Chronic Disease
Arthritis and Osteoporosis
Objectives/Targets
Arthritis
Reduce the percent of persons with arthritis who report their
general health as fair to poor.
Target: 31.8 percent.
Baseline, 1998: 35.2 percent of persons with arthritis report their general health as fair or poor.
Target Setting Method: 10 percent improvement.
Osteoporosis
Reduce the rate of adults age 65 and older who are hospitalized for vertebral fractures associated with osteoporosis.
Target: 34.4 per 10,000.
Baseline, 1998: 38.2 per 10,000 adults age 65 and older were hospitalized for vertebral fractures associated with osteoporosis.
Target Setting Method: 10 percent improvement.
Reduce the rate of adults age 65 and older who are hospitalized for hip fractures associated with osteoporosis.
Target: 81.2 per 10,000.
Baseline, 1998: 90.2 per 10,000 adults age 65 and older were hospitalized for hip fractures associated with osteoporosis.
Target setting Method: 10 percent improvement.
Chronic Disease - Arthritis and Osteoporosis
Arthritis
Arthritis, which encompasses more than 100 diseases and conditions involving the joints, the surrounding tissues, and other connective tissues, is the major cause of disability in the United States. Arthritis affects one in six Americans. It is estimated that 60 million people will be affected by arthritis by the year 2020. Arthritis limits the independence of affected persons and disrupts the lives of family members and other caregivers. This is particularly alarming because some forms of arthritis like osteoarthritis are preventable.
According to the Healthy People 2010 Report, arthritis is the cause of at least 44 million visits to a health care provider, 744,000 hospitalizations, and 4 million days of hospital care per year. Estimated medical care costs for persons with arthritis were $15 billion, and total costs (medical care plus lost productivity) were $65 billion in 1992. Behavioral Risk Factor Surveillance System data collected in North Carolina in 1998 showed North Carolina among the states with the highest incidence of arthritis. According to these estimates, arthritis is more prevalent in older individuals, in those with lower income, and in those with fewer years of education. Also, more persons with arthritis reported their general health as fair to poor.
Osteoporosis
Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and increased susceptibility to fracture. Osteoporosis occurs in over half of all women and one in eight men over age fifty. This translates into about one million men and women in North Carolina with osteoporosis or low bone mass.
In 1995, and estimated 13,576 North Carolinians were hospitalized with an osteoporosis-related fracture, representing 110,000 hospital days and charges of over $145 million. Nearly 60 percent of individuals who fracture a hip are discharged from the hospital to a nursing home or rehabilitation center, and approximately 20 percent of hip fracture patients die within one year of the fracture. National data for vertebral fractures show an overall hospitalization rate of 14.5 per 100,000, and Medical Review of North Carolina data indicate an average hip fracture rate among North Carolina Medicare beneficiaries of 821 per 100,000 for 1994-1997. Also, the number of hospitalizations due to osteoporotic fractures is expected to increase 75 percent by the year 2020.
While osteoporosis is preventable and treatable, many individuals do not realize their risk for the disease and are not diagnosed until they sustain fracture. According to the Piedmont Health Survey of older adults conducted by Duke University, the proportion of older adults reporting osteoporosis is lower than the proportion estimated to have osteoporosis. It is estimated that osteoporosis is under-reported by 60 percent among White women age 80+ years, 66 percent among elderly African-American women, and 90 percent among elderly African-American men.
Disparities
Arthritis
Arthritis is a leading health problem among all demographic groups. Arthritis affects 50 percent of people age 65 years and older. However, most people with arthritis are younger than 65 years of age and are working. Arthritis is more common in women than in men. Whites and African American/Blacks have similar rates of disease, but African American/Blacks have greater rates of activity limitation. The rate of arthritis and its associated disabilities is higher among persons with low education and low income. The risk of chronic back pain increases with age.
Osteoporosis
White women account for the majority of hospitalizations due to hip fracture; however, both men and African American/Blacks face a higher mortality rate after sustaining a fracture. The gap between the fracture risk of African American/Blacks and Whites also decreases as age increases. Currently, over 100,000 African American/Blacks in North Carolina have low bone mass.
Determinants/Risk Factors
Arthritis
Women aged 15 years and older account for 60 percent of arthritis cases; arthritis risk increases with age; certain genes are known to be associated with a higher risk of some types of arthritis; lower levels of education and lower income; obesity; joint injuries; infections; certain occupations (e.g., shipyard work, farming, heavy industry, and occupations with repetitive knee-bending)
Osteoporosis
Bone resorption can exceed bone formation as people age; females face greater risk than males: Caucasians and Asians are at greater risk than African-American/Blacks or Hispanics/Latinos; bone structure and body weight (person with thin, small frame is at greater risk); early menopause (natural or surgical) or disruption in menstrual cycle due to excessive exercise, anorexia or bulimia; inactivity; smoking; excessive alcohol intake; lack of calcium and/or vitamins; certain medications and medical conditions increase risk; and family history
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Asthma
Objectives/Targets
Reduce the number of school days missed by children with asthma.
Reduce the rate of asthma related hospitalizations.
Target: 118 per 100,000.
Baseline, 1998: 143.9 per 100,000 persons were hospitalized for asthma.
Target setting method: 18 percent improvement.
Chronic Disease - Asthma
Asthma is a respiratory condition causing the airways in the bronchial tubes to be obstructed. The prevalence of asthma in children has increased significantly over the past two decades with associated increases in hospitalization, death, and restricted activity. In 2000, approximately 134,000 North Carolina children suffer from asthma and it is one of the most common causes of emergency department visits and hospitalization. Unfortunately, this number may not fully represent the prevalence of the disease among children, since many children go undiagnosed or misdiagnosed. Seventeen percent of all emergency department visits are due to asthma. It is reportedly the leading cause of school absence among children with chronic illnesses. In 1999, 50 percent of children with asthma missed school because of the disease. Asthma is improved by controlling environmental triggers, using appropriate medications, actively monitoring the disease, and patient education.
Disparities
African American/Black and Hispanic/Latino children more frequently use emergency departments for medical care of their asthma, are more likely to be hospitalized, and are more likely to die from asthma than White children. Research reveals a strong relationship between poverty and asthma. Counties with large populations of American Indians have also shown very high hospitalization rates for asthma.
Determinants/Risk Factors
Exposure to allergens and pollutants; lack of access to adequate primary care; inadequate financial resources; inadequate social support; respiratory infections; climate changes; physical and emotional changes (e.g., coughing, laughing, exercise, stress)
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Cancer
Objectives/Targets
Reduce the overall cancer death rate.
Target: 166.2 deaths per 100,000 population.
Baseline, 1994-1998: 207.8 cancer deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: 20 percent improvement.
Reduce the colorectal cancer death rate.
Target: 16.4 deaths per 100,000 population.
Baseline, 1996-1998: 20.5 colorectal deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: 20 percent improvement.
Increase the proportion of adults who have ever had a colorectal cancer screening examination.
Target: 49.8 percent.
Baseline, 1998-1999: 31.5 percent adults age 18 and older received a sigmoidoscopy or proctoscopy.
Target Setting Method: Better than the best. Represents 58 percent improvement. Reduce the breast cancer death rate.
Reduce the breast cancer death rate.
Target: 22.6 deaths per 100,000 population.
Baseline, 1996-1998: 28.2 breast cancer deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: 20 percent improvement.
Increase the proportion of women age 50 and older who have had a mammogram in the last 2 years.
Target: 85.2 percent.
Baseline, 1998-1999: 79.6 percent of women aged 50 years and older received a mammogram within the last 2 years.
Target Setting Method: 7 percent improvement.
Reduce cervical cancer death rate.
Target: 2.0 deaths per 100,000 population.
Baseline, 1996-1998: 3.4 cervical cancer deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: Better than the best.
Increase the proportion of women age 18 and older who have had a Pap test in the last 3 years.
Target: 94.7 percent.
Baseline, 1998-1999: 89.3 percent women, age 18 and older, have had a Pap test in the last 3 years.
Target Setting Method: Better than the best.
Chronic Disease - Cancer
Cancer is the out-of-control growth and spread of abnormal cells. These cells accumulate and form tumors (lumps) that may compress, invade and destroy normal tissue. It is the second leading cause of death in North Carolina and the United States. In 2000, over 15,000 North Carolinians die from cancer each year, 41 each day. One in every two men and one in every three women in North Carolina will be diagnosed with cancer in their lifetime. The lung, bronchus, prostate, female breast, colon and rectum were the most common cancer sites for all racial and ethnic populations. Together these cancers account for approximately 54 percent of all newly diagnosed cancers in the United States and 59 percent in North Carolina.
The financial costs of cancer are substantial. The annual costs for cancer are estimated to be $107 billion nationwide. In North Carolina in 1990, the annual costs for cancer were estimated to be $3.2 billion, with $1.11 billion for direct medical costs (the total of all health expenditures), $330 million for costs of illness (costs of low productivity due to illness) and $1.76 billion for costs of death (cost of lost productivity due to death). Treatment for lung, breast and prostate cancers alone accounts for more than half of the direct medical costs.
The burden of cancer can be dramatically reduced if proven advances in prevention, early detection and care are made available. For example, smoking is associated with 30 percent of all cancer deaths; mammography is proven to decrease mortality from breast cancer and there is evidence that early detection of colorectal cancer can decrease mortality by one-half. However, since cancer often takes a long time to develop, it can take 30 years or more for prevention efforts to lower mortality rates. In cases where effective screening techniques are available that lead to improved treatment outcomes, efforts to increase screening can result in more immediate reductions in morality rates.
Disparities
In 2000, North Carolina's, African American/Blacks are about 35 percent more likely to die of cancer than are Whites. African American/Black women are more likely to die of breast and colon cancers than are White women, even though their incidence rate is lower than that of White women. They have approximately the same lung cancer mortality rates as White women. African American/Black males have the highest mortality rates of colorectal, lung and prostate cancers. The biggest disparity in lung cancer mortality is between all males and all females. African American/Black and White male mortality rates are similar.
Determinants/Risk Factors
Inadequate education and awareness; inadequate diet; tobacco use; ultraviolet radiation; lack of early detection and treatment for breast, cervical, colorectal and other cancers; lack of access to treatment because of disproportionate geographic distribution of cancer facilities.
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Diabetes
Objectives/Targets
Reduce the diabetes death rate. >
Target: 67.4 deaths per 100,000. >
Baseline, 1996-1998: 89.9 deaths per 100,000 persons were related to diabetes (age adjusted to the year 2000 U.S. standard population). >
Target Setting Method: 25 percent improvement.
Increase the proportion of adults with diabetes who actively manage their disease by monitoring through the following clinical and laboratory measures:
Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least once a year. >
Target: 41 percent.>
Baseline, 19995-1999: 28.3 percent of adults ages 18 years and older with diabetes had a glycosylated hemoglobin measurement at least once a year.>
Target Setting Method: 45 percent improvement.
Increase the proportion of older adults with diabetes who have an annual dilated eye examination. >
Target: 73.6 percent. >
Baseline, 1995-1999: 66.9 percent of adults ages 18 years and older with diabetes had an annual dilated eye exam. >
Target Setting Method: 10 percent improvement.
Increase the proportion of older adults with diabetes who have an annual foot examination. >
Target: 84.9 percent. >
Baseline, 1995-1999: 77.2 percent of adults ages 18 years and older with diabetes had an annual foot exam. >
Target Setting Method: 10 percent improvement.
Chronic Disease - Diabetes
Diabetes is a disease in which the body is unable to produce insulin (Type I Diabetes) or properly use the insulin it does produce (Type II Diabetes). Insulin is a hormone that regulates sugar (glucose) levels in the body. Without insulin, the amount of sugar in the blood stays too high, and this disturbs many critical body functions. If not successfully managed, diabetes can lead to serious medical complications involving the eyes, heart, kidneys, blood vessels, nerves, and feet.
In 2000, diabetes is the seventh leading cause of death in the United States and North Carolina. It is a major contributor to deaths from cardiovascular disease. Diabetes is the leading cause of blindness, renal failure, and non-traumatic amputations. In North Carolina, during 1998, about 360,000 adults were diagnosed with diabetes. Another 130,000 adults are believed to have diabetes and are not aware of it. Each day, diabetes causes about 15 deaths, eight leg and foot amputations, and more than 600 hospitalizations for treatment or surgery for heart or stroke complications or poor circulation in the feet and legs.
Diabetes was responsible for 14 percent of all hospitalizations, costing approximately $1.5 billion in 1998, with approximately $645 million being attributed to secondary complications of diabetes such as cardiovascular disease, amputation, and renal failure. These facts are disturbing given the validated efficacy and economic benefits of secondary prevention (controlling glucose, lipid, and blood pressure levels) and tertiary prevention (screening for early diabetes complications (eye, foot, and kidney abnormalities), followed by appropriate treatment and prevention strategies.
Inadequate access to proper diabetes prevention and control programs is a major issue. There is a significant gap between what is known about the current practice of care and the recommended standard of care. Diabetes services, such as self-management training programs or eye-retina examinations, are often not part of routine diabetes care. These essential diabetes services often are provided by specialists and many diabetes "at risk" reside in medically underserved areas or are without adequate insurance and do not receive these types of preventive services. Diabetes, especially its serious complications, disproportionately affect certain racial/ethnic populations, older adults, and the rural and economically disadvantaged. Within the past five years, the incidence of Type II diabetes has been rising among school age children.
Disparities
In 2000, diabetes is approximately 57 percent more common among African American/Blacks than Whites. African American/Blacks are approximately three times as likely to die from diabetes as Whites. One in five African American/Blacks over the age of 65 has diabetes. Diabetes-associated renal failure is two and a half times as high in Hispanic/Latino individuals with diabetes compared to Whites. Most population studies indicate that American Indians are at very high risk for diabetes, and North Carolina has the largest American Indian population in the eastern United States. Diabetes is more common among people over age 60. Diabetes, and especially its serious complications, disproportionately affect rural and the economically disadvantaged people.
Determinants/Risk Factors
Family history of the disease, improper nutrition (diet high in fat and processed foods as well as high in total calories), obesity; lack of physical activity, and difficulties in managing disease due to rural living conditions, limited access to health care, lack of economic resources, and lack of education
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Heart Disease and Stroke
Objectives/Targets
Reduce heart disease death rates.
Target: 219.8 deaths per 100,000 population.
Baseline, 1996-1998: 274.7 heart disease deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: 20 percent improvement.
Reduce stroke death rates.
Target: 61.0 deaths per 100,000 population.
Baseline, 1996-1998: 76.2 stroke deaths per 100,000 population (age adjusted to the year 2000 U.S. standard population).
Target Setting Method: 20 percent improvement.
Increase the proportion of adults who have had their cholesterol checked within the preceding five years.
Target: 90.9 percent.
Baseline, 1995, 1997, 1999: 79.1 percent of adults ages 18 years and older had their blood cholesterol checked within the preceding 5 years.
Target Setting Method: 15 percent improvement.
Increase the proportion of adults who have had their blood pressure measured within the last year.
Target: 95 percent.
Baseline, 1995,1997, 1999: 88.9 percent of adults ages 18 years and older had their blood pressure measured in the past year.
Target Setting Method: Better than the best.
Chronic Disease - Heart Disease and Stroke
Cardiovascular disease (CVD) is a general term used to describe all diseases of the heart and blood vessels. CVD includes conditions such as heart attack and other coronary heart diseases (narrowing or blockage of the coronary arteries); stroke (interruption of blood flow and oxygen supply to the brain due to blockage or bleeding of the arteries); hypertension (high blood pressure); congestive heart failure; congenital heart problems; other heart diseases; and other conditions affecting blood vessels throughout the body.
Heart disease is the leading cause of death in North Carolina and the United States for men and women of every race. Stroke is the third leading cause of death. The decline in heart disease and stroke deaths over the past 30 years has slowed during the 1990's. In fact, stroke death rates have remained nearly flat, with little or no improvement, since about 1992. The coastal plains region of North Carolina has some of the very highest stroke death rates in the entire nation. This region in North Carolina, along with counties in South Carolina and Georgia, has been called the "Buckle" of the Stroke Belt. In addition, heart disease and stroke are both major causes of hospitalizations and disability, and account for a significant proportion of health care costs. Each year 22,000 North Carolinians ages 45-64 are hospitalized for a heart attack for the first time. Stroke is the leading cause of serious, long-term disability in the nation, and likely in North Carolina as well. The aging of North Carolina's population is likely to increase the incidence of CVD in North Carolina and may further slow or reverse the decades-long downward trend in death rates. North Carolina's high prevalence rates of major behavioral risk factors also portend further reversals in the progress made. For example: 80 percent of the adult population in North Carolina do not get the recommended amount of physical activity each day.
Disparities
There are significant and growing disparities between African American/Blacks and Whites in North Carolina for CVD deaths, hospitalizations, and risk factors. While hard data are lacking for other minority groups, American Indians, Hispanics/Latinos, and African American/Blacks appear to suffer disproportionately from diabetes, a major risk factor for CVD. More women die of CVD than any other cause. Being over the age of 65 is a risk factor for CVD. North Carolinians with lower household incomes have a higher prevalence of risk factors for CVD, including sedentary lifestyle, being overweight, and having diabetes.
Determinants/Risk Factors
Elevated blood cholesterol; elevated blood pressure; family history of heart disease, blood pressure, high cholesterol, and stroke; diabetes; lack of early detection and treatment; overweight/obesity; physical inactivity; diet high in fat and sodium; and tobacco use.
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Overweight and Obesity
Objectives/Targets
Reduce the percent of children and adolescents who are overweight or obese.
Target and Baseline , 1999: Children seen in health department clinics and WIC programs - specific age
Baseline, 1999:
Age > 95th percentile Target
2-4 years 11.8 10 percent
5-11 years 16.7 10 percent
12-18 years 20.3 10 percent
Target Setting Method: Better than the best.
Reduce the proportion of adults who are obese.
Target: 16.8 percent.
Baseline, 1995-1999: 19.8 percent of persons ages 18 and older were identified as obese (BMI > 25 percent).
Target Setting Method: 15 percent improvement.
Increase the proportion of adults who are at a healthy weight.
Developmental Objective, baseline data to be collected in 2001.
Chronic Disease - Overweight and Obesity
Obesity is medical condition characterized by storage of excess body fat. A measure of body mass index (BMI) is often used to determine desirable weights. BMI is calculated metrically as weight divided by height squared (kg/m2). People with a BMI of 25 to 29.9 are considered overweight and people with a BMI of 30 or above are considered obese. Elevated cholesterol levels, high blood pressure, and Type II Diabetes are associated with overweight and obesity and are independent risk factors for coronary heart disease. Being overweight or obese also increases the risk for gall bladder disease, sleep apnea, respiratory problems, some types of cancer, and have been implicated in the development of osteoarthritis. Obese individuals may also experience psychological stress although this is highly dependent on their culture. Overweight and obesity are multifactorial in origin reflecting inherited, metabolic, behavioral, environmental, cultural, psychosocial, and socioeconomic conditions. Lifestyle behaviors, diet, and physical activity are major contributors to the obesity epidemic in the United States.
Dietary behaviors are also independent risk factors for chronic disease. There is strong evidence that high intake of fruits and vegetables are associated with a decreased risk of cancer. Excessive fat intake increases the risk of developing some types of cancer and is a major contributor to cardiovascular disease.
Children
Patterns of healthy eating behavior need to begin in childhood. There is much concern about the increasing prevalence of obesity in children and adolescents. In North Carolina in 1999, data on children seen in local health department sponsored clinics indicate that approximately 11.8 percent of 2-4 year-olds were at or above the 95th percentile weight-for-height. Using the BMI measure, 16.7 percent of 5-11 year-olds and 20.3 percent of 12-18 year-olds were at or above the 95th percentile for gender and age.
In recent years there has been an alarming increase in the number of children with elevated cholesterol and blood pressure levels and adolescents with hyperinsulinimia and Type II diabetes secondary to obesity. The Cardiovascular Health in Children (CHIC) study conducted in North Carolina reported that 12.6 percent of elementary school children had high cholesterol (>200mg/dl) and 12 percent had hypertension (blood pressures exceeding the 95th percentile). Children and adolescents with early onset of risk factors for chronic disease are likely to develop complications of those diseases at a younger age than past generations
Adults
There has been an alarming increase in the number of overweight and obese persons during the last decade. Approximately 56 percent of North Carolinians are overweight. Approximately 25 percent of adult females and 20 percent of adult males in the United States are obese.
Good nutrition and dietary habits need to begin in childhood and be practiced throughout adulthood. In the United States in 1995, the total costs (medical costs and lost productivity) attributable to obesity alone amounted to an estimated $99 billion. The potential benefits from reduction in the prevalence of overweight and obesity are of considerable public health importance and deserve particular emphasis and attention.
Older Adults
Only 36 percent of adults 60 years and older reported a healthy weight between 1988-1994. This included only 34 percent African-American men and only 29 percent of African-American women. Overall only 24 percent of all respondents age 60 or older reported being obese, however 38 percent of African-American women reported being obese.
Disparities
Overweight and obesity are observed in all population groups, but obesity is particularly common among Hispanics/Latinos, African American/Blacks and American Indians, especially females of these groups. The prevalence of overweight and obesity increases with advancing age in both males and females. Some segments of the population are at higher risk for under-nutrition, such as the socially isolated, persons with disabilities (physical, mental, developmental) living in community settings, persons who are homeless, and the very old who live independently.
Determinants/Risk Factors
Overweight and Obesity
Advancing age, inactivity or no physical activity, sedentary lifestyles, and certain lifestyles (e.g., eating away from home, eating fast foods, and eating foods high in fats, sugars, and salt)
Under-Nutrition
Socially isolated persons, persons with disabilities (physical, mental, developmental) living in community settings, homeless persons, and elderly who live independently
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