the risk of heart disease and stroke in alabama: burden document

te risk of eart disease and stroke in alabama: burden document finding te Pat to CardioVasCUlar ealt 21

table of Contents executive Summary... 1 demograpic caracteristics of Alabama... 2 Leading causes of deat... 3 cardiovascular disease... 4 Heart disease... 8 Stroke... 11 cardiovascular risk Factors: Hig blood Pressure... 14 cardiovascular risk Factors: Hig blood colesterol... 16 cardiovascular risk Factors: diabetes... 18 cardiovascular risk Factors: overweigt and obesity... 2 cardiovascular risk Factors: Smoking... 22 cardiovascular risk Factors: Pysical Inactivity... 24 cardiovascular risk Factors: Fruit and Vegetable consumption... 26 economic cost of cardiovascular disease... 28 Access to care... 29 Signs and Symptoms of Heart Attack or Stroke... 32 Sodium consumption... 33 references... 34

executive summary cardiovascular disease (cvd), wic includes eart disease and stroke, is te leading cause of deat in te united States and in Alabama. Heart disease, te most common form of cvd, is te single leading cause of deat in Alabama. In 26, eart disease accounted for 12,583 (26.7 percent) deats in te state. men continue to ave a iger age-adjusted eart disease mortality rate tan women. coronary eart disease, te most common type of eart disease, can result in a eart attack. Heart attacks may be preventable by modifying risk factors. brain attack, a cerebrovascular accident (cva) also known as stroke, is te tird leading cause of deat in Alabama, following eart disease and cancer. In 26, strokes accounted for 2,74 (5.83 percent) deats in te state. men are about 5 percent more likely to die from stroke tan women, and tere are strong race/etnic differences. blacks ave significantly iger age-adjusted stroke mortality rates wen compared to wites. As wit eart disease, cerebrovascular accidents can be preventable by modifying risk factors. modifiable risk factors for eart disease and stroke are as follows: 1. Hig blood pressure 2. Hig blood colesterol 3. diabetes 4. overweigt and obesity 5. Smoking 6. Pysical inactivity 7. Inadequate fruit and vegetable consumption compared to te nation, Alabama continues to ave a ig prevalence of tese risk factors. te following Alabama statistical data compiled in 29 revealed tat all tese factors contributed to an increase in cvd in te state. 27.2 percent of Alabama adults reported being affected by ig blood pressure. 39.9 percent of Alabama adults were diagnosed wit elevated blood colesterol. Prevalence of diabetes in Alabamians is 12.2 percent an increase of 74 percent since 1998. currently, 68.1 percent of obese and overweigt individuals in Alabama ave multiple risk factors tat contribute to cvd. 22.5 percent of Alabama adults are smokers doubling an individual s risk for cvd. 31 percent of Alabama adults indicated tey were pysically inactive. only 2.6 percent of Alabama adults met recommended fruit and vegetable intake requirements. Focusing on prevention can elp reduce deats from eart disease and stroke by: 1. reducing risk factors 2. Increasing public awareness of warning signs and symptoms of eart attack and stroke 3. decreasing te time between te appearance of warning signs and symptoms and te receipt of appropriate medical care tis report provides details about te burden of cvd by describing te mortality rates and risk factors associated wit eart disease and stroke. finding te Pat to CardioVasCUlar ealt 21 1

demograpics table 1: demograpic CaraCteristiCs of alabama, 28 demograpic Variable AL (#) AL (%) u.s. total PoPUlation 4,625,354 (x) 31,237,73 male 2,239,148 48.4 49.3% Female 2,386,26 51.6 5.7% median age (years) 37.3 (x) 36.7 under 5 years 34,772 6.6 6.9% 5-17 years 814,745 17.6 17.6% 18 years and over 3,55,837 75.8 75.5% 65 years and over 625,94 13.5 12.6% one race 4,568,89 98.8 97.8% Wite 3,254,119 7.4 74.3% black or African-American 1,29,666 26.2 12.3% American Indian or Alaska native 22,66.5.8% Asian 44,778 1. 4.4% two or more races 56,464 1.2 2.2% Hispanic or Latino (of any race) 122,924 2.7 15.1% civilian veterans (civilian population 18 years and over) 46,777 11.7 1.1% Foreign born 132,599 2.9 12.5% male, married, except separated (population 15 years and over) 956,12 54.1 52.2% Female, married, except separated (population 15 years and over) 937,34 48.4 48.2% Speak a language oter tan englis at ome (population 5 years and over) 18,916 4.2 19.6% (x) te value is not applicable or not available. Source: united States census bureau, 28 2 te risk of eart disease and stroke in alabama: burden document

figure 1: leading CaUses of deat in alabama, 26 all oter CaUses 36.2% eart disease 26.7% stroke 5.8% CanCer 21.1% CroniC lower respiratory disease 4.9% accidents 5.3% cvd is te leading cause of deat and disability in Alabama. Heart disease is te leading cause of deat in Alabama and kills over 12, residents eac year. Stroke is te tird leading cause of deat, killing nearly 3, Alabamians eac year. 26.7 percent of te deats in Alabama were due to eart disease and 5.8 percent were due to stroke in 26. Source: centers for disease control and Prevention (cdc) Wonder finding te Pat to CardioVasCUlar ealt 21 3

CardioVasCUlar disease cvd refers to a wide variety of eart and blood vessel diseases, including iscemic eart disease, ypertension, stroke, and reumatic eart disease. cvd accounts for more deats in Alabama tan any oter cause of deat. Altoug cvd remains te number one cause of deat for Alabamians, many adults do not recognize te signs and symptoms of a eart attack or stroke. most victims surviving a eart attack or stroke often require long-term, expensive medical treatment, and experience a compromised quality of life. tere are decreasing trends in mortality rates for cvd and stroke in Alabama. (Figure 2) figure 2: age-adjusted mortality rates for CVd, eart disease, and stroke in alabama, 1999-26 4 35 396.6 393.7 379.8 377.7 37.6 355.7 349.3 33.9 rate Per 1, 3 25 2 15 33. 299.5 289.7 285.7 28.9 269.3 264.5 254. 1 5 71.5 71.5 66.1 69.5 64.9 63.1 6.9 55.5 1999 2 21 22 23 24 year 25 26 CVd Source: cdc Wonder eart disease stroke 4 te risk of eart disease and stroke in alabama: burden document

cvd, a preventable disease, includes conditions of te eart, arteries, and veins tat supply oxygen to vital life-sustaining s of te body like te brain, te eart, and oter vital organs. If oxygen does not arrive, te tissue or organ will die. In Alabama, as in te nation, cvd, including eart disease and stroke, is te leading cause of deat. About one-tird of adult Americans ave some form of cvd. In 26, te age-adjusted deat rate for Alabama was 33.9 per 1, population, a decrease from 396.6 in 1999. cvd age-adjusted deat rates in Alabama exceeded te comparable rates for te united States over te past eigt years. (Figure 3) figure 3: age-adjusted deat rates for CVd in alabama and te United states, 1999-26 4 35 3 396.6 35.8 393.7 341.4 379.8 377.7 328.2 319. 37.6 37.7 355.7 288. 349.3 278.9 33.9 262.5 rate Per 1, 25 2 15 1 5 1999 2 21 22 23 24 25 26 year alabama United states Source: cdc Wonder finding te Pat to CardioVasCUlar ealt 21 5

figure 4: CardioVasCUlar deats by age GroUP in alabama, 26 6 5 5,33 4,733 number of deats 4 3 2 1,925 2,749 1 1,256 682 <45 45-54 55-64 65-74 75-84 85+ age in years Source: cdc Wonder Age is a non-modifiable risk factor for cvd. te number of cvd deats increases significantly wit age. deats from cvd occurred often in tose over te age of 75. nearly one out of four deats from cvd occurred in tose below te age of 65 in 26. (Figure 4) figure 5: age-adjusted deat rates for CVd by Gender and race in alabama, 26 6 5 54.9 rate Per 1, 4 3 2 366.7 336.6 267.8 1 male Gender female Source: cdc Wonder black wite In 26, te age-adjusted deat rate was igest among black males (54.9/1, population). males were at a iger risk of dying due to cvd tan females in 26. overall, blacks ad a iger age-adjusted deat rate compared to wites. (Figure 5) 6 te risk of eart disease and stroke in alabama: burden document

figure 6: CVd mortality rate in alabama by CoUnty, 22-26 Combined LAMAR LAUDERDALE LIMESTONE MADISON JACKSON 392.1 33.2 LAWRENCE MORGAN DEKALB MARSHALL MARION WINSTON CULLMAN BLOUNT FAYETTE ST. CLAIR JEFFERSON PICKENS TUSCALOOSA SHELBY GREENE SUMTER MARENGO CHOCTAW WASHINGTON MOBILE 271.5 36.4 COLBERT FRANKLIN 415.5 CLARKE HALE WALKER PERRY WILCOX BIBB CHILTON AUTAUGA LOWNDES COOSA ELMORE ETOWAH CALHOUN CHEROKEE RANDOLPH CLAY CHAMBERS TALLAPOOSA 455.6 MACON 274.5 DALLAS MONTGOMERY RUSSELL ESCAMBIA 384. 344.9 388.1 398.6 391.9 347.8 354.6 392.6 345.4 465.5 44.4 44.7 47.6 333.3 352.7 372.4 382.2 461. 42.2 419.1 425. 332.7 426.9 393. 453. BUTLER COVINGTON 422.5 41.3 414.8 386. 366.8 415.8 325.5 311.7 416.8 417.7 BULLOCK PIKE BARBOUR CRENSHAW MONROE HENRY CONECUH DALE COFFEE 341.7 411.2 357. 334.4 46.8 352.1 313.7 476. 369.3 369.4 4.7 423.3 CLEBURNE 388.8 394.3 4.2 TALLADEGA 361.2 377.9 476.1 353.9 GENEVA 323.6 356.7 343.6 LEE 375.7 HOUSTON 321. BALDWIN 293.8 Age-Adjusted per 1, Source: cdc Wonder cvd mortality rate 271.5-347.8 352.1-386. 388.1-415.5 415.8-476.1 finding te Pat to CardioVasCUlar ealt 21 7

eart disease Heart disease is a grouping of various conditions of te eart including coronary eart disease, congestive eart failure, eart attack, ypertension, and oters. It is te leading cause of deat for bot men and women. more tan 6, deats occur eac year in te united States. It is te most common form of cvd and can cause angina (cest pain), myocardial infarction (eart attacks), and cardiac arrest. many times, a eart attack is te first sign of eart disease. In 26, te age-adjusted mortality rate for eart disease was 254. per 1, population in Alabama and 2.2 per 1, population in te united States. Heart disease deat rates in Alabama ave sown to be consistently iger tan te united States eart disease deat rates since 1999. (Figure 7) figure 7: age-adjusted deat rates for eart disease in alabama and te United states, 1999-26 3 25 33. 266.4 299.5 289.7 285.7 257.6 247.8 24.8 28.9 232.3 269.3 264.5 254 rate Per 1, 2 15 1 217. 211.1 2.2 5 1999 2 21 22 23 24 year 25 26 Source: cdc Wonder alabama United states 8 te risk of eart disease and stroke in alabama: burden document

figure 8: eart disease deats by age GroUP in alabama, 26 number of deats 4 3 2 1 3,558 3,824 2,1 1,545 998 558 <45 45-54 55-64 65-74 75-84 85+ Source: cdc Wonder age in years deats from eart disease increase wit age. A total of 12,583 people died from eart disease in Alabama during 26. twenty-five percent of te deats occurred in tose below te age of 65. te majority of deats from eart disease occur in individuals 75 years of age and older. (Figure 8) figure 9: age-adjusted deat rates for eart disease by Gender and race in alabama, 26 4 357.3 rate Per 1, 3 2 1 299.1 237.9 23.5 male Source: cdc Wonder Gender female black wite In 26, te age-adjusted mortality rate for eart disease was igest among black males wit a rate of 357.3 per 1, population. risk of deat from eart disease was iger among males compared to females. risk of deat from eart disease was sligtly iger among blacks compared to wites. (Figure 9) finding te Pat to CardioVasCUlar ealt 21 9

figure 1: eart disease mortality rate in alabama by CoUnty, 22-26 Combined SUMTER 296.1 CHOCTAW 33.3 263.1 LAMAR WASHINGTON 278.4 MOBILE 277. 32.9 PICKENS GREENE LAUDERDALE 289.6 197.9 289.1 COLBERT 33.6 FRANKLIN 32.5 313.4 MARION 392.5 FAYETTE MARENGO CLARKE 256.4 247.2 TUSCALOOSA 298.2 HALE 348. 231.7 LAWRENCE 333.3 WINSTON 389.6 PERRY WILCOX MONROE WALKER BIBB 253.3 291.9 337.4 258.2 LIMESTONE MORGAN CULLMAN JEFFERSON SHELBY CHILTON BLOUNT AUTAUGA LOWNDES MARSHALL ST. CLAIR COOSA ELMORE ETOWAH DEKALB CALHOUN CLAY TALLAPOOSA CHEROKEE RANDOLPH CHAMBERS 351.1 MACON 197.3 DALLAS MONTGOMERY RUSSELL ESCAMBIA 261.5 CONECUH 277.9 238.4 316.9 31.8 338.7 BUTLER MADISON 226.8 286.1 233.1 31. 377.2 388.1 CRENSHAW COVINGTON 283.5 34.2 335.4 JACKSON 345.1 297.5 273.7 36.7 261.3 254.1 233. 284.7 317.1 337.8 CLEBURNE 33.3 294.1 39.4 TALLADEGA 276.9 36.8 PIKE 393.4 COFFEE 281.2 334.1 323.1 GENEVA 254.8 BULLOCK LEE BARBOUR HENRY DALE 272.9 252.8 277.3 281.5 HOUSTON 26.6 BALDWIN 224.8 Age-Adjusted per 1, Source: cdc Wonder Heart disease mortality rate 197.3-261.3 261.5-291.9 294.1-323.1 333.3-393.4 1 te risk of eart disease and stroke in alabama: burden document

stroke A brain attack, more commonly known as a stroke, and medically called a cerebrovascular accident (cva), is te tird leading cause of deat in Alabama, following only eart disease and cancer. A brain attack is te early pase or first few ours of a stroke. tese ours are a critical time wen doctors can attempt to stop and even reverse te effects tat lead to disability. A stroke occurs wen a blood vessel in or near te brain is blocked or bursts, interrupting te flow of blood to te brain. tis causes a lack of oxygen wic leads to brain cells dying. tere are two primary types of stroke: iscemic and emorragic. Iscemic stroke, te most common cause, occurs wen tere is a blockage of a blood vessel tat is supplying te brain. A emorragic stroke occurs wen a blood vessel ruptures or leaks in or around te brain. te stroke mortality rate declined over te past few years in Alabama. te stroke mortality rate in te united States ad been declining over te past few years. Age-adjusted mortality rates were 55.5 per 1, population for Alabama and 43.6 per 1, population in te united States. (Figure 11) figure 11: age-adjusted deat rates for stroke in alabama and United states, 1999-26 8 7 6 5 71.5 71.5 61.6 6.9 66.1 57.9 69.5 56.2 64.9 53.5 63.1 5. 6.9 46.6 55.5 rate Per 1, 4 3 2 43.6 1 1999 2 21 22 23 24 25 26 year alabama United states Source: cdc Wonder finding te Pat to CardioVasCUlar ealt 21 11

figure 12: stroke deats by age GroUP in alabama, 26 1 8 879 922 number of deats 6 4 2 252 441 168 78 <45 45-54 55-64 65-74 75-84 85+ Source: cdc Wonder age in years deats from stroke occurred more often in tose over age 65. 2,74 deats occurred from stroke in 26. (Figure 12) figure 13: age-adjusted deat rates for stroke by Gender and race in alabama, 26 1 8 97.2 rate Per 1, 6 4 2 48.7 68.7 49. male Source: cdc Wonder Gender female black wite In 26, black males sowed te igest stroke deat rate of 97.2 per 1, population followed by black females wit te rate of 68.7 per 1, population. te stroke deat rate between wite males and wite females sowed no significant difference. For stroke, race is a better predictor of deat tan gender, wit te black race being at iger risk tan wites. (Figure 13) 12 12 te risk of eart disease and stroke in alabama: burden document

figure 14: stroke mortality rate in alabama by CoUnty, 22-26 Combined LAMAR LAUDERDALE FAYETTE LIMESTONE MADISON JACKSON 71.5 54.9 LAWRENCE MORGAN DEKALB MARSHALL CULLMAN JEFFERSON BLOUNT PICKENS TUSCALOOSA SHELBY GREENE SUMTER MARENGO CHOCTAW WASHINGTON MOBILE 6.3 52.9 COLBERT FRANKLIN 79.3 MARION WINSTON CLARKE HALE WALKER PERRY WILCOX BIBB CHILTON AUTAUGA LOWNDES ST. CLAIR ETOWAH TALLADEGA COOSA ELMORE CALHOUN CHEROKEE CLEBURNE RANDOLPH CLAY CHAMBERS TALLAPOOSA 77.2 MACON 58.3 DALLAS MONTGOMERY RUSSELL BUTLER BULLOCK PIKE CRENSHAW MONROE HENRY ESCAMBIA 66.4 CONECUH 51. 58.6 46.6 65.3 69.1 63.5 62.7 67.9 54. 76.7 7.9 87.3 77.6 57.9 61.2 6.4 54.2 141.7 14.2 7.1 58.5 58.7 72.1 78.4 6.8 64.9 48.5 67. 57.8 69.3 COVINGTON 7.2 67.5 6. 51.1 6.5 59.6 92.5 47.3 56. 68.1 66.9 63.7 66.5 74.3 55.4 58.6 COFFEE 51.9 55.6 64.4 GENEVA 59. 59. DALE 46.2 58.5 62.1 69.3 LEE 72.5 BARBOUR 97.1 HOUSTON 47. BALDWIN 48. Age-Adjusted per 1, Source: cdc Wonder Stroke mortality rate 46.2-57.8 57.9-62.1 62.7-7.1 7.2-141.7 finding te Pat to CardioVasCUlar ealt 21 13

CardioVasCUlar risk factors: ig blood PressUre Hig blood pressure or ypertension is common in te united States, wit at least one in tree individuals being at risk of developing it. tere are often no symptoms to signal ig blood pressure. Lowering blood pressure by canges in lifestyle and/ or by medication can lower te risk of eart disease and eart attack. figure 15: PreValenCe of reported ig blood PressUre in alabama and te United states, 1995-29 4 37.2 3 24.8 28.9 23. 31.2 31.6 33.1 31.2 24. 25.6 24.8 25.5 33.1 27.5 28.6 PerCent 2 1 22.2 1995 1997 1999 21 23 25 year alabama United states Source: Alabama beavior risk Factor Surveillance System (brfss) 27 29 te prevalence of ig blood pressure in Alabama as continually increased since 1995 from 24.8 percent to 37.2 percent in 29. te prevalence as consistently remained above te national average in Alabama. over 37 percent of adults in Alabama reported aving ig blood pressure in 29. (Figure 15) figure 16: PreValenCe of reported ig blood PressUre in alabama by Gender, age, and race, 29 8 6 64.9% PerCent 4 2 37.7% 37.2% 36.6% 26.2% 4.8% 52.7% 35.3% 43.1% overall male female 8.7% 18-24 13.1% 25-34 35-44 45-54 55-64 65+ wite black males ad a similar prevalence of ig blood pressure wen compared to females in Alabama. tere was a significant increase of reported ig blood pressure wit increasing age. blacks ad a iger prevalence of ig blood pressure tan wites. (Figure 16) 14 te risk of eart disease and stroke in alabama: burden document

figure 17: PerCentaGe of adults wit ig blood PressUre (ypertension) in alabama by PUbliC ealt, 29 LAMAR PICKENS LAUDERDALE 1 GREENE COLBERT FRANKLIN 45% MARION 37% FAYETTE TUSCALOOSA 3 LAWRENCE WINSTON WALKER BIBB LIMESTONE 34% MORGAN CULLMAN 4 38% JEFFERSON SHELBY CHILTON 2 MADISON BLOUNT MARSHALL 41% ST. CLAIR TALLADEGA COOSA JACKSON ETOWAH DEKALB CALHOUN CLAY 6 5 TALLAPOOSA CHEROKEE 39% CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY 47% DALLAS WILCOX AUTAUGA LOWNDES ELMORE 31% MONTGOMERY 8 MACON BULLOCK LEE RUSSELL WASHINGTON 34% CLARKE PIKE BUTLER CRENSHAW MONROE 9 CONECUH DALE COFFEE 38% COVINGTON 41% 1 ESCAMBIA GENEVA BARBOUR HENRY HOUSTON MOBILE 11 BALDWIN 15 finding te Pat to CardioVasCUlar ealt 21 15

CardioVasCUlar risk factors: ig blood Colesterol colesterol is a waxy, fat-like substance tat occurs naturally in all parts of te body. te body needs some colesterol to work properly, but too muc in your blood can stick to te walls of te arteries causing problems wit te circulation of blood. tis is called plaque. Plaque can narrow te arteries or even block tem. Hig levels of colesterol in te blood can increase te risk of eart disease. to travel in te bloodstream, colesterol is carried in small packages called lipoproteins. tere are two types of colesterol in te body, low-density lipoprotein (LdL), sometimes called bad colesterol, and ig-density lipoprotein (HdL), sometimes called good colesterol. figure 18: PreValenCe of reported ig blood Colesterol in alabama and te United states, 1995-29 4 3 27.3 28.8 28.1 28. 33.2 32.9 3.1 3.3 36. 33.1 38.3 39.4 39.9 35.6 37.5 37.5 PerCent 2 1 1995 1997 1999 21 23 25 year alabama United states 27 29 In 29, 39.9 percent of Alabama adults reported tey were diagnosed wit ig blood colesterol, wile only 37.5 percent of te united States reported tey were diagnosed wit ig blood colesterol. In te past seven years, bot te united States and Alabama ave sown an increase in numbers of tose diagnosed wit ig blood colesterol. (Figure 18) figure 19: PreValenCe of reported ig blood Colesterol in alabama by Gender, age, and race, 29 8 6 PerCent 4 2 39.9% 4.6% 38.6% 19.9% 3.% 4.9% 52.7% 52.8% 4.7% 34.5% overall male female 8.2% 18-24 25-34 35-44 45-54 55-64 65+ wite black males ad similar rates compared to females for ig blood colesterol in Alabama. te ig blood colesterol rate increased wit increasing age up until about age 55 and ten levels off. Among te race and etnic groups, wites reported aving te igest rate of 4.7 percent. (Figure 19) 16 16 te risk of eart disease and stroke in alabama: burden document

figure 2: PerCentaGe of adults wit ig Colesterol in alabama by PUbliC ealt, 27 LAMAR PICKENS LAUDERDALE 1 GREENE COLBERT FRANKLIN 45% MARION FAYETTE TUSCALOOSA 3 LAWRENCE WINSTON WALKER BIBB LIMESTONE 39% MORGAN CULLMAN 4 44% 37% JEFFERSON SHELBY CHILTON 2 MADISON BLOUNT MARSHALL 44% ST. CLAIR TALLADEGA COOSA JACKSON ETOWAH DEKALB CALHOUN CLAY 6 41% 5 TALLAPOOSA CHEROKEE CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY WILCOX DALLAS 58% AUTAUGA LOWNDES ELMORE MONTGOMERY 8 MACON BULLOCK LEE 36% RUSSELL WASHINGTON 36% CLARKE PIKE BUTLER CRENSHAW 44% MONROE 9 CONECUH DALE COFFEE 36% COVINGTON 1 ESCAMBIA GENEVA BARBOUR HENRY HOUSTON MOBILE 11 BALDWIN finding te Pat to CardioVasCUlar ealt 21 17

CardioVasCUlar risk factors: diabetes A person wit diabetes as an automatic cardiovascular risk because tey are at te same risk of eart attacks as people wo ave already suffered a eart attack. diabetes is a disease in wic te body does not produce or properly use insulin. tere are more tan 25 million cildren and adults in te united States, wic translates into 8.3 percent of te population, wo ave diabetes. te cdc estimates tat as many as 2, or more ave te condition, but are unaware of it. tere are two major types of diabetes. type 1 diabetes results from te body s failure to produce insulin, and type 2 diabetes results from insulin resistance, a condition in wic te body fails to properly use insulin, combined wit relative insulin deficiency. figure 21: PreValenCe of adult-diagnosed diabetes in alabama and te United states, 1998-29 12 11.2 12.2 1 9.6 9.7 9.9 1.3 PerCent 8 6 7. 7.4 7.4 5.4 5.4 6.1 6.4 8.5 6.7 8.7 8.1 7.2 7.1 7.3 7.5 8.1 8.3 8.3 4 2 1998 1999 2 21 22 23 24 25 26 27 28 29 year alabama United states te prevalence of self-reported doctor-diagnosed diabetes among adults in Alabama in 29 was 12.2 percent, compared to te united States wit 8.3 percent of adults diagnosed wit diabetes. te prevalence of diabetes in Alabama was consistently iger tan in te united States from 1998-29. (Figure 21) figure 22: PreValenCe of adults diagnosed wit diabetes in alabama by Gender, age, and race, 29 2 22.5% 22.6% 15 PerCent 1 12.2% 13% 11.5% 12.7% 11.2% 14.1% 5 6.6% overall male female.5% 18-24 2.5% 25-34 35-44 45-54 55-64 65+ wite black te prevalence of adults diagnosed wit diabetes was similar in males and females. tere was a significant increase in te percentage of diabetes wit an increase in age. te prevalence of diabetes was greater among blacks tan wites. (Figure 22) 18 te risk of eart disease and stroke in alabama: burden document

figure 23: PerCentaGe of adults wit diabetes in alabama by PUbliC ealt, 29 LAUDERDALE 1 COLBERT FRANKLIN 16% MARION LAWRENCE WINSTON LIMESTONE MORGAN CULLMAN 2 MADISON 12% MARSHALL JACKSON DEKALB 5 CHEROKEE LAMAR PICKENS GREENE FAYETTE TUSCALOOSA 3 WALKER BIBB 4 11% 1% JEFFERSON SHELBY CHILTON BLOUNT 13% ST. CLAIR TALLADEGA COOSA ETOWAH CALHOUN CLAY 6 14% TALLAPOOSA CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY WILCOX DALLAS 17% AUTAUGA LOWNDES ELMORE MONTGOMERY 8 MACON BULLOCK LEE 11% RUSSELL WASHINGTON 11% CLARKE PIKE BUTLER CRENSHAW 15% MONROE 9 CONECUH DALE COFFEE 11% COVINGTON 1 ESCAMBIA GENEVA BARBOUR HENRY HOUSTON MOBILE 11 BALDWIN finding te Pat to CardioVasCUlar ealt 21 19

CardioVasCUlar risk factors: overweigt and obesity overweigt and obesity are two common factors contributing to te risk of eart disease and stroke. overweigt is defined as a body mass index (bmi) of 25. - 29.9 kg/m2 and obesity is a bmi greater tan 3. kg/m2. overweigt and obese individuals are also more likely to ave oter risk factors for eart disease and stroke, including ig blood pressure, ig colesterol, ig triglycerides, diabetes, and some types of cancer. Persons wo are obese ave medical costs tat are $1,429 per year iger tan tose of normal weigt. figure 24: PreValenCe of overweigt and obesity in alabama and te United states, 1998-29 8 6 59.6 6.8 6.7 61.7 62.7 63.2 64.6 64.5 65. 66.6 67.9 68.1 54.6 56.6 56.8 58.3 59.2 59.5 6.1 61.1 61.6 63. 63.2 62.1 PerCent 4 2 1998 1999 2 21 22 23 24 25 26 27 28 29 year alabama United states te prevalence of overweigt and obesity ad increased significantly in Alabama from 1998 to 29. te trend followed te same pattern for te united States, wit a sligt decrease in 29. In 29, te prevalence of reported overweigt and obesity was 6 percent iger in Alabama tan te national average. (Figure 24) figure 25: PreValenCe of overweigt and obesity in alabama by Gender, age, and race, 29 8 6 68.2% 73.9% 62.8% 64.5% 7.4% 74.7% 74.9% 67.6% 66.1% 74.2% PerCent 4 2 45.5% overall male female 18-24 25-34 35-44 45-54 55-64 65+ wite black te prevalence of overweigt and obesity was iger in males tan in females. overweigt and obesity increased wit age. blacks reported aving a iger prevalence of being overweigt and obese compared to wites in 29. (Figure 25) 2 te risk of eart disease and stroke in alabama: burden document

figure 26: PerCentaGe of adults wo are overweigt or obese in alabama by PUbliC ealt, 29 LAMAR PICKENS LAUDERDALE 1 GREENE COLBERT FRANKLIN 74% MARION FAYETTE TUSCALOOSA 3 LAWRENCE WINSTON WALKER BIBB LIMESTONE 62% MORGAN CULLMAN 4 71% 66% JEFFERSON SHELBY CHILTON 2 MADISON BLOUNT MARSHALL 69% ST. CLAIR TALLADEGA COOSA JACKSON ETOWAH DEKALB CALHOUN CLAY TALLAPOOSA CHEROKEE 6 5 72% CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY WILCOX DALLAS 78% AUTAUGA LOWNDES ELMORE 8 MONTGOMERY MACON 69% BULLOCK LEE RUSSELL WASHINGTON 66% CLARKE PIKE BUTLER CRENSHAW 73% MONROE 9 CONECUH DALE COFFEE 69% COVINGTON 1 ESCAMBIA GENEVA BARBOUR HENRY HOUSTON MOBILE 11 BALDWIN finding te Pat to CardioVasCUlar ealt 21 21

CardioVasCUlar risk factors: smoking cigarette smoking is a major cause of eart disease and stroke. It increases te clotting factors in te blood, damages te linings of te blood vessels, and decreases HdL (te good colesterol) in te blood. Smokers ave twice te risk of eart attack or stroke of non-smokers. Smoking is te single largest preventable cause of eart disease in te united States. figure 27: PreValenCe of CUrrent smokers in alabama and United states, 1998-29 PerCent 26 24 22 2 24.6 22.9 23.5 22.6 25.2 23.2 23.8 24.4 22.8 23. 25.4 22. 24.8 24.8 21.2 2.5 23.2 2. 22.5 19.7 22.1 22.5 18 18.3 17.9 16 1998 1999 2 21 22 23 24 25 26 27 28 29 year alabama United states te prevalence of current smokers ad decreased in te united States since 22, wile Alabama ad been fluctuating until 28, ten increased sligtly. Alabama s rate of current smokers was iger tan te national average rates from 1998-29. 22.5 percent of Alabama residents reported tat tey smoked in 29. (Figure 27) figure 28: PreValenCe of CUrrent smokers by Gender, age, and race, 29 4 3 PerCent 2 1 22.5% 25.7% 19.7% 25.% 26.9% 26.9% 27.% 2.5% 1.5% 22.6% 2.6% overall male female 18-24 25-34 35-44 45-54 55-64 wite black males were significantly more likely to be smokers tan females. up to te 55-64 age group, te prevalence rate of current smokers sowed little to no variance; owever, after age 55, te prevalence dropped significantly. te rates were similar between blacks and wites, wit wites sligtly iger tan blacks. (Figure 28) 65+ 22 te risk of eart disease and stroke in alabama: burden document

figure 29: PerCentaGe of adults wo are CUrrent smokers in alabama by PUbliC ealt, 29 LAUDERDALE 1 COLBERT FRANKLIN 24% MARION LAWRENCE WINSTON LIMESTONE MORGAN CULLMAN 2 MADISON 24% MARSHALL JACKSON DEKALB 5 CHEROKEE LAMAR PICKENS GREENE FAYETTE 22% TUSCALOOSA 3 WALKER BIBB 4 21% JEFFERSON SHELBY CHILTON BLOUNT 21% ST. CLAIR TALLADEGA COOSA ETOWAH CALHOUN CLAY 6 27% TALLAPOOSA CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY 22% WILCOX DALLAS AUTAUGA LOWNDES ELMORE 8 MONTGOMERY MACON 2% BULLOCK LEE RUSSELL WASHINGTON 27% CLARKE PIKE BUTLER CRENSHAW 2% MONROE 9 CONECUH DALE COFFEE 22% COVINGTON 1 ESCAMBIA GENEVA BARBOUR HENRY HOUSTON MOBILE 11 BALDWIN finding te Pat to CardioVasCUlar ealt 21 23

CardioVasCUlar risk factors: PysiCal inactivity te cance of developing eart disease is 1.5 to 2.5 times iger among tose wo are pysically inactive compared to tose wo are pysically active. exercise reduces te development of ig blood pressure, controls diabetes, lowers weigt, and decreases ig blood colesterol. figure 3: PreValenCe of PysiCal inactivity* in alabama and te United states, 1998-29 35 PerCent 3 25 2 31.6 31.2 26.7 25.2 27.3 24.6 29.9 29.6 29.7 29.2 29.3 22.9 22.6 23.7 22.6 22.5 31. 23.6 15 1998 21 22 23 24 25 26 27 29 year alabama United states In Alabama, te prevalence of pysical inactivity gradually declined from 1998 to 27, wit an increase of individuals wo were pysically inactive in 29 to 31. percent. Alabama consistently ad iger rates of pysical activity compared to te united States. (Figure 3) * Pysical inactivity is defined as tose reporting no pysical activity or exercise in te last tirty days. figure 31: PreValenCe of PysiCal inactivity in alabama by Gender, age, and race, 29 4 PerCent 3 2 31.% 26.4% 35.2% 21.1% 26.1% 28.6% 34.1% 34.6% 36.1% 29.4% 35.2% 1 overall male female 18-24 25-34 35-44 45-54 55-64 65+ wite black In Alabama, females were more likely to be pysically inactive tan males. te prevalence rate of pysical inactivity increased wit age. Among race and etnic groups, blacks ad a iger prevalence of pysical inactivity compared to wites. (Figure 31) 24 te risk of eart disease and stroke in alabama: burden document

figure 32: PerCentaGe of adults wo are PysiCally inactive* in alabama by PUbliC ealt, 29 LAUDERDALE 1 COLBERT FRANKLIN 37% LAWRENCE MARION WINSTON LIMESTONE MORGAN CULLMAN 2 MADISON 3% MARSHALL JACKSON DEKALB 5 CHEROKEE LAMAR PICKENS GREENE FAYETTE 32% TUSCALOOSA 3 WALKER BIBB 4 27% JEFFERSON SHELBY CHILTON BLOUNT 34% ST. CLAIR TALLADEGA COOSA ETOWAH CALHOUN CLAY 6 31% TALLAPOOSA CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY WILCOX DALLAS 37% AUTAUGA LOWNDES ELMORE 8 MONTGOMERY MACON 3% BULLOCK LEE RUSSELL WASHINGTON 29% MOBILE 11 CLARKE BALDWIN BUTLER PIKE CRENSHAW MONROE 9 CONECUH DALE COFFEE ESCAMBIA 33% COVINGTON 31% 1 GENEVA BARBOUR HENRY HOUSTON * Pysical inactivity is defined as tose reporting no pysical activity or exercise in te last 3 days. finding te Pat to CardioVasCUlar ealt 21 25

CardioVasCUlar risk factors: fruit and VeGetable ConsUmPtion daily consumption of five or more servings of fres fruits and vegetables is associated wit a reduced risk of eart disease and stroke. te consumption of recommended amounts of fruits and vegetables results in te intake of antioxidants, natural vitamins, and fiber. figure 33: PreValenCe of ConsUminG five or more fruits and VeGetables Per day in alabama and te United states, 1996-29 3 PerCent 25 2 15 23.7 21.4 23.9 23.8 23.2 22.7 22.7 22.6 21.1 22.6 23.2 2.1 24.3 23.3 2.6 2.3 1 1996 1998 2 22 23 25 27 29 year alabama United states te prevalence of adequate amounts of fruit and vegetable consumption as been rougly te same since 1996 in bot Alabama and te united States. te prevalence of individuals consuming five or more fruits and vegetables per day in te united States was 23.3 percent, sligtly iger tan Alabama at 2.3 percent in 29. (Figure 33) figure 34: PreValenCe of ConsUminG five or more fruits and VeGetables Per day in alabama by Gender, age, and race, 29 4 3 PerCent 2 19.6% 17.6% 21.5% 2.2% 23.5% 17.3% 18.% 21.% 18.6% 19.9% 18.7% 1 overall male female 18-24 25-34 35-44 45-54 55-64 65+ wite black Females were more likely to consume five or more servings per day of fruits and vegetables compared to males. Wen all age groups were compared, te 25-34 age group consumed te most fruits and vegetables at 23.5 percent. Among race and etnic groups, wites and blacks ad similar prevalence of adequate consumption of fruits and vegetables, wit wites sligtly iger tan blacks. (Figure 34) 26 te risk of eart disease and stroke in alabama: burden document

figure 35: PerCentaGe of adults ConsUminG five servings of fruit and VeGetables in alabama by PUbliC ealt, 29 LAMAR PICKENS 1 GREENE LAUDERDALE COLBERT FRANKLIN 17% MARION FAYETTE TUSCALOOSA 3 LAWRENCE WINSTON WALKER BIBB LIMESTONE 23% MORGAN CULLMAN 4 16% 21% JEFFERSON SHELBY CHILTON 2 MADISON BLOUNT MARSHALL 17% ST. CLAIR TALLADEGA COOSA JACKSON ETOWAH DEKALB CALHOUN CLAY 6 17% 5 TALLAPOOSA CHEROKEE CLEBURNE RANDOLPH CHAMBERS HALE SUMTER CHOCTAW 7 MARENGO PERRY WILCOX DALLAS 2% AUTAUGA LOWNDES ELMORE 8 MONTGOMERY MACON 26% BULLOCK LEE RUSSELL WASHINGTON 17% MOBILE 11 CLARKE BALDWIN PIKE BUTLER CRENSHAW MONROE CONECUH DALE COFFEE 9 18% COVINGTON 15% 1 BARBOUR HENRY ESCAMBIA HOUSTON GENEVA finding te Pat to CardioVasCUlar ealt 21 27

economic Cost of CVd te economic cost associated wit any disease can be immense, but tis is especially te case wit cvd. te American Heart Association estimates tat te cumulative cost associated wit cvd in te united States in 21, is 53.2 billion dollars. tis estimate includes direct costs (concerning doctors and oter ealtcare professionals, ospitals, medications, and nursing ome facilities) as well as indirect costs (mainly te loss of productivity due to increased morbidity and mortality). figure 36: estimated Cost (in billions of dollars) of CVd and stroke in te United states, 21 6 5 $53.2 4 PerCent 3 2 1 $117.1 Coronary eart disease $73.7 stroke $76.6 ypertensive disease $39.2 eart failure total CVd Source: Personal communication, tomas tom, nhlbi. coronary eart disease makes up te largest proportion of te total cost for cvd primarily due to ospital costs and loss of productivity due to mortality. Heart failure represents te smallest proportion of te total cost for cvd wit te primary direct cost being ospitalization. (Figure 36) 28 te risk of eart disease and stroke in alabama: burden document

access to Care Access to all types of ealt care as been and continues to be a serious problem in Alabama. In situations were literally every second counts, suc as during a eart attack or stroke, being able to receive prompt medical care is critical to te survival of te patient. tis can be quite a daunting task in some s of te state were te nearest ospital can be several ours drive. Hospitals in Alabama are categorized as follows: General ospitals (including te cildren s Hospital), reabilitation Long term care, Psyciatric, and te Veterans Administration (VA) ospitals. For te purpose of tis report, General, reabilitation, and VA ospitals will be igligted. Wen preparing te state to care for patients aving a stroke or reabilitating from a stroke, access to a neurologist is a vital part of any plan of care. In te united States tere are approximately 4. neurologists per 1, people caring for more tan 7, acute strokes per year. In Alabama, tere are 44 out of 67 counties witout a neurologist. Some stroke victims ave to travel across tree counties to access a neurologist for care. Figure 37 and 38 sows obvious gaps in access to care involving ospitals and neurologists wic also correlate to te stroke mortality rate maps included in tis document. once diagnosed wit an iscemic stroke te neurosurgeon may be asked to evaluate te patient and determine weter tey are a candidate for surgical intervention. te only university in Alabama training neurosurgeons and is limited to six per year is te university of Alabama at birmingam (uab). tis past year only one of six neurosurgeons stayed in Alabama to practice. Please refer to Figure 38 for a comparison of te availability of neurologists and neurosurgeons. recovering from a stroke can be a long process, financially tasking, and overwelming to a patient and teir family. A reabilitation ospital as a team of igly focused professionals tat include pysicians, nurses, occupational terapists, pysical terapists, and speec terapists. tese professionals will custom design programs specific to individual patient s needs wit terapy and treatment programs tat ave a goal to ultimately get te patient back to living life to te fullest. Wen needing te specialty care of a cardiovascular reabilitation facility te urban s ave better access tan rural. many counties in te rural soutern portions of te state do not ave a facility leaving tose residents at risk of not receiving proper reabilitation. Forty-tree counties in te state do not ave reabilitation ospitals or centers of any kind for patients to access. In Alabama, ospitals tend to be concentrated in igly populated, urban regions of te counties. Several counties in te state do not ave a ospital: cleburne, coctaw, coosa, Henry, Lamar, Lowndes, and Perry counties. only two ospitals in Alabama are Joint commission certified Primary Stroke centers: decatur General in morgan county, and Huntsville Hospital in madison county. (Figure 37) finding te Pat to CardioVasCUlar ealt 21 29

figure 37: ospitals in alabama by CoUnty, 21 SUMTER CHOCTAW LAMAR WASHINGTON MOBILE PICKENS GREENE LAUDERDALE COLBERT FRANKLIN MARION FAYETTE MARENGO CLARKE TUSCALOOSA HALE BALDWIN LAWRENCE WINSTON PERRY WILCOX MONROE WALKER BIBB DALLAS ESCAMBIA LIMESTONE MORGAN CULLMAN JEFFERSON CONECUH SHELBY CHILTON BLOUNT AUTAUGA LOWNDES BUTLER MADISON MARSHALL ST. CLAIR TALLADEGA COOSA ELMORE ETOWAH MONTGOMERY CRENSHAW COVINGTON JACKSON DEKALB CALHOUN CLAY TALLAPOOSA PIKE COFFEE GENEVA CHEROKEE MACON BULLOCK CLEBURNE DALE RANDOLPH CHAMBERS LEE BARBOUR RUSSELL HENRY HOUSTON General Hospital including cildren s Hospital Joint commission certified Primary Stroke center VA Hospital reabilitation Hospital Source: Alabama Hospital Association, te Internet Stroke center *map does not include long term care or psyciatric ospitals. 3 te risk of eart disease and stroke in alabama: burden document

figure 38: alabama neurologists and neurosurgeons by CoUnty, 21 n 3 n 1 n 1 LAUDERDALE COLBERT FRANKLIN n 2 LAWRENCE LIMESTONE MORGAN n 2 n 15 MADISON JACKSON n 7 n 1 DEKALB MARSHALL MARION LAMAR FAYETTE n 5 WINSTON n 2 WALKER n 2 CULLMAN BLOUNT n 8 JEFFERSON n 13 n 41 n 5 PICKENS TUSCALOOSA SHELBY n 2 n 2 ST. CLAIR n 3 ETOWAH n 6 n 1 n 6 n 2 CHEROKEE CALHOUN CLEBURNE TALLADEGA RANDOLPH CLAY GREENE BIBB CHILTON COOSA TALLAPOOSA CHAMBERS SUMTER CHOCTAW MARENGO HALE PERRY n 1 DALLAS WILCOX AUTAUGA LOWNDES n 3 ELMORE MONTGOMERY n 6 n 6 n 2 LEE n 4 MACON RUSSELL BULLOCK BUTLER PIKE BARBOUR CLARKE WASHINGTON n 16 MONROE CONECUH ESCAMBIA CRENSHAW n 1 COVINGTON COFFEE GENEVA n 1 DALE HENRY n 4 HOUSTON n 8 n 11 MOBILE n 6 BALDWIN 42 counties witout a neurologist or neurosurgeon n neurologists n neurosurgeons Source: Alabama board of medical examiners, July 21 finding te Pat to CardioVasCUlar ealt 21 31

signs and symptoms of a eart attack or stroke one of te Healty People 21 objectives is to increase te proportion of people wo are aware of te early warning signs and symptoms of stroke. te time variance between te onset of symptoms and actually receiving treatment can adversely affect te outcome of an acute eart attack or stroke event. tere are tree stages at wic time delays can occur: te onset of symptoms and te 911 call for elp; during pre-ospital care; and during transportation. Stroke: Te FAST test te fast test is an easy way to recognize and remember te signs of stroke or a transient iscemic attack (tia). using te fast test involves asking tree simple questions. fast stands for: F = Facial weakness - can te person smile; as is or er mout or eyes drooped? A = Arm weakness - can te person raise bot arms; is one arm sligtly lower? S = Speec/sigt difficulty - can te person speak or see clearly and understand wat you say? T = time to act - time loss is brain lost. call 911. If you suddenly experience any of tese symptoms, go to a ospital immediately. remember, stroke is a life-treatening emergency. Heart Attack: Signs and Symptoms: Pain or discomfort in jaw, neck, or back Feeling weak, ligteaded, faint cest pain or discomfort Sortness of breat Pain or discomfort in arms or soulders A risk factor tat can cause eart attack and stroke is ig blood pressure or ypertension. te national guidelines for defining ypertension are te following: ClassifiCation of blood PressUre (bp) category SbP mm Hg Systolic dbp mm Hg diastolic normal <12 and <8 Pre-ypertension 12-139 or 8-89 Hypertension, Stage 1 14-159 or 9-99 Hypertension, Stage 2 >16 or >1 Sevent report of te Joint national committee on Prevention, detection, evaluation, and treatment of Hig blood Pressure (Jnc7) Guidelines. Help For Smoking cessation Anoter risk factor tat can lead to eart attack and stroke is smoking. Imagine yourself tobacco free! call te AdPH tobacco Quitline at 1-8-QuIt-noW, or go online at www.alabamaquitnow.org. 32 te risk of eart disease and stroke in alabama: burden document

sodium: te facts Americans consume too muc sodium. Hig sodium consumption raises blood pressure, and ig blood pressure is a major risk factor for eart disease and stroke. Heart disease and stroke are te nation s first and tird leading causes of deat. salt and ig blood pressure researc strongly sows a dose-dependent relationsip between consuming too muc salt and raised levels of blood pressure. Wen salt intake is reduced, blood pressure begins decreasing witin weeks on average. Populations wo consume diets low in salt do not experience te increase in blood pressure wit age tat is seen in most Western countries. is it salt or is it sodium? Sodium cloride is te cemical name for salt. te words salt and sodium are not exactly te same, yet tese words are often used in place of eac oter. For example, te nutrition Facts Panel uses sodium, wereas te front of te package may say low salt. ninety percent of te sodium we consume is in te form of salt. sodium consumption and sodium in our food supply We all need a small amount of sodium to keep our bodies working properly. te 25 dietary Guidelines for Americans recommend limiting sodium to less tan 2,3 milligrams (mg) per day (about one teaspoon of table salt). Individuals wit ypertension, blacks, and middleaged and older adults sould limit intake to 1,5 mg of sodium per day. tese specific populations account for about 7 percent of adults. te average daily sodium intake for Americans age two years and older is more tan 3,4 mg. te majority of te sodium consumed is from processed and restaurant foods; only a small portion is used in cooking or added at te table. nutrition labeling and package messaging are easily misunderstood by consumers. Sodium information is not readily available for restaurant foods and can be ard for te consumer to estimate. For example, consumers migt be surprised to find tat te restaurant salad tey are consuming may contain more tan 9 mg of sodium and could only find tis information on te company s website. reducing sodium, reducing CVd burden In general, even if a person does not ave ig blood pressure, te lower one s blood pressure, te lower te risk of eart disease and stroke. Sodium intake from processed and restaurant foods contributes to ig rates of ig blood pressure, eart attack, and stroke. because nearly 4, deats eac year are attributed to ig blood pressure, decreasing sodium intake could prevent tousands of deats annually. te abcs of eart disease and stroke eart disease and stroke are Preventable! A = Aspirin use. Ask your provider about taking: one baby aspirin (81 mg) every day, or one regular aspirin (325 mg) every oter day. B = blood pressure treatment and control. bp <12/8 consume only 23 mg sodium daily. c = colesterol. Ask your provider about ow often to ceck your colesterol. total colesterol < 2 LdL (bad colesterol) < 1 S = Smoking cessation. researc sows using a quitline wit medication increases abstinence rates. call 1-8-QuItnoW for more details or ask your provider. Source: cdc Salt finding te Pat to CardioVasCUlar ealt 21 33

acknowledgements Alabama department of Public Healt...donald e. Williamson, m.d., State Healt officer Alabama department of Public Healt...tomas m. miller, m.d., m.p.h., Assistant State Healt officer bureau of Healt Promotion and cronic disease...jim mcvay, dr.p.a., bureau director cronic disease Prevention office...bob Hinds, director cronic disease epidemiology branc...sondra reese, m.p.h., director brfss unit...jesse Pevear, III, m.s.p.h., coordinator cardiovascular Healt branc...melanie rigtmyer, r.n., m.s.n., Program manager references American Heart Association. Heart disease and Stroke Statistics 28 update. retrieved from: ttp://www.americaneart.org centers for disease control and Prevention (cdc). beavioral risk Factor Surveillance System (brfss): overview and a brief History. retrieved from: ttp://www.cdc.gov/brfss/about.tm centers for disease control and Prevention (cdc). beavioral risk Factor Surveillance System (brfss). retrieved from: ttp://www.cdc.gov/brfss centers for disease control and Prevention. cdc Wonder. retrieved from: ttp://wonder.cdc.gov united States census bureau. American Fact Finder. (27). retrieved from: ttp://www.census.gov Alabama board of medical examiners. (21). Systems network. tis publication was supported by Grant/cooperative Agreement number 5u5dP732-4 from te cdc. Its contents are solely te responsibility of its autors and do not necessarily represent te official views of te cdc. 34 te risk of eart disease and stroke in alabama: burden document