Preventable Chronic Disease in U.S. Metropolitan Areas
Chronic disease in the United States is responsible for a range of social and economic problems, including rising health care costs, reduced productivity, increased disability, and premature death. The prevalence of chronic diseases has grown significantly over the past several decades and is projected to continue growing as the population ages. Researchers have also linked rising disease prevalence to the dramatic recent growth in the obesity rate among Americans.
These troubling trends for the financial and physical well-being of the nation have generated interest in finding ways to reduce the burden of chronic illness. Urban Institute researchers estimate that roughly one-third of health expenditures in the United States are attributable to a cluster of chronic conditions-diabetes, hypertension, heart disease, stroke, and renal disease-that may be amenable to prevention through lifestyle changes. Prevention approaches seek to modify behavioral risk factors including smoking, diet, and lack of exercise. Several promising interventions of this type have been subject to clinical trials and have effectively reduced the prevalence of both the risk factors and the associated diseases. The Affordable Care Act of 2010 included new funding for such interventions through the Prevention and Public Health Fund, although one-third of the original funding was cut earlier this year.
This reduction in funding makes it even more important to target prevention resources as efficiently as possible. This commentary uses data from the Behavioral Risk Factor Surveillance System (BRFSS) to identify metropolitan areas in the United States where the prevalence of preventable disease and risk factors is the highest. The BRFSS is a cross-sectional telephone survey conducted by state health departments with technical and methodological assistance provided by the Centers for Disease Control and Prevention. In 2009, the BRFSS collected data on 432,607 noninstitutionalized adults. For this analysis, I limited the sample to people living in the top 100 metropolitan areas, 78 of which contained a sufficient number of cases for analysis.
The map in Figure 1 contains data on the prevalence of three chronic diseases-diabetes, hypertension, and heart disease-and three behavioral risk factors-obesity, smoking, and lack of exercise. To focus on geographic differences in prevalence rates rather than age distribution, these rates have been standardized to the national age distribution. Figure 1 shows the following ranges:
- The share of adults who smoke shows the largest relative difference from highest to lowest rates by metro area: 28.9 percent in Scranton-Wilkes-Barre, Pennsylvania, compared with 7.9 percent in San Jose-Sunnyvale-Santa Clara, California.
- The share reporting no physical exercise in the last month ranges from 14.2 percent in Minneapolis-St. Paul-Bloomington, Minnesota, to 40.3 percent in McAllen-Edinburg-Mission, Texas.
- The obesity rate ranges from 16.1 percent in Bridgeport-Stamford-Norwalk, Connecticut, to 34.5 percent in Jackson, Mississippi.
- The rate of diagnosed diabetes or pre-diabetes ranges from 6.6 percent in Bridgeport to 14.0 percent in El Paso, Texas.
- Hypertension ranges from 21.8 percent in Bridgeport to 41.2 percent in Memphis, Tennessee.
- Heart disease ranges from 2.8 percent in Bridgeport to 5.5 percent in Jacksonville, Florida.
To identify the areas most and least in need of prevention initiatives, Table 1 combines the data on individual risk factors and diseases, pinpointing the areas ranked consistently high or low across multiple measures. The areas classified as highest risk are those with the largest number of indicators ranked in the top 10 nationwide, while those classified as lowest risk are those with the largest number of indicators in the bottom 10 nationwide. At the top of the list of high-risk areas are Tulsa, Oklahoma, and Louisville-Jefferson County, Kentucky. While neither has the distinction of topping the list on any one measure, both have 5 of 6 measures in the top 10. Chattanooga, Tennessee; Jackson; and Memphis each have 4 out of 6 measures in the top 10.
The areas ranked consistently near the bottom of disease and risk-factor prevalence include Bridgeport-Stamford-Norwalk, where all 6 indicators are in the bottom 10 and 4 are the lowest of any metro area; Denver-Aurora, Colorado, and San Jose-Sunnyvale-Santa Clara, where 5 of 6 indicators rank in the bottom 10, and Colorado Springs and Minneapolis-St. Paul-Bloomington, where 4 of 6 indicators are near the bottom nationally.
Local governments have a significant role in designing and implementing initiatives that can improve diet and exercise and reduce smoking. If successful at reducing disease prevalence rates, as demonstration projects have shown is possible, the benefits of these interventions would be shared broadly. Taxpayers and employers benefit from reduced public- and private-sector health costs, and families benefit from reduced rates of disability and premature death.
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