Lifestyle Behaviors. Actual Causes of Death, United States 2000

Lb Lifestyle Behaviors Lifestyle Behaviors Chronic diseases, such as cancer, heart disease, stroke and diabetes, are among the most common and costly of all health problems. Fortunately, they are also among the most preventable. Tobacco use, obesity, physical inactivity and poor nutrition are responsible for much of the illness, suffering and premature death related to chronic diseases. 1 From 2000-2010, the prevalence of cigarette smoking among Kansas adults has decreased significantly, while the prevalence of adult obesity has increased. The prevalence of no leisure time physical activity and the percentage of adults who consume fruits and vegetables at least 5 times per day have remained relatively stable during this time period. 2 Actual Causes of Death, United States 2000 Tobacco Diet / Physical Inactivity Alcohol consumption Microbial agents (e.g. influenza, pneumonia) Toxic Agents (e.g. pollutants, asbestos) Motor vehicles Firearms Sexual behavior Illicit drug use 0 5 10 15 20 Percentage (of all deaths) Source: The Henry J. Kaiser Family Foundation. www.statehealthfacts.org 65

Prevalence of Selected Chronic Disease Risk and Protective Factors Among Adults 18 Years Old and Older, Kansas BRFSS, 2000-2010 Source: 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE. *Data not available in 2000. **Data for nutrition indicators are collected in alternate years. The following pages provide more detailed information on the burden of tobacco use, obesity, physical inactivity and unhealthy diet, as well as substance abuse, among Kansans. References 1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: Actual Causes of Death in the United States, 2000. JAMA. 2005;293 (3): 293. 2. 2000-2010 Kansas Behavioral Risk Factor Surveillance System. Kansas Department of Health and Environment, Bureau of Health Promotion. 66

Tobacco Reduce tobacco use by adults Reduce tobacco use by adolescents Summary HP 2020 Objectives Target: 12% Target: 16% This section reviews tobacco surveillance data from the past decade for both youth and adults. Trends and demographic characteristics associated with cigarette smoking are used to articulate the burden of cigarette smoking throughout Kansas. Distribution of other types of tobacco use is also briefly discussed. Introduction Nationally and in Kansas, tobacco use is the leading underlying cause of death, and is associated with heart disease, stroke, cancer, chronic lung diseases and other conditions. Cigarette smoking is the primary driver of tobacco-related morbidity and mortality, although other tobacco products are also associated with disease. 1 On state and national surveys of adults, current cigarette smoking status is usually defined as having smoked at least 100 cigarettes in one s life and are now smoking cigarettes every day or on some days. Current use of other tobacco products such as cigars or smokeless tobacco, is defined as having used a given product in the past month. On surveys of youth, all types of current tobacco use, including cigarette smoking, are defined as past-month use. 67

Adult Tobacco Use Time Trends The prevalence of cigarette smoking among Kansas adults fell from 22.2 percent (95% CI: 20.9%- 23.5%) in 2001 to 17.0 percent (95% CI: 15.8%-18.2%) in 2010. The majority of the reduction in smoking occurred between 2001 and 2005, with a flattening trend appearing between 2005 and 2010. This mirrors national trends in smoking prevalence, which demonstrate reductions in the first half of the decade followed by a flattening of progress in smoking reduction. 2 Adult Current Smoking Prevalence, KS BRFSS 2001-2010 Age, Gender and Geographic Variation In 2010, adult current smoking prevalence in Kansas varied significantly by age group. Smoking prevalence appears to decline among older adult populations, ranging from 23.0 percent (95% CI: 16.5%-29.5%) among 18 and 24 year olds to 7.9 percent (95% CI: 6.8%-8.9%) among those 65 years old and older. In 2010, adult current smoking prevalence did not vary significantly by gender or county population density in Kansas. 2 68

Table 1. Adult current smoking prevalence by age group, KS BRFSS, 2010 Age Group Weighted Percentage 95% Confidence Interval Age 18-24 23.0% 16.5% 29.5% Age 25-34 20.8% 17.3% 24.3% Age 35-44 15.8% 13.4% 18.3% Age 45-54 19.7% 17.5% 21.8% Age 55-64 16.7% 14.8% 18.5% Age 65+ 7.9% 6.8% 8.9% Race and Ethnicity In 2010, the prevalence of cigarette smoking among white-only Kansas adults was significantly lower than the smoking prevalence among African-American-only Kansas adults. There was no significant variation in adult cigarette smoking prevalence by ethnicity. 2 Table 2. Adult current smoking prevalence by race, KS BRFSS, 2010 Race Weighted Percentage 95% Confidence Interval White only 16.4% 15.1% 17.6% African American only 25.2% 18.8% 31.5% Other race only 18.3% 12.9% 23.6% More than One race 23.7% 15.0% 32.3% Economic and Social Factors In 2010, the prevalence of adult cigarette smoking varied significantly by level of education in Kansas. The prevalence of cigarette smoking among adults who did not attend college (high school graduates or G.E.D. or did not graduate high school) is more than three times that of college graduates. A similar association exists with annual household income. Kansas adults with an annual household income less than $25,000 have a cigarette smoking prevalence nearly three times that of adults with an annual household income of $50,000 or more. 2 Table 3. Adult current smoking prevalence by education, KS BRFSS, 2010 Education Weighted Percentage 95% Confidence Interval Did not graduate high school 30.9% 25.0% 36.8% High school graduate 24.8% 22.1% 27.6% Some college 18.6% 16.4% 20.9% College graduate 7.8% 6.5% 9.1% 69

Table 4. Adult current smoking prevalence by ethnicity, KS BRFSS, 2010 Annual Household Income Weighted Percentage 95% Confidence Interval Less than $25,000 per year 29.0% 25.6% 32.5% $25,000 to less than $50,000 per year 19.4% 16.8% 22.0% $50,000 or more per year 11.2% 9.8% 12.7% Other Measures of Tobacco Use Cigarette smoking is the most common form of tobacco use; however, there are a variety of other tobacco products on the market that contribute to tobacco morbidity and addiction. In 2010, the overall prevalence of smokeless tobacco use among Kansas adults was 5.1 percent. Males, however, had a much higher prevalence of smokeless tobacco use (9.8%; 95% CI: 8.4%- 11.3%) than female adults (0.6%; 95% CI: 0.3%-0.8%). In 2010, 56.8 percent of Kansas adult smokers stopped smoking cigarettes for one or more days because they were trying to quit smoking. 2 Youth and Tobacco Kansas estimates of high school smoking are generally lower than national estimates, but appear to follow a similar downward pattern. In 2005, 21 percent (95% CI: 17.2 25.5%), or about 1 in 5 high school students, reported smoking cigarettes on at least one day in the past 30 days. In 2011, the estimate was significantly lower at 14.4 percent (95% CI: 12.0 17.2%) of high school students. High School Current Smoking Prevalence, KS YRBS, 2005-2011 70

The prevalence of cigarette smoking among high school students does not vary significantly by gender. Non-Hispanic high school students who list multiple races have a significantly higher prevalence of cigarette smoking than black non-hispanic, Hispanic or white non-hispanic students. Table 5. High school current smoking prevalence by race, KS YRBS, 2011 Race/Ethnicity Weighted Percentage 95% Confidence Interval Black non-hispanic 7.9% 4.0% 15.1% Hispanic 11.7% 8.1% 16.5% White non-hispanic 15.5% 12.2% 19.5% Multiple Races non-hispanic 21.5% 21.5% 34.4% In 2011, 52.1 percent of Kansas high school students who smoke cigarettes tried to quit smoking cigarettes in the past year. In 2011, the prevalence of smokeless tobacco use (i.e., chewing tobacco, snuff or dip) was 8.8 percent among high school students. The percent of male high school students who use smokeless tobacco (14.1%; 95% CI: 11.0%-17.9%) was more than four times that of female high school students (3.0%; 95% CI: 1.7%-5.2%). Similarly, the prevalence of cigar smoking among high school students (10.7%; 95% CI: 8.9%-12.9%) was much higher in males (14.1%; 95% CI: 11.5%-17.2%) than females (7.1%, 95% CI: 5.3%-9.4%). 3 References 1. Centers for Disease Control and Prevention (US); National Center for Chronic Disease Prevention and Health Promotion (US); Office on Smoking and Health (US). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta,GA: Centers for Disease Control and Prevention. 2010. Available at: http://www.ncbi.nlm.nih.gov/books/nbk53017/. Accessed February 10, 2014. 2. 2001-2010 Kansas Behavioral Risk Factor Surveillance System. Kansas Department of Health and Environment, Bureau of Health Promotion. 3. Centers for Disease Control and Prevention (CDC). 1991-2011 High School Youth Risk Behavior Survey Data. Available at: http://apps.nccd.cdc. gov/youthonline. Accessed on February 10, 2014. 71

Nutrition HP 2020 Objectives Increase the contribution of fruits to the diets of the population aged 2 years and older. Increase the contribution of total vegetables to the diets of the population aged 2 years and older. Summary Target 0.9 cup equivalent per 1,000 calories Target 1.1 cup equivalent per 1,000 calories This section reviews surveillance data on fruit and vegetable consumption from the past decade for both youth and adults. Time trends and demographic characteristics associated with fruit and vegetable are used to articulate the burden of an unhealthy diet throughout Kansas. Estimates of sugar-sweetened beverage consumption and frequency of eating breakfast among youth are also presented. Introduction Fruit and vegetable intake (at least 2 ½ cups daily) is associated with reduced risk of many chronic diseases, including heart attack, stroke and certain types of cancer. Most fruits and vegetables, when prepared without added fats or sugars, are also relatively low in calories and can help adults and children achieve and maintain a healthy weight. In addition to its recommendation to increase fruit and vegetable intake, the 2010 Dietary Guidelines for Americans recommend consuming at least half of all grains as whole grains; increasing intake of fat-free or low-fat milk and milk products; and choosing a variety of protein foods, including seafood, lean meat and poultry, eggs, beans and peas, soy products and unsalted nuts and seeds. Additional recommendations include reducing daily intake of sodium, saturated fats and dietary cholesterol, and reducing the intake of calories from solid fats and added sugars, including sugar-sweetened beverages. 1 Adult Fruit and Vegetable Intake Time Trends The prevalence of consuming fruits or vegetables fewer than five times per day did not increase or decrease significantly among Kansas adults between 2002 and 2009. 2 Geographic Variation In 2009, there was no significant variation in the percentage of Kansas adults consuming fruits or vegetables fewer than five times per day by county population density. 3 Age and Gender In 2009, the percentage of Kansas adults consuming fruits or vegetables fewer than five times per day was significantly higher among persons 18 to 24 years old (85.6%; 95% CI: 82.2-88.9) compared to Kansans 55 to 64 years old (79.5%; 95% CI: 78.2-80.9) and 65 years old and older (75.7%; 95% CI: 74.5-76.9). 3 72

Percentage of Adults Consuming Fruits or Vegetables Fewer Than 5 Times Per Day by Age Groups, Kansas 2009 Percentage of Adults Consuming Fruits or Vegetables Fewer Than 5 Times Per Day by Gender, Kansas 2009 73

Race and Ethnicity In 2009, the percentage of Kansas adults consuming fruits or vegetables fewer than five times per day did not differ significantly across race groups. However, a significantly higher percentage of Hispanic Kansas adults (85.8%; 95% CI: 82.6-89.0) consumed fruits and vegetables fewer than five times per day compared to non-hispanics (81.1%; 95% CI: 80.3-81.9). 3 Percentage of Adults Consuming Fruits or Vegetables Fewer Than 5 Times Per Day by Race and Ethnicity, Kansas 2009 Economic and Social Factors In 2009, Kansas adults with college graduate education (77.5%, 95% CI: 76.3-78.7) had significantly lower prevalence of consuming fruits or vegetables fewer than five times per day as compared to those with lower levels of education. 3 There was no significant difference in the percentage of Kansas adults who consumed fruits or vegetables fewer than five times per day by annual household income status in 2010. 3 Percentage of Adults Consuming Fruits or Vegetables Fewer Than 5 Times Per Day by Education Status, Kansas 2009 74

Youth Nutrition Similar to recommendations for adults, the 2010 Dietary Guidelines for Americans recommends that children and adolescents consume a diet rich in fruits and vegetables, whole grains, and fat-free and low-fat dairy products while limiting intake of solid fats, cholesterol, sodium, added sugars and refined grains. 1 Individual recommendations specific to fruit and vegetable consumption are based on age, gender and activity level and can be calculated online using the Centers for Disease Control and Prevention (CDC) Fruit and Vegetable Calculator. Eating a healthy breakfast daily is also recommended due to its association with improved memory, reduced school absenteeism and improved mood. 5,6,7 During the 2010/2011 school year, about 17.0 percent (95% CI: 15.1% to 19.1%) of Kansas high school students in grades 9 through 12 ate fruits and vegetables five or more times per day in the past week. There were no significant differences in eating fruits and vegetables five or more times per day in the past week among gender, age or race/ethnicity groups, or across grade levels or by obesity status. 8 More than three-fourths (76.8%) of Kansas high school students in grades 9 through 12 drank a can, bottle or glass of soda or pop less than one time per day during the 2010/2011 school year. However, 8.6 percent (95% CI: 7.0% to 10.4%) drank a can, bottle or glass of soda one time per day in the past week and an additional 14.6 percent (95% CI: 12.2% to 17.3%) drank a can, bottle or glass of soda or pop two or more times per day in the past week. The percentage who drank a can, bottle or glass of soda or pop one or more times per day in the past week was significantly higher among males (26.5%; 95% CI: 23.5% to 29.7%) compared to females (19.6%; 95% CI: 16.6% to 23.1%). 8 During the 2010/2011 school year, 36.9 percent (95% CI: 33.3% to 40.7%) of Kansas high school students in grades 9 through 12 ate breakfast every day in the past week. However, 12.8 percent (95% CI: 10.6% to 15.3%) did not eat breakfast on any day in the past week. There were no significant differences in eating breakfast every day in the past week among gender, age, or race/ethnicity groups, across grade levels or by overweight/obesity status. 8 References 1. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. U.S. Department of Health and Human Services. Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication No. 98-4083; 1998. 2. 2002-2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 3. 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 4. Centers for Disease Control and Prevention. How many fruits and vegetables do you need? http://www.cdc.gov/nutrition/everyone/fruitsvegetables/ howmany.html. Accessed January 11, 2012. 5. Taras HL. Nutrition and student performance at school. Journal of School Health. 2005;75:199-213. 6. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. JADA. 2005;105:743-760. 7. Hoyland A, Dye L, Lawton CL. A systematic review of the effect of breakfast on cognitive performance of children and adolescents. Nutrition Research Reviews. 2009;22:220-243. 8. 2011 Kansas Youth Risk Behavior Survey, Kansas State Department of Education. 75

Obesity HP 2020 Objectives Reduce the proportion of adults who are obese. Reduce the proportion of adolescents aged 12 to 19 years who are considered obese. Introduction Target: 30.5% Target: 16.1% Since 2000, overweight and obesity have reached epidemic proportions in the United States and in Kansas. Since 1995, the prevalence of obesity among Kansas adults has nearly doubled, and by 2010, approximately two-thirds of the state s adult population was either overweight or obese. 1 Obesity increases the risk for several chronic diseases, including coronary heart disease, type 2 diabetes, certain cancers, stroke and osteoarthritis. 2 Such chronic diseases are increasingly burdensome to the health care system due to ongoing medical monitoring, intervention and hospitalization. Researchers have estimated that, in Kansas, $1.327 billion in medical expenditures are attributable to obesity, of which 29 percent is financed by Medicare ($286 million) and Medicaid ($99 million). 3 Body mass index (BMI) is an inexpensive, convenient and reliable measure used to estimate body fatness. BMI is calculated as weight in kilograms divided by height in meterssquared. Categories and associated ranges for BMI among adults are as follows: underweight (BMI < 18.5), healthy weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9) and obese (BMI 30.0). Adult Obesity Time Trends The percentage of Kansas adults who are obese has increased significantly during the past decade from 20.8 percent (95% CI: 19.4% to 22.2%) in 2000 to 30.1 percent (95% CI: 28.8% to 31.5%) in 2010 (Figure 1). This increase mirrors national data. However, in 2010, the prevalence of obesity was higher among Kansas adults 18 years old and older as compared to the U.S. median prevalence (27.5%). 4 76

Prevalence of Obesity Among Adults 18 Years Old and Older, Kansas and the U.S. 2000-2010. Sources: 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2000-2010. Vertical bars indicate 95% confidence intervals. Due to changes in the 2011 BRFSS methodology, obesity prevalence trends among adults in Kansas and the U.S. cannot be compared with previous years. Geographic Variation In 2010, there was no significant variation in adult obesity prevalence by county population density (Table 1). 5 Prevalence of adult obesity by age groups, Kansas 2010 Age and Gender In 2010, the percentage of Kansans 18 years and older who were obese was significantly higher among persons in groups 25 years old and older compared to Kansans 18 to 24 years old. About 1 in 3 adults 35 to 44 years old, 45 to 54 years old and 55 to 64 years were obese, while 1 in 4 adults (25.7%) ages 65 years old and older was obese. 5 77

In 2010, the prevalence of adult obesity did not differ significantly between genders. About, 32.0% (95% CI: 29.8-34.2) of males and 28.2% (95% CI: 26.6-29.8) of females were obese in 2010. 5 Race and Ethnicity In 2010, the prevalence of obesity was significantly higher among African-Americans (39.2%, 95% CI: 32.2-46.2) as compared to whites (29.7%, 95% CI: 28.2-31.1). About 1 in 3 (35.3%, 95% CI: 27.9-31.3) Hispanic adults and 1 in 4 (29.9%, 95% CI: 28.5-31.3) non-hispanic adults were obese in 2010. 5 Prevalence of Adult Obesity by Race and Ethnicity, Kansas 2010 Economic and Social Factors In 2010, Kansas adults who were high school graduates (31.6%, 95% CI: 28.9-34.4); and some college education (33.3%, 95% CI: 30.6-36.0) had significantly higher prevalence of obesity as compared to college graduates (26.2%, 95% CI: 24.2-28.1). 5 Prevalence of Adult Obesity by Education Status, Kansas 2010 78

In 2010, adults with an annual household income of $50,000 or more (26.8%, 95% CI: 24.9-28.7) had significantly lower prevalence of obesity as compared to those with lower incomes (less than $15,000: 36.0%, 95% CI: 30.0-42.1; $15,000- $24,999: 35.9%, 95% CI: 31.6-40.2; $25,000- $34,999: 34.6%, 95% CI: 30.3-39.0; and $35,000- $49,999: 35.3%, 95% CI: 31.5-39.1). 5 Prevalence of Adult Obesity by Annual Household Income, Kansas 2010 Youth Obesity In contrast to adults, BMI is age- and sex-specific for youth and is often referred to as BMI-for-age. 6 For children and adolescents, BMI is plotted on Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts for either boys or girls to obtain a percentile ranking. The percentile allows comparison of the child s BMI to youth of the same sex and age. Categories and associated ranges for BMI percentiles among youth are as follows: underweight (< 5th percentile), healthy weight (5th to less than 85th percentile), overweight (85th to less than 95th percentile) and obese (95th percentile or greater). During the 2010/2011 school year, 13.9 percent (95% CI: 12.2% to 15.7%) of Kansas high school students in grades 9-12 were overweight and 10.2 percent (95% CI: 8.8% to 11.8%) were obese. In total, 24.1 percent (95% CI: 21.9% to 26.5%) of Kansas high school students in grades 9-12 were overweight or obese during this time period. The percentage of Kansas high school students in grades 9-12 who were obese did not differ significantly among gender or age groups or across grade levels. However, the percentage of Kansans high school students in grades 9-12 who were obese during this time period was significantly higher among non-hispanic African Americans (18.1%; 95% confidence interval: 11.4% to 27.6%) compared to non-hispanic whites (9.1%; 95% confidence interval: 7.6% to 10.8%). 7 References 1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1995-2010. 2. U.S. Department of Health and Human Services. Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication No. 98-4083; 1998. 3. Trogdon JG, Finkelstein EA, Feagan CW, Cohen JW. State- and payer-specific estimates of annual medical expenditures attributable to obesity. Obesity. 2012;20:214-220. 4. 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 5. 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 6. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. About BMI for Children and Teens. Available at: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html#normal weight ranges. Accessed December 19, 2012. 79

Physical Activity HP 2020 Objectives Reduce the proportion of adults who engage in no leisure-time physical activity. Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activity. Summary Target: 32.6% Target: 20.2% This section reviews physical activity surveillance data from the past decade for both youth and adults. Time trends and demographic characteristics associated with no leisure time physical activity are used to articulate the burden of physical inactivity throughout Kansas. Introduction Research has demonstrated strong evidence for a positive association between regular physical activity and several health benefits, including lower risks of coronary heart disease, stroke, high blood pressure, adverse blood lipid profile, type 2 diabetes, colon cancer and breast cancer. The U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans recommends that adults do at least 150 minutes a week of moderate-intensity aerobic activity, or 75 minutes a week of vigorous-intensity aerobic activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity plus muscle-strengthening activities that involve all major muscle groups two or more times per week. 1 Adult Physical Inactivity The Kansas Behavioral Risk Factor Surveillance System (BRFSS) includes a question on leisure time physical activity that assesses participation in any physical activity or exercise other than regular job such as running, calisthenics, golf, gardening or walking for exercise. Time Trends Since 2001, the percentage of adult Kansans not participating in any leisure time physical activity has declined slightly from 27 percent (95%CI: 25.3-28.1) in 2001 to 24 percent (95%CI: 22.8-25.2) in 2010. 2 80

Percentage of Adults Not Participating in Leisure Time Physical Activity, Kansas 2001-2010. Source: 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE. Geographic Variation In 2010, there was a significant variation in the percentage of adults in Kansas who do not participate in any leisure time physical activity by county population density (Table 1). County population density peer groups are based on the population for each county in 2010 and are defined as follows: frontier (fewer than 6 persons per square mile), rural (6 to 19.9 persons per square mile), densely-settled rural (20 to 39.9 persons per square mile), semi-urban (40 to 149.9 persons per square mile), and urban (150 or more persons per square mile). The percentage of Kansas adults who do not participate in any leisure time physical activity was significantly higher among those living in frontier, rural and densely-settled rural counties compared to those living in urban counties. 3 Table 1. Percentage of adults not participating in leisure time physical activity by population density peer group, KS BRFSS, 2010 Population Density Weighted Percentage 95% Confidence Interval Frontier 30.7% 23.9% 37.4% Rural 28.6% 25.1% 32.0% Densely-settled Rural 28.4% 25.1% 31.8% Semi-urban 22.3% 19.4% 25.2% Urban 21.6% 20.0% 23.3% 81

Age and Gender In 2010, almost 1 in 3 Kansas adults 65 years old and older (31.0%) did not participate in leisure time physical activity. The percentage of adults not participating in leisure time physical activity was significantly higher for older adults (55-64 years: 29.1%, 95% CI: 26.9-31.2; 65+ years: 31.0%, 95% CI: 29.2-32.9) as compared to younger adults (18-24 years: 18.5%, 95% CI: 13.0-24.0; 25-34 years: 17.7%, 95% CI: 14.4-21.0). 3 Percentage of Adults Not Participating in Leisure Time Physical Activity by Age Groups, Kansas 2010 In 2010, about 1 in 4 adult males in Kansas (22.5%, 95% CI: 20.7-24.4) and 1 in 4 females (25.4%, 95% CI: 23.8-26.9) did not participate in any leisure time physical activity. The percentage of Kansas adults not participating in leisure time activity did not vary statistically by gender in 2010. 3 Race and Ethnicity In 2010, about 1 in 4 African-American (23.7%) and white (23.4%) Kansas adults did not participate in leisure time physical activity. More than 1 in 3 (37.5%) of Kansas Hispanic adults did not participate in leisure time physical activity in 2010. 3 Percentage of Adults Not Participating in Leisure Time Physical Activity by Race and Ethnicity, Kansas 2010 82

Economic and Social Factors In 2010, nearly half of Kansas adults with less than high school education (44.8%) did not participate in leisure time physical activity. The percentage of Kansas adults not participating in leisure time activity was significantly higher among those with less than high school education (44.8%, 95% CI: 38.9-50.7) as compared to those with college or more education (15.8%, 95% CI: 14.1-17.4). 3 Percentage of Adults Not Participating in Leisure Time Physical Activity by Education Status, Kansas 2010 In 2010, the percentage of Kansas adults not participating in leisure time physical activity was higher among adults with a lower annual household income. About 2 in 5 Kansas adults (42.8%) with an annual household income less than $15,000 did not participate in leisure time physical activity in 2010. 3 Percentage of Adults Not Participating in Leisure Time Physical Activity by Annual Household Income, Kansas 2010 Youth Physical Activity As in adults, regular physical activity in youth promotes health and fitness. Compared to those who are inactive, physically active children and adolescents have higher levels of cardiorespiratory fitness, stronger muscles, lower body fat, stronger bones, and reduced symptoms of anxiety and depression. The U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans recommends that children and adolescents do 60 minutes or more of physical activity daily, including vigorous-intensity aerobic activity, muscle-strengthening activity and bonestrengthening activity on at least 3 days a week. 1 During the 2010/2011 school year, nearly one-third (30.2%; 95% CI: 27.7% to 32.7%) of Kansas high school students in grades 9-12 met physical activity guidelines (i.e. were physically active for at least 60 minutes daily). However, 11.6 percent (95% CI: 9.8% to 13.7%) did not participate in physical activity for at least 60 minutes on any day in the past week. The percentage of Kansas high school students who met physical activity guidelines did not differ significantly among age, race/ethnicity or weight groups or across grade levels. However, the percentage of Kansas high school students who met physical activity guidelines during this time period was significantly higher among males (40.5%; 95% CI: 37.0% to 44.1%) compared to females (19.5%; 95% CI: 16.9% to 22.3%). 4 83

References 1. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans (2008). U.S. Department of Health and Human Services. Public Health Service; National Institutes of Health; National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication No. 98-4083; 1998. 2. 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 3. 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 4. 2011 Kansas Youth Risk Behavior Survey, Kansas State Department of Education. 84

Substance Abuse HP 2020 Objectives Reduce binge drinking in the past month by adults. Reduce binge drinking in the past month by high school students. Summary Target: 24.4% Target: 8.6% This section reviews substance abuse surveillance data from the past decade for both youth and adults. Time trends and demographic characteristics associated with binge drinking are used to articulate the burden of excessive alcohol use throughout Kansas. The burden of heavy drinking among adults, as well as illicit drug use among adults and youth in Kansas, is also presented. Introduction Alcohol consumption is the third leading preventable cause of death in the United States. 1 Binge drinking is defined as adult males having five or more drinks on one occasion and adult females having four or more drinks on one occasion in past 30 days. Binge drinking is associated with alcohol poisoning, unintentional injuries, suicide, hypertension, pancreatitis, sexually transmitted diseases and meningitis, among other disorders. The National Institute on Alcohol Abuse and Alcoholism reported that binge drinking underlies many negative social costs, including interpersonal violence, drunk driving and lost economic productivity. 2 Adult Binge Drinking Time Trends In 2006, the Behavioral Risk Factor Surveillance System definition of binge drinking changed to males having five or more drinks on one occasion in the past month and females having four or more drinks on one occasion in the past month. The previous definition was consumption of five or more drinks on at least one occasion in the past month, without regard to gender. Despite the change in the definition of binge drinking in 2006, the prevalence of binge drinking among Kansas adults between 2001 and 2010 was relatively stable. The prevalence of binge drinking between 2006 and 2010 was consistently around 15 percent. 3 85

Prevalence of Binge Drinking Among Adults, Kansas BRFSS 2001-2010 Note: The definition of binge drinking changed in 2006 to males having five or more drinks on one occasion in the past month, and females having four or more drinks on one occasion in the past month. The previous definition was consumption of five or more drinks on at least one occasion in the past month, without regard to gender. Geographic Variation In 2010, there was no significant difference in adult binge drinking prevalence by county population density in Kansas. 4 Age and Gender In 2010, the prevalence of binge drinking was 21.4 percent (95% CI: 19.3-21.6) among Kansas adult males and 9.0 percent (95% CI: 7.8-10.2) among females. A significantly higher percentage of males were binge drinkers than females. Binge drinking is also associated with age, falling from 27.8 percent among adults 18 to 24 years old to 2.1 percent among adults 65 years old and older. 4 Binge Drinking by Age Groups, Kansas 2010, BRFSS 86

Binge Drinking by Gender, Kansas 2010, BRFSS Race and Ethnicity In 2010, there was no significant difference in adult binge drinking prevalence by race or ethnicity in Kansas. 4 Economic and Social Factors In 2010, the prevalence of adult binge drinking did not vary significantly by level of education or annual household income in Kansas. About 1 in 6 Kansas adults (16.6%; 95% CI: 14.0-19.2) with some college education reported engaging in binge drinking in 2010. 4 Adult Heavy Drinking Heavy drinking is associated with a number of chronic health conditions, including chronic liver disease and cirrhosis, gastrointestinal cancers, heart disease, stroke, pancreatitis, depression as well as a variety of social problems. 2 Heavy alcohol consumption is defined as adult men having more than two drinks per day and adult women having more than one drink per day in the past 30 days. In 2010, the prevalence of heavy alcohol consumption among Kansas adults was 4 percent, remaining fairly consistent since 2001 (5%; 95% CI: 4.0-5.6). 4 Youth and Alcohol Kansas estimates of high school binge drinking appear to have declined since 2005. In 2005, 29 percent (95% CI: 25.2 33.1%) of high school students reported drinking five or more drinks of alcohol in a row within a couple hours on at least one day in the past 30 days. In 2011, the estimate was significantly lower at 20.7 percent (95% CI: 18.3 23.3%) of high school students. The prevalence of binge drinking among high school students does not vary significantly by gender or race/ethnicity. 6 Prevalence of Binge Drinking Among Kansas High School Students, YRBS, 2005-2011 87

Illicit Drug Use The National Survey on Drug Use and Health (NSDUH) collects information on nine different categories of illicit drug use: marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, and the nonmedical use of prescriptiontype pain relievers, tranquilizers, stimulants and sedatives. Estimates of illicit drug use reported from NSDUH reflect the use of any of the nine drug categories listed above. Use of alcohol and tobacco products is not included in these estimates. 7 In 2009-2010, more than 1 in 6 (17.4%) Kansas adults 18 to 25 years old and nearly 1 in 20 (4.8%) Kansas adults 26 years old and older has used illicit drugs in the past month. 7 In 2006, Kansas showed a one-day total of 10,470 residents in treatment for substance use disorders; of which 14 percent were under the age of 18 years. Between 1992 and 2006, drug-only admission to treatment centers doubled from 12 percent to 27 percent while alcohol-only admissions declined from 44 percent to 16 percent. 8 During the 2010/2011 school year, nearly 1 in 3 Kansas high school students had ever used marijuana and nearly 1 in 6 had ever used prescription drugs without a doctor s prescription. 6 Prevalence of Drug Use (Ever Use) Among High School Students in Grades 9-12, KS YRBS, 2011 References 1. Kelly E. Courtney and John Polich. Binge Drinking in Young Adults: Data, Definitions, and Determinants. Psychological Bulletin. 2009; 135(1): 142 156. 2. Naimi T. et al. Binge Drinking Among U.S. Adults. JAMA. 2003; 289:70 5. 3. 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 4. 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. 5. 2005-2011 Kansas Youth Risk Behavior Survey, Kansas State Department of Education. 6. 2011 Kansas Youth Risk Behavior Survey, Kansas State Department of Education. 7. 2009-2010 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration (SAMHSA), Center of Behavioral Health Statistics and Quality. 8. Substance Abuse and Mental Health Services Administration (SAMHSA). States in Brief: Kansas. 2008. Available at: http://www.samhsa.gov/data/ StatesInBrief/2k9/KANSAS_508.pdf. Accessed February 13, 2014. 88

Strengths and Assets Strengths Obesity, Physical Activity and Nutrition The Chronic Disease Risk Reduction Program provides guidance and funding to communities to address tobacco, physical activity and nutrition. Obesity reduction efforts focus on increasing access to healthy foods through farmers markets and building public/private partnerships to develop and enhance walking and biking trails. In 2011 there were at least 94 farmers markets held across the state with 1,175 farmers selling goods. The Senior Farmers Market Nutrition Program is designed to provide fresh, nutritious, unprepared, locally grown fruits, vegetables and herbs from farmers markets, roadside stands and community-supported agriculture programs to low income seniors. More than 5,500 seniors received vouchers to purchase fruits and vegetables or received food bundles in 2011. The Sunflower Foundation supports environmental changes that encourage increased physical activity. Specifically, the foundation s priorities are school and community-based walking and multi-use trails. The Foundation has provided grants for more than 80 school and community-based walking and multi-use trails across Kansas. Tobacco Use Kansas Tobacco Quitline provides telephone and online cessation counseling to Kansas tobacco users. The Quitline is promoted through advertising, community coalitions, and health and dental providers. During SFY 2012 more than 2,800 Kansas tobacco users registered for Quitline cessation support. Seatbelt, Booster Seat and Helmet Use Safe Kids Kansas provides reduced cost bicycle helmets through the Cycle Smart program and provides child safety and booster seats to lowincome families through the Buckle Up Program. In 2011 Safe Kids Kansas distributed 8,452 bicycle helmets and 1,280 child safety and booster seats. Healthy Communities The Kansas Health Foundation s Healthy Communities Initiative supports communities as they create a healthier environment for their citizens to promote physical activity, increase access to healthy foods and decrease use of and exposure to tobacco products. United Health Ministry Fund Fit for Kansas Kids initiative provides grants to support families, communities and agencies in creating environments that encourage young children to be physically active and eat healthful, nutritious foods from birth onwards. Blue Cross & Blue Shield of Kansas Healthy Habits for Life initiative provides funding to schools to implement programs aimed at youth to reduce cardiovascular risk, increase physical activity and teach healthy eating habits. 89

Assets Strong Coalitions Tobacco Free Kansas Coalition, Kansas Breastfeeding Coalition, Kansas Cancer Partnership, Safe Kids Kansas, Kansas Chronic Disease Alliance of Kansas, local wellness/ health and prevention coalitions, etc. Knowledgeable and committed public health professionals working on these issues KDHE, KSDE, KDADS, local agencies, communities, voluntary organizations Solid data to support work Examples: BRFSS, YRBS, substance abuse data Natural and local resources for physical activity and nutrition Supportive policies on select issues Examples: Good motor vehicle laws, Indoor Clean Air Act Emerging best practices and increasing attention on lifestyle behaviors at the community, state and national levels CDC s Winnable Battles, growing community infrastructure, Governor s Council on Fitness Obesity Summit 90