Prevalence of Adults With No Known Major Risk Factors for Coronary Heart Disease -- Behavioral Risk Factor Surveillance System, 1992

Although the death rate for coronary heart disease (CHD) in the United States has declined approximately 50% since 1970, CHD remains the leading cause of death for both men and women and, in 1990, accounted for 489,340 deaths (1). National strategies and programs have targeted individual risk factors for death attributed to CHD. However, an alternative approach may be to measure the prevalence of adults who have no known risk factors for CHD. This report provides state-specific estimates of and characterizes adults who report having no known major risk factors for CHD.

Data were analyzed from 91,428 persons aged greater than or equal to 18 years who resided in 48 states and the District of Columbia and participated in the 1992 Behavioral Risk Factor Surveillance System (BRFSS), a random-digit-dialed telephone survey. The analysis examined survey responses regarding the following risk factors: current cigarette smoking (smoked at least 100 cigarettes in their lifetime and now smoking), physical inactivity (no or irregular leisure-time physical activity), overweight (body mass index greater than or equal to 27.3 for women and greater than or equal to 27.8 for men), high blood pressure (told more than once by a health professional he/she has high blood pressure or is currently taking antihypertensive medications), high blood cholesterol (ever told by a health professional he/she has high blood cholesterol), and diabetes (ever told by a doctor he/she has diabetes). Persons who reported having none of these risk factors were defined as having no known risk factors for CHD.

The results were weighted to account for the distribution of demographic characteristics in each state. To determine the actual prevalence of adults in each state with no known CHD risk factors, state-specific estimates were not standardized to a referent population. For data aggregated from all states, census data for the 1980 U.S. population were used to standardize comparisons by age, race, and educational status; aggregated analyses were restricted to black and white respondents for whom the age, race, and education distributions of the population were known. SESUDAAN was used to calculate the standard errors for the prevalence estimates (2).

Of the 91,428 respondents, 18% reported having none of the six major CHD risk factors; 35% reported having one risk factor; 29%, two risk factors; 13%, three risk factors; and 5%, four to six risk factors. In every state, less than 30% of the population had no known risk factors. The state-specific proportion of respondents with no known risk factors varied minimally; in 45 (92%) of the states, the proportion ranged from 14% to 26% (Table_1).

For both males and females, the percentage of respondents with no known risk factors was highest for 18-34-year-olds. Among males, the percentage was lowest for those aged 50-64 years, and among females, the percentage varied inversely with age (Table_2). The prevalence of no known risk factors for CHD increased directly with increasing level of education. Reported by the following BRFSS coordinators: M Scott, Alabama; P Owen, Alaska; R Porter, Arizona; L Lund, California; M Leff, Colorado; M Adams, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, Florida; E Pledger, Georgia; F Newfield, Hawaii; G Louis, Idaho; B Steiner, Illinois; R Guest, Indiana; P Busick, Iowa; K Pippert, Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, Louisiana; D Maines, Maine; A Weinstein, Maryland; R Lederman, Massachusetts; H McGee, Michigan; N Salem, Minnesota; E Jones, Mississippi; J Jackson-Thompson, Missouri; P Smith, Montana; S Huffman, Nebraska; M Atherton, Nevada; K Zaso, New Hampshire; G Boeselager, New Jersey; E Plunkett, New Mexico; C Baker, New York; C Washington, North Carolina; B Burgum-Lee, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J Grant-Worley, Oregon; C Becker, Pennsylvania; J Buechner, Rhode Island; M Lane, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, Texas; R Giles, Utah; P Brozicevic, Vermont; R Schaeffer, Virginia; T Jennings, Washington; F King, West Virginia; E Cautley, Wisconsin. P Remington, Bur of Public Health, Wisconsin Div of Health. Cardiovascular Health Studies Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The finding in this report that, in 1992, only 18% of adults reported having no known risk factors for CHD indicates that, despite improvements in the treatment and control of CHD-related conditions, a substantial percentage of adults continue to be at risk for CHD. This low prevalence underscores the need for primary prevention efforts that focus on achieving behavioral changes that prevent the occurrence of risk factors. Several of the year 2000 national health objectives target the primary prevention of specific risk factors for CHD, including overweight (objective 15.10), physical inactivity (objective 15.11), high blood cholesterol (objective 15.7), and cigarette smoking (objective 15.12) (3). Achievement of these objectives should substantially increase the number of U.S. adults who have no known major risk factors for CHD and should further reduce CHD-associated mortality.

The prevalences of two risk factors -- cigarette smoking and high blood cholesterol -- have decreased substantially. In 1965, approximately 40% of U.S. adults smoked cigarettes; in comparison, by 1991, 26% smoked cigarettes (4). In addition, from the second National Health and Nutrition Examination Survey (NHANES II) (1976- 1980) to NHANES III (1988-1991), the proportion of adults with high blood cholesterol levels (greater than or equal to 240 mg/dL) decreased from 26% to 20% (5). For other risk factors, however, prevalences have remained constant or increased. For example, when compared with 1987, the proportion of adults who engaged in no leisure-time physical activity (24%) in 1991 was unchanged, and the proportion who engaged in moderate physical activity five or more times per week increased only slightly (22% in 1987 and 24% in 1991) (6). From 1987 through 1991, the proportion of U.S. adults who were overweight increased from 26% to 28%, respectively (6). Finally, despite substantial improvements in the awareness, treatment, and control of hypertension, hypertension continues to affect an estimated 50 million persons in the United States (7).

Although the findings in this report assist in targeting efforts to reduce specific risk factors for CHD, these findings are subject to at least two limitations. First, because BRFSS estimates are based on self-reports, the prevalence of most risk factors, especially overweight and current smoking status, are likely to be underreported. Second, risk factors for which awareness is low are underreported; for example, only an estimated 29% of adults know their cholesterol level (8). Therefore, this report most likely overestimates the proportion of adults without CHD risk factors.

To assist in reducing the prevalence of CHD risk factors, health programs and organizations have intensified advocacy of primary prevention strategies. For example, the National High Blood Pressure Education Program has developed policy recommendations for implementing primary prevention interventions for hypertension (9), and the National Cholesterol Education Program has made dietary recommendations to reduce cholesterol levels (10). The need for the primary prevention of CHD risk factors also is important because education or treatment of persons with established risk factors may not reduce their risk to the level of persons who never have the risk factor; for example, persons who effectively control their hypertension remain at higher risk for CHD than do persons who never develop hypertension (9).

References

1. American Heart Association. 1993 Heart and stroke facts statistics. Dallas: American Heart Association, 1992.

2. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

4. CDC. Cigarette smoking among adults -- United States, 1991. MMWR 1993;42:230-3.

5. Sempos CT, Cleeman JI, Carroll MD, et al. Prevalence of high blood cholesterol among US adults: an update based on guidelines from the second report of the National Cholesterol Education Program Adult Treatment Panel. JAMA 1993;269:3009-14.

6. CDC. Health, United States, 1992, and healthy people 2000 review. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1993; DHHS publication no. (PHS)93-1232.

7. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993;153:154-83.

8. CDC. Cholesterol screening and awareness -- Behavioral Risk Factor Surveillance System, 1990. MMWR 1992;41:669,675-8.

9. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med 1993;153:186-208.

10. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;269:3015-23.

Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Percentage of adults who reported having no known major risk factors for
coronary heart disease,* by state -- Behavioral Risk Factor Surveillance System, 1992
==================================================================================================
                       % With                                          % With
               Sample  no risk                                 Sample  no risk
State           size   factors  (95% CI +)   º   State          size   factors  (95% CI)
----------------------------------------------------------------------------------------
Alabama         2115    24.5    (+/-2.0)     º  Montana         1160    22.8    (+/-2.8)
Alaska          1463    26.4    (+/-3.6)     º  Nebraska        1527    21.1    (+/-2.4)
Arizona         1737    19.9    (+/-2.7)     º  Nevada          1561    22.8    (+/-2.5)
California      3831    24.8    (+/-1.6)     º  New
Colorado        1753    28.2    (+/-2.4)     º   Hampshire      1408    23.8    (+/-2.7)
Connecticut     1630    21.0    (+/-2.2)     º  New Jersey      1363    19.6    (+/-2.4)
Delaware        1417    19.3    (+/-2.5)     º  New Mexico      1127    21.6    (+/-2.8)
District of                                  º  New York        2227    18.1    (+/-1.8)
 Columbia       1405    19.4    (+/-2.6)     º  North Carolina  2012    17.5    (+/-1.9)
Florida         2613    20.4    (+/-1.7)     º  North Dakota    1731    19.9    (+/-2.2)
Georgia         1903    17.8    (+/-2.1)     º  Ohio            1232    16.7    (+/-2.3)
Hawaii          1853    21.5    (+/-2.3)     º  Oklahoma        1419    18.7    (+/-2.6)
Idaho           1697    25.1    (+/-2.4)     º  Oregon          3158    26.0    (+/-1.7)
Illinois        2095    19.9    (+/-2.0)     º  Pennsylvania    2309    18.7    (+/-1.8)
Indiana         2277    17.2    (+/-1.9)     º  Rhode Island    1733    24.5    (+/-2.3)
Iowa            1601    18.9    (+/-2.2)     º  South Carolina  1860    14.4    (+/-2.0)
Kansas          1338    23.6    (+/-2.6)     º  South Dakota    1667     9.4    (+/-1.6)
Kentucky        2039    15.2    (+/-1.9)     º  Tennessee       2582    16.9    (+/-1.6)
Louisiana       1560    15.9    (+/-2.2)     º  Texas           2361    21.1    (+/-1.9)
Maine           1205    20.7    (+/-2.6)     º  Utah            1721    28.9    (+/-2.4)
Maryland        2038    18.5    (+/-1.9)     º  Vermont         1819    24.7    (+/-2.3)
Massachusetts   1408    26.1    (+/-2.6)     º  Virginia        1683    24.1    (+/-2.3)
Michigan        2344    18.6    (+/-1.8)     º  Washington      2425    26.9    (+/-2.0)
Minnesota       3339    22.4    (+/-1.6)     º  West Virginia   2318    14.1    (+/-1.6)
Mississippi     1450    14.3    (+/-2.2)     º  Wisconsin       1469    20.6    (+/-2.5)
Missouri        1440    18.5    (+/-2.2)     º
----------------------------------------------------------------------------------------
* Risk factors: current cigarette smoking (smoked at least 100 cigarettes in their lifetime and
  now smoking), physical inactivity (no or irregular leisure-time physical activity), overweight
  (body mass index >=27.3 for women and >=27.8 for men), high blood pressure (told more than
  once by a health professional he/she has high blood pressure or is currently taking antihyper-
  tensive medications), high blood cholesterol (ever told by a health professional he/she has
  high blood cholesterol), and diabetes (ever told by a doctor he/she has diabetes)
+ Confidence interval.
==================================================================================================

TABLE 2. Percentage of adults who reported having no known major risk factors for
coronary heart disease, * by age group, education level, and sex -- Behavioral Risk
Factor Surveillance System, 1992
==================================================================================================
                                    Men                              Women
                      -------------------------------    -----------------------------
                      Sample   % With no                 Sample   % With no
  Characteristic       size   risk factor  (95% CI +)     size   risk factor  (95% CI)
--------------------------------------------------------------------------------------
  Age group (yrs) &
    18-34             12,202     24.5      (+/-1.3)      14,647     22.7      (+/-1.1)
    35-49             11,652     12.6      (+/-0.9)      13,955     17.9      (+/-1.0)
    50-64              6,598      9.4      (+/-1.0)       8,515     11.6      (+/-0.9)
     >=65              5,601     13.4      (+/-1.2)      10,488      9.2      (+/-0.8)
  Education (yrs) @
    <12                4,961     10.4      (+/-1.5)       7,145      8.5      (+/-1.2)
     12               11,577     14.6      (+/-0.9)      16,941     15.9      (+/-0.8)
    >12               19,515     25.4      (+/-0.9)      23,519     26.9      (+/-0.8)
--------------------------------------------------------------------------------------
* Risk factors: current cigarette smoking (smoked at least 100 cigarettes in their lifetime and
  now smoking), physical inactivity (no or irregular leisure-time physical activity), overweight
  (body mass index >=27.3 for women and >=27.8 for men), high blood pressure (told more than
  once by a health professional he/she has high blood pressure or is currently taking antihyper-
  tensive medications), high blood cholesterol (ever told by a health professional he/she has
  high blood cholesterol), and diabetes (ever told by a doctor he/she has diabetes).
+ Confidence interval.
& Age comparisons were standardized for education and race by using 1980 U.S. Bureau of the
  Census data.
@ Number of years completed; education comparisons were standardized for age and race by
  using 1980 U.S. Bureau of the Census data.                                              *.
==================================================================================================

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