1. Chronic Disease in Missouri: Progress and Challenges Shumei Yun, MD, PhD Public Health Epidemiologist and Team Leader Chronic Disease and Nutritional Epidemiology Team Section of Epidemiology for Public Health Practices July 12, 2012

2. Acknowledgement Chronic Disease and Nutritional Epidemiology Team (CDNET) members – Jiaqing Li, MD, PhD – Noaman Kayani, PhD – Dave McBride, PhD – Arthur Pashi, PhD – Janet Wilson, MEd, MPA – Sherri Homan, RN, FNP, PhD

3. Acronyms List AA – African-American BRFSS - Behavioral Risk Factor Surveillance System CDC – Centers for Disease Control and Prevention CLS – Missouri 2007 County-level Study DHSS - Missouri Department of Health and Senior Services F & V <5 - Fruit and vegetable consumption less than 5 times per day HP2020 - Healthy People 2020 Objective HS - High School Low SES – Low Socioeconomic Status MICA - Missouri Information for Community Assessment MO – State of Missouri PedNSS - Missouri Pediatric Nutrition Surveillance System US – United States of America WONDER – Wide-ranging Online Data for Epidemiological Research YRBS - Youth Risk Behavior Survey YTS - Youth Tobacco Survey

4. Chronic Diseases in the US Almost 1 out of every 2 adults has at least one chronic illness. Chronic diseases are the number one cause of death and disability in the US. Treating patients with chronic diseases accounts for 75 percent of the nation’s health care spending.

5. Chronic Diseases in the US Chronic diseases share major risk factors beyond genetics and social inequalities: – Tobacco use – Unhealthy diet – Physical inactivity – Heavy drinking – Lack of access to preventive care The vast majority of cases of chronic disease could be better prevented or managed. Some populations have a greater burden of chronic disease than others.

6. Leading Causes of Death Missouri, 2009 Source: Missouri Department of Health and Senior Services, Missouri Information for Community Assessment

7. Heart Disease Mortality Rates* Missouri and US, 2000-2009 Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

8. Heart Disease Mortality Rates* By Race and Sex Missouri, 2000-2009 Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

9. Cerebrovascular Disease Mortality Rates* Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER, HP2020 *Age-adjusted using 2000 US standard population

10. Cerebrovascular Disease Mortality Rates* By Race and Sex, Missouri, 2000-2009 Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

11. Major Risk Factors for Cardiovascular Diseases Behaviors – Tobacco use – Unhealthy diets – Physical inactivity – Heavy drinking Chronic conditions/disease – Hypertension – Dyslipidemia – Obesity – Diabetes Lack of chronic disease management and self- management

12. Risk Behaviors

13. Current Smoking Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

14. Current Smoking among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

15. Current Smoking Among Adults By Education Level, Missouri Source: Behavioral Risk Factor Surveillance System

16. Current Smoking Among Adults By Insurance Status, Missouri, 2007 Source: Missouri 2007 County-Level Study

17. Current Smoking Among Middle School Students By Race, Missouri Source: Youth Tobacco Survey

18. Current Smoking Among High School Students Missouri and US Source: Youth Risk Behavior Survey

19. Current Smoking Among High School Students By Race, Missouri Source: Youth Tobacco Survey

20. Fruit and Vegetable Intake <5 Times Per Day Among Adults, Missouri and US Source: Behavioral Risk Factor Surveillance System

21. Fruit and Vegetable Intake <5 Times Per Day Among Adults, By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

22. No Leisure-time Physical Activity Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

23. No Leisure-time Physical Activity Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

24. Did not meet CDC Physical Activity Recommendations Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

25. Did not meet CDC Physical Activity Recommendations Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

26. Heavy Drinking Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

27. Heavy Drinking Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

28. Chronic Conditions

29. Prevalence of Hypertension Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

30. Prevalence of Hypertension Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

31. Prevalence of High Cholesterol Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

32. Prevalence of High Cholesterol Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

33. Prevalence of Obesity Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

34. Prevalence of Obesity Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

35. Prevalence of Obesity* Among Children aged 2 to 5 Years Enrolled in WIC, Missouri, 2009

36. Prevalence of Obesity Among Middle School Students Missouri Source: Youth Tobacco Survey

37. Prevalence of Obesity Among Middle School Students By Race and Sex, Missouri Source: Youth Tobacco Survey

38. Prevalence of Obesity Among High School Students Missouri and US Source: Youth Risk Behavior Survey

39. Prevalence of Obesity Among High School Students By Race, Missouri Source: Youth Risk Behavior Survey

40. Prevalence of Diabetes Among Adults Missouri and US Source: Behavioral Risk Factor Surveillance System

41. Prevalence of Diabetes Among Adults By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

42. Education, Risk Behaviors and Health Conditions Missouri, 2010 Source: Behavioral Risk Factor Surveillance System

43. Chronic Disease Self-management

44. Ever Attended a Diabetes Self-management Class Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

45. Ever Attended a Diabetes Self-management Class Among Adults with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

46. Daily Self-Monitoring of Blood Glucose Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

47. Daily Self-Monitoring of Blood Glucose Among Adults with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

48. Ever Taken a Course to Learn How to Manage Arthritis or Joint Symptoms Among Adults with Arthritis Missouri and US Source: Behavioral Risk Factor Surveillance System

49. Ever Taken a Course to Learn How to Manage Arthritis or Joint Symptoms Among Adults with Arthritis By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

50. Current Smoking Among Adults with Chronic Disease Missouri 2008-2010

51. Current Smoking Among Adults with Chronic Disease/Conditions By Insurance Status, Missouri, 2007 Source: Missouri 2007 County-Level Study

52. Current Smoking Among Adults with Chronic Diseases By Education Level, Missouri, 2008-2010 Source: Behavioral Risk Factor Surveillance System

53. Physical Inactivity Among Adults with Chronic Disease/Conditions Missouri, 2009 Source: Behavioral Risk Factor Surveillance System

54. Chronic Disease Management and Care

55. Had 2 or More A1c Tests in the Last Year Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

56. Had 2 or more A1c Tests in the Last Year Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

57. Had a Foot Exam in the Last Year Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

58. Had a Foot Exam in the Last Year Among Adults with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

59. Had a Dilated Eye Exam in the Last Year Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

60. Had a Dilated Eye Exam in the Last Year Among Adults with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

61. Had a Flu Shot in the Last Year Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

62. Had a Flu Shot in the Last Year Among People with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

63. Ever Had a Pneumococcal Vaccination Among Adults with Diabetes Missouri and US Source: Behavioral Risk Factor Surveillance System

64. Ever Had a Pneumococcal Vaccination Among Adults with Diabetes By Race and Sex, Missouri Source: Behavioral Risk Factor Surveillance System

65. Good Job! Chronic disease management and self- management – Chronic disease self-management education – Self-monitor blood glucose – Foot exam – Vaccinations among people with diabetes

66. Cancer Cancer affects three out of four Missouri families. Cancer is the leading cause of death for individuals younger than 80 years of age and the leading cause of premature death. In 2010, cancer cost $263.8 billion, including $102.8 billion for direct medical costs. Cancer screening is very important.

67. Cancer Incidence Mortality Screening

68. All-Cancer Incidence Rates*by Sex Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using the 2000 US standard population

69. All-cancer Incidence Rates* by Race and Sex Missouri *Age-adjusted using the 2000 US standard population Source: Missouri Information for Community Assessment

70. All-cancer Mortality Rates* by Sex Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

71. All-cancer Mortality Rates* by Race and Sex Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

72. Lung Cancer Incidence Rates*by Sex Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

73. Lung Cancer Incidence Rates* by Race and Sex Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

74. Lung Cancer Mortality Rates* Missouri and US Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

75. Lung Cancer Mortality Rates*by Race and Sex Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

76. Breast Cancer Incidence Rates* Among Women Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

77. Breast Cancer Incidence Rates* Among Women By Race, Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

78. Breast Cancer Mortality Rates* Among Women Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

79. Breast Cancer Mortality Rates*by Race Missouri Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

80. Had Mammogram Within the Past Two Years Among Women Age 40+ Missouri and US Source: Behavioral Risk Factor Surveillance System

81. Had Mammogram Within the Past Two Years Among Women Age 40+ By Race, Missouri Source: Behavioral Risk Factor Surveillance System

82. Prostate Cancer Incidence Rates* Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

83. Prostate Cancer Incidence Rates* by Race Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

84. Prostate Cancer Mortality Rates* Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

85. Prostate Mortality Rates* by Race Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

86. Colorectal Cancer Incidence Rates* by Sex Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

87. Colorectal Cancer Incidence Rates* By Race and Sex, Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

88. Colorectal Cancer Mortality Rates* Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

89. Colorectal Cancer Mortality Rates* By Race and Sex, Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

90. Ever had a Sigmoidoscopy or Colonoscopy Among Adults Age 50+ Missouri and US Source: Behavioral Risk Factor Surveillance System

91. Ever had a Sigmoidoscopy or Colonoscopy Among Adults Age 50+ by Race and Sex Missouri Source: Behavioral Risk Factor Surveillance System

92. Cervical Cancer Incidence Rates* Missouri and US Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

93. Cervical Cancer Incidence Rates* by Race Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

94. Cervical Cancer Mortality Rates* Missouri and US Source: Missouri Information for Community Assessment, CDC-WONDER *Age-adjusted using 2000 US standard population

95. Cervical Cancer Mortality Rates* by Race Missouri Source: Missouri Information for Community Assessment *Age-adjusted using 2000 US standard population

96. Had a Pap Test Within the Past 3 Years Among Women Age 18+ Missouri and US Source: Behavioral Risk Factor Surveillance System

97. Had a Pap Test Within the Past 3 Years Among Women Age 18+ by Race Missouri Source: Behavioral Risk Factor Surveillance System

98. Similar to or Better than the US Heavy drinking Chronic disease management and self-management (better) – Diabetes self-management education – Daily self-monitoring blood glucose – Having a foot exam in the last year among adults with diabetes – Flu shoot and pneumococcal vaccination among adults with diabetes Breast cancer screening (better) Colorectal cancer screening Cervical cancer screening All-cancer incidence (better) Breast cancer incidence Cervical cancer incidence Prostate cancer incidence and mortality (better)

99. Worse than the US Risk behaviors (except heavy drinking) Disease and conditions Cancer incidence (lung, colorectal) A1C test and dilated eye exam among adults with diabetes Heart disease, cancer, and stroke mortality

100. Progress Behaviors – Current smoking prevalence among youth and adults (white men) – Not meeting CDC physical activity recommendation (white men and women) – Heavy drinking among AA men – Colorectal cancer screening (white men and women) – Diabetes self-management education, especially AA women – Self-monitoring blood glucose up to 2008 – Flu shot among AA men with Diabetes – Pneumococcal Vaccination among adults with diabetes, especially AA men

101. Progress Cancer Incidence – Colorectal cancer incidence (except AA men) – Lung cancer incidence ( white and AA men) and racial disparity – Cervical cancer incidence and racial disparity – Breast cancer incidence Mortality – Heart disease and stroke mortality rates – All cancer mortality rates and racial disparity – Colorectal cancer mortality (white men and women) – Lung cancer mortality (white and AA men) and racial disparity – Breast cancer mortality and racial disparity – Prostate cancer mortality and racial disparity

102. Challenges Smoking – Burden – Disparity (low education, on Medicaid, no insurance, AA men) Physical inactivity – Burden – Disparity (Low SES, AA) Inadequate fruit and vegetable consumption (healthy eating) – Burden

103. Challenges Hypertension – Burden – Trend – Disparity ( Low SES, AA) High cholesterol – Burden – Trend Obesity – Burden – Trend – Disparity (Low SES, AA) Diabetes – Burden – Trend – Disparity (Low SES, AA)

104. Challenges Chronic disease self-management – Smoking prevalence among people with chronic disease/conditions (especially those who are on Medicaid, Low SES) – Physical inactivity among people with chronic disease/conditions – A1C test among people with diabetes – Annual dilated eye exam among people with diabetes

105. Challenges All-cancer incidence – Disparity (white men and AA men) Lung cancer incidence – Burden – Disparity Colorectal cancer incidence – Burden – Disparity (especially among men) Prostate cancer incidence – Racial disparity

106. Challenges All-cancer mortality – Burden – Disparity (white and AA) Lung cancer mortality – Burden Breast cancer mortality – Burden Colorectal cancer mortality – Burden – Disparity Cervical cancer mortality – Burden and disparity Prostate Cancer mortality – Disparity Data gaps

107. Highlights Progress – Tobacco control Adults and youth smoking prevalence has declined – Colorectal cancer prevention and control Screening increased Incidence decreased Mortality decreased Challenges – Tobacco control People with less than high school education People who are on Medicaid and who are uninsured – Colorectal cancer prevention and control Incidence and mortality higher than the US Racial disparities

108. Highlights What Mo did well – Secondary and tertiary prevention What Mo did not do well – Primary prevention High prevalence risk behaviors High prevalence chronic conditions/diseases

109. Highlights Physical inactivity Unhealthy diet Tobacco use Obesity High cholesterol High blood pressure Diabetes Heart attack Stroke Primary Prevention

110. Resource List DHSS – Missouri Department of Health and Senior Services MICA – Missouri Information for Community Assessment CDC – Centers for Disease Control and Prevention WONDER – Wide-ranging Online Data for Epidemiological Research AA – African-American HP2020 – Healthy People 2020 Objectives BRFSS – Behavioral Risk Factor Surveillance System CLS – Missouri 2007 County-level Study YTS – Youth Tobacco Survey YRBS – Youth Risk Behavior Survey PedNSS – Missouri Pediatric Nutrition Surveillance System HS – High School F & V <5 – Fruit and vegetable consumption less than 5 times per day Low SES – Low Socio-econimic Status

111. Thank You Shumei Yun, MD, PhD Shumei.yun@health.mo.gov