, 55.4%--81.4% for MMSAs, and 50.5%--83.5% for counties. Pneumococcal vaccination among adults aged ≥65 years: 19.1%--73.9% for states and territories, 52.9%--81.3% for MMSAs, and 41.9%--82.0% for counties. Adults who had their cholesterol checked within the preceding 5 years: 67.5%--85.3% for states and territories, 58.2%--88.8% for MMSAs, and 58.2%--92.4% for counties. Adults who consumed at least five servings of fruits and vegetables per day: 14.6%--31.5% for states and territories, 12.6%--33.0% for MMSAs, and 13.4%--34.9% for counties. Adults who engaged in moderate or vigorous physical activity: 28.0%--60.7% for states and territories, 34.6%--64.9% for MMSAs, and 33.6%--67.3% for counties. Adults who engaged in only vigorous physical activity: 13.7%--40.1% for states and territories, 13.8%--43.3% for MMSAs, and 14.2%--50.0% for counties. Current cigarette smoking among adults: 6.4%--25.6% for states and territories, 5.7%--29.0% for MMSAs, and 5.6%--29.8% for counties. Binge drinking among adults: 6.8%--23.9% for states and territories, 3.5%--23.2% for MMSAs, and 3.4%--26.3% for counties. Heavy drinking among adults: 1.9%--8.1% for states and territories, 1.0%--11.1% for MMSAs, and 0.9%--11.1% for counties. Adults who reported no leisure-time physical activity: 15.8%--45.6% for states and territories, 13.3%--40.2% for MMSAs, and 10.5%--40.2% for counties. Adults aged ≥18 years who were overweight: 31.6%--38.7% for states and territories, 28.7%--44.1% for MMSAs, and 25.6%--46.7% for counties. Adults aged ≥20 years who were obese: 19.7%--36.0% for states and territories, 15.4%--43.6% for MMSAs, and 13.8%--45.7% for counties. Adults aged ≥18 years who did not get enough rest or sleep: 34.3%--52.6% for states and territories, 28.2%--54.8% for MMSAs, and 24.5%--55.6% for counties. Adults who had received a high blood pressure diagnosis: 22.1%--38.5% for states and territories, 18.8%--43.9% for MMSAs, and 17.2%--43.6% for counties. Adults who had a high blood cholesterol diagnosis: 24.9%--42.2% for states and territories, 27.5%--47.8% for MMSAs, and 26.7%--51.4% for counties. Adults who had received a diagnosis of coronary heart disease: 2.5%--10.3% for states and territories, 2.6%--11.6% for MMSAs, and 1.6%--12.3% for counties. Adults who had received a stroke diagnosis: 1.4%--3.9% for states and territories, 0.8%--5.9% for MMSAs, and 0.8%--6.6% for counties. Adults who had received a diabetes diagnosis: 5.8%--12.9% for states and territories, 2.8%--15.4% for MMSAs, and 2.8%--14.7% for counties. Adults who had received a cancer diagnosis: 3.0%--12.6% for states and territories, 5.8%--15.1% for MMSAs, and 3.9%--16.2% for counties. Adults who had asthma: 4.4%--11.1% for states and territories, and 3.2%--15.3% for MMSAs, and 3.2%--15.7% for counties. Adults who had arthritis: 10.7%--35.6% for states and territories, 16.2%--36.0% for MMSAs, and 12.6%--39.4% for counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10.2%--27.1% for states and territories, 13.1%--33.7% for MMSAs, and 10.4%--36.1% for counties. Adults who required special equipment because of health problems: 3.6%--10.2% for states and territories, 3.4%--11.5% for MMSAs, and 1.7%--13.0% for counties. INTERPRETATION: The findings in this report indicate substantial variations in self-rated general health status, health-care coverage, use of preventive health-care services, health risk behaviors and health conditions, cardiovascular conditions, other chronic diseases, and health impairments and disabilities among U.S. adults at the state and territory, MMSA, and county levels. The findings show that Healthy People 2010 objectives had not been met in many areas by 2009, which underscores the continued need for surveillance of general health status, use of preventive health-care services, health risk behaviors and conditions, chronic diseases, and health impairment and disability. PUBLIC HEALTH ACTION: Data on health risk behaviors, chronic health conditions, preventive care practices, and chronic diseases are used to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels.. The overarching goals of Healthy People 2010 are to increase quality and years of healthy life and to eliminate health disparities. Local and state health departments and federal agencies should continue to use BRFSS data to identify populations at high risk for certain health risk behaviors and conditions, cardiovascular conditions, and other chronic diseases and to evaluate the use of preventive health-care services. In addition, BRFSS data can be used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality.

BACKGROUND: Unhealthy lifestyle behaviors during pregnancy often predispose women to multiple risks including adverse pregnancy outcomes and impaired health status for mothers. This study assessed the trends in the prevalence of health-related behavioral risk factors over time among U.S. pregnant women. METHODS: Data from 22,604 pregnant women aged 18-44 years who participated in the 2001-2009 Behavioral Risk Factor Surveillance System were analyzed to assess the trends in the prevalence of behavioral risk factors. Correlates of having individual or clustering healthy behaviors were also assessed among 2295 pregnant women in the 2009 survey. RESULTS: From 2001 to 2009, among pregnant women, the age-adjusted prevalence of engaging in leisure-time exercise and receiving influenza vaccination increased significantly (p<0.05 for linear trends); the prevalence of any alcohol consumption decreased marginally (p=0.065 for linear trend); and the prevalence of binge drinking, smoking, and consuming fruits and vegetables ≥5 times/day varied little. Over the 9 years, the percentages of pregnant women who reported having all four healthy behaviors (i.e., not currently smoking, no alcohol consumption, engaging in leisure-time exercise, and receiving influenza vaccination) increased linearly from 7.3% in 2001 to 21.2% in 2009 (p<0.001). Sociodemographic characteristics, perceived health status, and health-care availability were differentially associated with certain individual or clustered healthy behaviors. CONCLUSION: Increased efforts emphasizing multiple health-related behavioral risk factors including reducing alcohol use, binge drinking, and smoking and improving fruit and vegetable consumption during pregnancy are needed.

BACKGROUND: Evidence suggests that folate deficiency may be causatively linked to depressive symptoms. However, little is known on the status of use of folic acid and vitamin supplements among people with mental disorders. This study examined the prevalence and the likelihood of use of folic acid or vitamin supplements among adults with depression and anxiety in comparison to those without these conditions. METHODS: Using data from 46,119 participants (aged ≥ 18 years) in the 2006 Behavioral Risk Factor Surveillance System survey, we estimated the adjusted prevalence and odds ratios with 95% confidence intervals for taking folic acid and vitamin supplements among those with ever diagnosed depression (n = 8, 019), ever diagnosed anxiety (n = 5, 546) or elevated depressive symptoms (n = 3, 978, defined as having a depression severity score of ≥ 10 on the Patient Health Questionnaire-8 diagnostic algorithm). RESULTS: Overall, women were more likely than men to take folic acid supplements 1-4 times/day (50.2% versus 38.7%, P < 0.001) and vitamin supplements (62.5% versus 49.8%, P < 0.001). After multivariate adjustment, men with ever diagnosed depression or anxiety were 42% and 83%, respectively, more likely to take folic acid supplements < 1 time/day; 44% and 39%, respectively, more likely to take folic acid supplements 1-4 times/day; and 40% and 46%, respectively, more likely to take vitamin supplements compared to men without these conditions (P < 0.05 for all comparisons). Women with ever diagnosed depression were 13% more likely to take folic acid supplements 1-4 times/day and 15% more likely to take vitamin supplements than women without this condition (P < 0.05 for both comparisons). Use of folic acid and vitamin supplements did not differ significantly by elevated depressive symptoms in either sex. CONCLUSION: The prevalence and the likelihood of taking folic acid and vitamin supplements varied substantially by a history of diagnosed depression among both men and women and by a history of diagnosed anxiety among men, but not by presence of elevated depressive symptoms in either sex.

OBJECTIVE: The purpose of this study is to examine the associations among depression, anxiety, use of oral health services, and tooth loss. MEYHODS: Data were analysed for 80 486 noninstitutionalized adults in 16 states who participated in the 2008 Behavioral Risk Factor Surveillance System. Binomial and multinomial logistic regression analyses were used to estimate predicted marginals, adjusted prevalence ratios, adjusted odds ratios (AOR) and their 95% confidence intervals (CI). RESULTS: The unadjusted prevalence for use of oral health services in the past year was 73.1% [standard error (SE), 0.3%]. The unadjusted prevalence by level of tooth loss was 56.1% (SE, 0.4%) for no tooth loss, 29.6% (SE, 0.3%) for 1-5 missing teeth, 9.7% (SE, 0.2%) for 6-31 missing teeth and 4.6% (SE, 0.1%) for total tooth loss. Adults with current depression had a significantly higher prevalence of nonuse of oral health services in the past year than those without this disorder (P < 0.001), after adjustment for age, sex, race/ethnicity, education, marital status, employment status, adverse health behaviours, chronic conditions, body mass index, assistive technology use and perceived social support. In logistic regression analyses employing tooth loss as a dichotomous outcome (0 versus ≥1) and as a nominal outcome (0 versus 1-5, 6-31, or all), adults with depression and anxiety were more likely to have tooth loss. Adults with current depression, lifetime diagnosed depression and lifetime diagnosed anxiety were significantly more likely to have had at least one tooth removed than those without each of these disorders (P < 0.001 for all), after fully adjusting for evaluated confounders (including use of oral health services). The adjusted odds of being in the 1-5 teeth removed, 6-31 teeth removed, or all teeth removed categories versus 0 teeth removed category were increased for adults with current depression versus those without (AOR = 1.35; 95% CI = 1.14-1.59; AOR = 1.83; 95% CI = 1.51-2.22; and AOR = 1.44; 95% CI = 1.11-1.86, respectively). The adjusted odds of being in the 1-5 teeth removed and 6-31 teeth removed categories versus 0 teeth removed category were also increased for adults with lifetime diagnosed depression or anxiety versus those without each of these disorders. CONCLUSIONS: Use of oral health services and tooth loss was associated with depression and anxiety after controlling for multiple confounders.

OBJECTIVES: This study compared the use of complementary and alternative medicine (CAM) to treat health conditions with CAM use for general wellness or disease prevention among USA adults with and without functional limitations. DESIGN: This was a cross-sectional survey. METHODS: Data were obtained from the 2007 U.S. National Health Interview Survey (n=20,710). RESULTS: Overall use of CAM treatment was higher among adults with functional limitations than among those without (61.4% versus 41.8%; p<0.001). Adults with functional limitations were more likely to use 3 of 4 CAM groupings: biologically based therapies (BBT) (47.9% versus 29.5%, p<0.001), manipulative and body-based therapies (73.7% versus 54.1%, p<0.001), and mind-body therapies (MBT) (39.3% versus 17.4%, p<0.001). Use of alternative medical systems for treatment was highly prevalent among adults (86.9% versus 80.0%, p=0.06), regardless of functional status. Adults with functional limitations were as likely to use CAM to treat the condition underlying their functioning difficulty (48.7%) as they were to treat other conditions (51.3%). Massage therapy was used most often to treat conditions that limited functional ability (53.4%). Older age was a predictor of the use of BBT for treatment, whereas younger age was a predictor of the use of MBT. CONCLUSIONS: The prevalence of CAM use for treatment of conditions is high. Public health strategies are needed to promote disclosure of CAM use to health care providers, promote increased screening for CAM use by health care providers, and promote health care interactions that facilitate communication about CAM safety and efficacy.

BACKGROUND: Most ischemic heart disease (IHD) prevention programs that promote physical activity (PA) have focused on overweight/obese populations. Persons with normal body mass index (BMI) may mistakenly think that they are not at risk for IHD and remain physically inactive. Studies exploring the risk of IHD and PA level among adults aged 45 years and older with normal weight are limited. METHODS: Cross-sectional study to examine the prevalence of IHD and PA level among 94455 respondents aged 45 years and older with normal BMI using the 2007 Behavioral Risk Factor Surveillance System data. RESULTS: Approximately 50% of respondents reported low/inactive PA. The prevalence of IHD among persons with inactive, low, medium, and high PA was 16.6% (95% CI = 15.1-18.1%), 9.6% (8.9-10.3%), 8.9% (8.3-9.6%), and 5.4% (4.9-5.9%). The adjusted odds ratios of IHD among persons with low, medium, and high PA compared with those with inactive PA was 0.68 (95% CI = 0.59-0.79), 0.63 (0.54-0.73), and 0.49 (0.42-0.57). CONCLUSIONS: The percentage of respondents with low or inactive PA among populations aged 45 years and older with BMI 18 to <25 was alarmingly high and independently associated with higher IHD prevalence. Persons who are not overweight/obese still need to have adequate PA to reduce the risk of IHD.

OBJECTIVE: Although effective mental health treatments exist, few population data are available on treatment receipt by persons with psychological distress. This study aimed to understand the association between symptoms and treatment receipt with data from the U.S Behavioral Risk Factor Surveillance System (BRFSS) survey. METHODS: In the 2007 survey, psychological distress was assessed with the Kessler-6 scale, and respondents were asked about receipt of mental health treatment. Data from 197,914 respondents were analyzed. RESULTS: In the overall population 87.5% of respondents reported no psychological distress, 8.5% mild to moderate psychological distress, and 3.9% serious psychological distress. Those with serious distress were nearly ten times as likely to receive treatment (adjusted odds ratio=9.58, 95% confidence interval=8.53-10.75) as those with no distress. One in ten persons (10.7%) in the study population reported receiving treatment. CONCLUSIONS: Distinct U.S. subpopulations exist by treatment and symptom status. Better understanding of all these groups is essential for improving population-based mental health care. (Psychiatric Services 62:396-403, 2011).

OBJECTIVE: To compare depression prevalence estimates measured by the 8-item Patient Health Questionnaire (PHQ-8) with two administration modes in two national surveys. METHODS: Data on adults aged 18 years and older who participated in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) (n = 198,678) and those who participated in the 2005-2006 National Health and Nutrition Examination Survey (NHANES) (n = 4,800) were analyzed. RESULTS: The crude PHQ-8 depression prevalence estimate using the diagnostic algorithm was higher in BRFSS with computer-assisted telephone interviewing (CATI) (9.16%, SE 0.15) than in NHANES with computer-assisted personal interviewing (CAPI) (6.28%, SE 0.59) (P < 0.001). After adjustment for demographic characteristics, the difference in the prevalence estimates remained (9.68% in BRFSS vs. 6.13% in NHANES, P < 0.001). Similar differences in the depression prevalence estimates using the PHQ-8 cutoff score ≥10 were detected (9.22% in BRFSS vs. 5.15% in NHANES, P < 0.001). Significant differences in the depression prevalence persisted in subgroups stratified by demographic characteristics and major health risk factors and outcomes. CONCLUSIONS: The PHQ-8 administered by CATI yielded about 3.5% higher depression prevalence estimate than that by CAPI.

OBJECTIVE: To assess the association between diagnosed diabetes and self-reported cancer among U.S. adults. RESEARCH DESIGN AND METHODS: We analyzed data for 397,783 adults who participated in the 2009 Behavioral Risk Factor Surveillance System. RESULTS: After adjustment for potential confounders, diabetic men had higher adjusted prevalence ratios for cancer of the prostate (1.1 [95% CI 1.0-1.3]), colon (1.3 [1.0-1.7]), pancreas (4.6 [1.8-11.7]), rectum (2.2 [1.0-4.7]), urinary bladder (1.7 [1.2-2.2]), and kidney (1.9 [1.2-3.0]) than nondiabetic men (all P < 0.05). Diabetic women had higher adjusted prevalence ratios for cancer of the breast (1.1 [1.0-1.3]) and endometrium (1.6 [1.2-2.0]), and leukemia (2.3 [1.3-4.2]) than nondiabetic women (all P < 0.05). CONCLUSIONS: Our results suggest that diabetic adults have higher prevalences of certain cancers than nondiabetic adults.

BACKGROUND: Depression and anxiety are prevalent among adults with disabilities. However, little is known regarding the geographic variability of depression and anxiety among adults with disabilities in the United States. OBJECTIVES: We estimated prevalence of current depression, lifetime diagnoses of depression (LD), and lifetime diagnoses of anxiety (LA) among adults with disabilities by state, metropolitan and micropolitan statistical area (MMSA), and county. METHODS: We analyzed Behavioral Risk Factor Surveillance System data from 2006 for 41 states and territories, 74 MMSAs, and 112 counties. Stratified analyses by sociodemographic and health status variables were performed for the 10 MMSAs with the highest estimates of current depression, LD, and LA, respectively. Current depressive symptoms were assessed with the Patient Health Questionnaire-8. RESULTS: Estimates of current depression, LD, and LA among adults with disabilities varied substantially by state, MMSA, and county. Current depression estimates ranged from 14.7% in North Dakota to 30.1% in Mississippi; from 8.4% in San Francisco-Oakland-Fremont, CA, to 36.2% in Jacksonville, FL; and from 12.3% in Cumberland County, ME, to 44% in Orleans Parish, LA. There was major variation within some states (e.g., prevalence of current depression was 8.4% in San Francisco-Oakland-Fremont, CA compared to 25.5% in Los Angeles-Long Beach-Glendale, CA). In the 10 MMSAs with the highest estimates, estimates varied by age, gender, socioeconomic status, and health status. CONCLUSIONS: Public and mental health agencies may find these estimates useful for program planning purposes to address depression and anxiety among adults with disabilities.

OBJECTIVES: To compare the prevalence and correlates of meeting current recommendations for physical activity in older adults with and without diabetes mellitus (DM) in the United States. DESIGN: A cross-sectional, population-based sample. SETTING: The 2007 Behavioral Risk Factor Surveillance Survey, which employs random-digit dialing to interview noninstitutionalized U.S. adults. PARTICIPANTS: Ninety-nine thousand one hundred seventy-two adults (18,370 with DM) aged 65 and older. MEASUREMENTS: The age-adjusted prevalence and the odds ratios for physical activity patterns (defined on the basis of the physical activity guidelines from the American Diabetes Association (ADA 2007) and the Department of Health and Human Services (DHHS 2008)) were obtained using multiple logistic regression analyses. The correlates of meeting physical activity recommendations were assessed using log-binomial regression analyses. RESULTS: Overall, 25% and 42% of older adults with diabetes mellitus met recommendations for total physical activity based on the ADA 2007 and the DHHS 2008 guidelines, respectively. Adults with DM were 31% to 34% (P<.001) less likely to engage in physical activity at recommended levels and 13% to 19% (P<.001) less likely to be physically active at insufficient levels than those without DM. Analyses limited to participants who reported no disability yielded similar results. In adults with DM, older age (≥75); being female; being non-Hispanic black; and having obesity, coronary heart disease, and disability were associated with less likelihood, whereas advanced educational status was associated with greater likelihood of meeting physical activity recommendations. CONCLUSION: In the United States, efforts to boost physical activity participation in older adults with DM are needed.

BACKGROUND: Much research has been conducted relating total carotenoids-and beta-carotene in particular-to risk of cancer and cardiovascular disease (CVD). Limited data are emerging to implicate the important role of alpha-carotene in the development of CVD or cancer. METHODS: We assessed the direct relationship between alpha-carotene concentrations and risk of death among 15,318 US adults 20 years and older who participated in the Third National Health and Nutrition Examination Survey Follow-up Study. We used Cox proportional hazard regression analyses to estimate the relative risk for death from all causes and selected causes associated with serum alpha-carotene concentrations. RESULTS: Compared with participants with serum alpha-carotene concentrations of 0 to 1 mug/dL (to convert to micromoles per liter, multiply by 0.01863), those with higher serum levels had a lower risk of death from all causes (P < .001 for linear trend): the relative risk for death was 0.77 (95% confidence interval, 0.68-0.87) among those with alpha-carotene concentrations of 2 to 3 mug/dL, 0.73 (0.65-0.83) among those with concentrations of 4 to 5 mug/dL, 0.66 (0.55-0.79) among those with concentrations of 6 to 8 mug/dL, and 0.61 (0.51-0.73) among those with concentrations of 9 mug/dL or higher after adjustment for potential confounding variables. We also found significant associations between serum alpha-carotene concentrations and risk of death from CVD (P = .007), cancer (P = .02), and all other causes (P < .001). The association between serum alpha-carotene concentrations and risk of death from all causes was significant in most subgroups stratified by demographic characteristics, lifestyle habits, and health risk factors. CONCLUSIONS: Serum alpha-carotene concentrations were inversely associated with risk of death from all causes, CVD, cancer, and all other causes. These findings support increasing fruit and vegetable consumption as a means of preventing premature death.

OBJECTIVE: The aim of this study was to examine the association between the number of healthy behaviors (i.e., not currently smoking, not currently drinking excessively, physically active, and consuming fruits and vegetables five or more times per day) and optimal self-rated health (SRH) among U.S. adults or adults with cardiovascular diseases (CVDs) or diabetes. METHODS: We estimated the age-standardized prevalence of optimal SRH among a total of 430,912 adults who participated in the 2007 Behavioral Risk Factor Surveillance System (BRFSS). Prevalence ratios were produced with multivariate Cox regression models using number of healthy behaviors as a predictor; status of optimal SRH was used as an outcome variable while controlling for sociodemographic and health risk factors. RESULTS: The age-standardized prevalence of reporting optimal SRH was 83.5%, 55.6%, and 56.3% among adults overall, and adults with CVDs or diabetes, respectively. Also in the aforementioned order, adults who reported having four healthy behaviors had 33%, 85%, and 87% increased likelihoods of reporting optimal SRH, when compared to their counterparts who reported none of these behaviors. CONCLUSION: The findings of this study indicate that number of healthy behaviors is associated with optimal SRH among adults, especially adults with CVDs or diabetes. These findings reinforce the support for identifying and implementing clinical and population-based intervention strategies that effectively promote multiple healthier lifestyle behaviors among adults.

OBJECTIVE: Vitamin D deficiency or high levels of parathyroid hormone (PTH) appear to be emerging risk factors for hypertension. This study examined whether serum concentrations of 25-hydroxyvitamin D [25(OH)D] and PTH were independently associated with blood pressure and the presence of hypertension or prehypertension among the United States adults. METHODS: Cross-sectional data from 7228 participants (aged > or =20 years) in the 2003-2006 National Health and Nutrition Examination Survey were analyzed. The least square means and the regression coefficients of systolic blood pressure, diastolic blood pressure, and pulse pressure across quintiles of serum 25(OH)D and PTH were estimated by conducting multiple linear regression analyses. The adjusted prevalence ratios with 95% confidence intervals for hypertension and prehypertension were estimated using the log-binomial method. RESULTS: Among participants not taking blood pressure medications (n = 5414), the mean age- and sex-adjusted systolic and diastolic blood pressure decreased linearly across quintiles of serum 25(OH)D but increased linearly across quintiles of serum PTH (P < 0.001 for all); these relationships remained significant even after extensively adjusting for covariates. Similarly, across quintiles of serum 25(OH)D, the age-adjusted prevalence of hypertension and the adjusted prevalence ratios for both hypertension and prehypertension decreased linearly (P < 0.001 for all). In contrast, the prevalence of hypertension and prehypertension increased nonlinearly (P < 0.05 for both) and the adjusted prevalence ratios for hypertension increased linearly across quintiles of serum PTH (P < 0.001). CONCLUSION: Serum concentrations of 25(OH)D and PTH were independently associated with blood pressure and with the presence of hypertension or prehypertension among the United States adults, though casual relationships remain to be elucidated.

OBJECTIVE: To estimate the prevalence of self-reported clinically diagnosed sleep apnea (diagnosed sleep apnea) according to body mass index (BMI, measure of total obesity) and waist circumference (measure of abdominal obesity) in US adults. METHODS: Data from a representative sample of 4309 US adults in the National Health and Nutrition Examination Surveys 2005-2006 were analyzed. Log-linear regression analyses with a robust variance estimator were performed to estimate the prevalence ratios (PR) and 95% confidence intervals (CIs). RESULTS: The overall crude and age-adjusted prevalence estimates of diagnosed sleep apnea were 4.7% (95% CI=4.0%-5.5%) and 4.5% (95% CI=3.9%-5.2%) in adults. Age-adjusted prevalence in men (6.1%, 95% CI=5.0%-7.3%) was higher than that in women (3.1%, 95% CI=2.1%-4.0%; P<0.01). Age-adjusted prevalence was higher for persons with total obesity (i.e., BMI > or = 30 kg/m(2)) (12.1% vs. 3.0% in men, P<0.01; 7.0% vs. 0.7% in women, P<0.01) or abdominal obesity (10.9% vs. 1.9% in men, P<0.01; 4.6% vs. 0.6% in women, P<0.01) than that for those without total obesity (BMI <30 kg/m(2)) or without abdominal obesity. CONCLUSIONS: These results from a nationally representative sample suggest that diagnosed sleep apnea is highly prevalent among adults with obesity in the general population, especially among men.

Although there is evidence that vitamin D deficiency may play a role in depression, studies done on the associations have yielded mixed results. The present study aimed to examine the associations between serum concentrations of 25-hydroxyvitamin D (25(OH)D) and parathyroid hormone (PTH) and the presence of depression among US adults. A cross-sectional, population-based sample (including 3916 participants aged ≥ 20 years) from the 2005-6 National Health and Nutrition Examination Survey was used. Participants' depressive symptoms were assessed using the Patient Health Questionnaire-9 diagnostic algorithm. The associations of 25(OH)D and PTH with depression were explored using multivariate logistic regression models. For all the participants, the age-adjusted prevalence was 5.3 (95 % CI 4.3, 6.5) % for having moderate-to-severe depression, 2.3 (95 % CI 1.7, 3.1) % for having major depression and 3.8 (95 % CI 3.0, 4.6) % for having minor depression. Although the age-adjusted prevalence and the unadjusted OR of having moderate-to-severe depression or major depression decreased linearly with increasing quartiles of 25(OH)D (P < 0.05 for trends), no significant associations remained after adjusting for multiple potential confounders such as demographic variables, lifestyle factors and coexistence of a number of chronic conditions. Neither the age-adjusted prevalence nor the OR (unadjusted or adjusted) of having depression differed significantly by the quartiles of PTH. Thus, in contrast to some of the previous findings, the present results did not show significant associations between serum concentrations of 25(OH)D and PTH and the presence of moderate-to-severe depression, major depression or minor depression among US adults. However, these findings need to be further confirmed in future studies.