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National Center for Health Statistics (US) . Health, United States, 2004: With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics (US); 2004 Sep.

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Health, United States, 2004: With Chartbook on Trends in the Health of Americans.

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Chartbook on Trends in the Health of Americans

Population

Age

From 1950 to 2000 the total resident population of the United States increased from 150 million to 281 million, representing an average annual growth rate of 1 percent (figure 1). During the same period, the population 65 years of age and over grew almost twice as rapidly and increased from 12 to 35 million persons. The population 75 years of age and over grew almost three times as quickly as the total population, increasing from 4 to 17 million persons. Projections indicate that the rate of population growth during the next 50 years will be somewhat slower for all age groups and older age groups will continue to grow more than twice as rapidly as the total population.

Figure 1. Total population, population 65 years and over and 75 years and over: United States, 1950–2050.

Figure 1

Total population, population 65 years and over and 75 years and over: United States, 1950–2050. Click here for spreadsheet version Click here for PowerPoint NOTES: See Data Table for data points graphed (more...)

During 1950 to 2000, the U.S. population grew older (figure 2). From 1950 to 2000 the percent of the population under 18 years of age fell from 31 percent to 26 percent while the percent 65–74 years increased from 6 to 7 percent and the percent 75 years and over increased from 3 to 6 percent.

Figure 2. Percent of population in 4 age groups: United States, 1950, 2000, and 2050.

Figure 2

Percent of population in 4 age groups: United States, 1950, 2000, and 2050. Click here for spreadsheet version Click here for PowerPoint NOTES: See Data Table for data points graphed and additional notes.

From 2000 to 2050 it is anticipated that the percent of the population 65 years and over will increase substantially. Between 2000 and 2050 the percent of the population 65–74 years of age will increase from 7 to 9 percent and the population 75 years and over will increase from 6 to 12 percent. By 2040 the population 75 years and over will exceed the population 65–74 years of age.

The aging of the population has important consequences for the health care system (1,2). As the older fraction of the population increases, more services will be required for the treatment and management of chronic and acute health conditions. Providing health care services needed by Americans of all ages will be a major challenge in the 21st century.

References for figures 1 and 2

1.
Wolf DA. Population change: Friend or foe of the chronic care system? Health Aff. 2001;20(6):28–42. [PubMed: 11816669]
2.
Goulding MR, Rogers ME, Smith SM. Health and aging: Trends in aging—United States and worldwide. MMWR. 2003;52(06):101–6.

Race and Ethnicity

Changes in the racial and ethnic composition of the population have important consequences for the Nation’s health because many measures of disease and disability differ significantly by race and ethnicity (Health, United States, 2004, trend tables). One of the overarching goals of U.S. public health policy is elimination of racial and ethnic disparities in health.

Diversity has long been a characteristic of the U.S. population, but the racial and ethnic composition of the Nation has changed over time. In recent decades the percent of the population of Hispanic origin and Asian or Pacific Islander race has risen (figure 3). In 2000 over one-quarter of adults and more than one-third of children identified themselves as Hispanic, as black, as Asian or Pacific Islander, or as American Indian or Alaska Native.

Figure 3. Percent of population in selection race and Hispanic origin groups by age: United States, 1980–2000.

Figure 3

Percent of population in selection race and Hispanic origin groups by age: United States, 1980–2000. Click here for spreadsheet version Click here for PowerPoint NOTES: Persons of Hispanic origin may be (more...)

In the 1980 and 1990 decennial censuses, Americans could choose only one racial category to describe their race (1). In the 2000 census the question on race was modified to allow the choice of more than one racial category. Although overall a small percent of persons of non-Hispanic origin selected two or more races in 2000, a higher percent of children than adults were described as being of more than one race. The number of American adults identifying themselves or their children as multiracial is expected to increase in the future (2).

In 2000 the percent of persons reporting two or more races also varied considerably among racial groups. For example, the percent of all persons reporting a specified race who mentioned that race in combination with one or more additional racial groups was 1.4 percent for white persons and 37 percent for American Indians or Alaska Natives (3).

References for figure 3

1.
Grieco EM, Cassidy RC. Overview of race and Hispanic origin. Census 2000 Brief. United States Census 2000. March 2001.
2.
Waters MC. Immigration, intermarriage, and the challenges of measuring racial/ethnic identities. Am J Public Health. 2000;90(11):1735–7. [PMC free article: PMC1446407] [PubMed: 11076242]
3.
U.S. Census Bureau: Census 2000 Modified Race Data Summary File: 2000 Census of Population and Housing, September 2002.

Poverty

Children and adults in families with incomes below or near the Federal poverty level have worse health than those with higher incomes (see Appendix II, Poverty level for a definition of the Federal poverty level). Although, in some cases, illness can lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services (1).

In 2002 the overall percent of Americans living in poverty increased to 12.1 percent, up from 11.7 percent in 2001 and 11.3 percent in 2000, reflecting the recession that started in the spring of 2000 and the economic fallout from the September 11, 2001, attacks. These were the first increases in the poverty rate since 1993. Most of the increase in the poverty rate from 2000 to 2001 was accounted for by working-age adults who are less likely to receive income from government programs than are children and persons 65 years of age and over. However in 2002 the poverty rate increased for all ages (2).

Starting in 1974 children were more likely than either working-age adults or older Americans to be living in poverty (figure 4). In 1974 poverty among children started increasing and remained at 20 percent or above from 1981 to 1997. Since then, the children’s poverty rate gradually declined to 16 percent but increased to 17 percent in 2002.

Figure 4. Poverty rates by age: United States, 1966–2002.

Figure 4

Poverty rates by age: United States, 1966–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Data shown are the percent of persons with family income below the poverty level. See (more...)

Before 1974 persons 65 years of age and over were more likely to live in poverty than people of other ages. With the availability of inflation-adjusted government social insurance programs such as Social Security and Supplemental Security Income, the poverty rate of older Americans declined rapidly until 1974 and continued to decline gradually until the end of the 1990s (3). From 2000 to 2002 the poverty rate among persons 65 years of age and over increased.

In 2002 the percent of persons living in poverty continued to differ significantly by age, race, and ethnicity (figure 5). At all ages, a higher percent of Hispanic and black persons than non-Hispanic white persons were poor. In 2002, 29–32 percent of Hispanic and black children were poor compared with 10–12 percent of Asian and white non-Hispanic children. Similarly, among persons 65 years of age or over more than one-fifth of Hispanic and nearly one-quarter of black persons were poor, compared with 8 percent of Asians and white non-Hispanic persons. In 2000–2002 more than 1 in 5 American Indians and Alaska Natives lived in poverty. Poverty estimates for American Indians and Alaska Natives combine data for all age groups and several years in order to produce an estimate (4).

Figure 5. Low income population by age, race, and Hispanic origin: United States, 2002.

Figure 5

Low income population by age, race, and Hispanic origin: United States, 2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Poor is defined as family income less than 100 percent of the poverty level (more...)

References for figures 4 and 5

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, Maryland: National Center for Health Statistics. 1998.
2.
Proctor B, Dalaker J. Poverty in the United States: 2002. Current population reports, series P-60 no 222. Washington, DC: U.S. Government Printing Office. 2003.
3.
Hungerford T, Rassette M, Iams H, Koenig M. Trends in the economic status of the elderly. Social Security Bulletin 64(3). 2001–2002. [PubMed: 12655738]
4.

Health Insurance

Health Insurance

Health insurance coverage is an important determinant of access to health care (1). Uninsured children and adults under 65 years of age are substantially less likely to have a usual source of health care or a recent health care visit than their insured counterparts (Health, United States, 2004, tables 71, 74, 75, and 77). Uninsured persons are more likely to forgo needed health care due to cost concerns (1,2). The major source of coverage for persons under 65 years of age is private employer-sponsored group health insurance. Private health insurance may also be purchased on an individual basis, but it generally costs more and provides less adequate coverage than group insurance. Public programs such as Medicaid and the State Children’s Health Insurance Program provide coverage for many low-income children and adults.

Between 1984 and 1994 private coverage declined among persons under 65 years of age while Medicaid coverage and uninsurance increased. Since 1994 the age adjusted percent of the nonelderly population with no health insurance coverage has been between 16–17 percent, Medicaid between 9–12 percent, and private coverage between 70–73 percent (figure 6). In 2002 the percent with private health insurance decreased. This decrease was offset by an increase in the percent with Medicaid, resulting in little change in the percent uninsured.

Figure 6. Health insurance coverage among persons under 65 years of age: United States, 1984–2002.

Figure 6

Health insurance coverage among persons under 65 years of age: United States, 1984–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents are age adjusted. See Data Table (more...)

In 2002, 17 percent of Americans under 65 years of age reported having no health insurance coverage. The percent of adults under 65 years of age without health insurance coverage decreases with age. In 2002 adults 18–24 years of age were most likely to lack coverage and those 55–64 years of age were least likely (figure 7). Persons with incomes below or near the poverty level were at least three times as likely to have no health insurance coverage as those with incomes twice the poverty level or higher. Hispanic persons and non-Hispanic black persons were more likely to lack health insurance than non-Hispanic white persons. Persons of Mexican origin were more likely to be uninsured than non-Hispanic black persons or other Hispanics. Access to health insurance coverage through employment is lowest for Hispanic persons (Health, United States, 2004, table 129).

Figure 7. No health insurance coverage among persons under 65 years of age by selected characteristics: United States 2002.

Figure 7

No health insurance coverage among persons under 65 years of age by selected characteristics: United States 2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents by poverty level, (more...)

References for figures 6 and 7

1.
Institute of Medicine. Committee on the Consequences of Uninsurance. Series of reports: Coverage matters: Insurance and health care; Care without coverage; Health insurance is a family matter; A shared destiny: Community effects of uninsurance; Hidden costs, value lost: Uninsurance in America. Washington, DC: National Academy Press. 2001–2003.
2.
Ayanian JZ, Weissman JS, Schneider EC. et al. Unmet health needs of uninsured adults in the United States. JAMA. 2000;285(4):2061–9. [PubMed: 11042754]

Preventive Health Care

Prenatal Care

Prenatal care that begins in the first trimester and continues throughout pregnancy reduces the risk of maternal morbidity and poor birth outcomes. Appropriate prenatal care can enhance pregnancy outcome and long-term maternal health by managing preexisting and pregnancy-related medical conditions, providing health behavior advice, and assessing the risk of poor pregnancy outcome (1). Attitudes toward pregnancy, lifestyle factors, and cultural beliefs have been suggested as reasons women delay recommended prenatal care. Financial and health insurance problems are among the most important barriers to such care (2). Expansion of Medicaid coverage for pregnancy-related services has increased availability and use of prenatal care by low income women (3).

During the last three decades, the percent of mothers reporting prenatal care beginning in the first trimester rose from 68 percent in 1970 to almost 84 percent by 2002 (Health, United States, 2004, table 6). This upward trend reflects increases during the 1970s and the 1990s. Increases in use of prenatal care beginning in the first trimester are observed among mothers in all major racial and ethnic groups (figure 8). Increases in use of prenatal care in the 1990s were greatest for those with the lowest rates of care: Hispanic, non-Hispanic black, and American Indian or Alaska Native women.

Figure 8. Early prenatal care by race and Hispanic origin of mother: United States, 1980–2002.

Figure 8

Early prenatal care by race and Hispanic origin of mother: United States, 1980–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Early prenatal care begins during the first trimester (more...)

Important racial and ethnic differences in the percent of mothers reporting early prenatal care persist (figure 9). In 2002 the percent receiving early care was higher for non-Hispanic white women than for non-Hispanic black women, American Indian or Alaska Native women, and most groups of Hispanic women.

Figure 9. Early prenatal care by detailed race and Hispanic origin of mother: United States, 2002.

Figure 9

Early prenatal care by detailed race and Hispanic origin of mother: United States, 2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Early prenatal care begins during the first trimester (more...)

In 2002 about 4 percent of women began care in the third trimester of pregnancy or received no care at all, compared with 6 percent in 1990. The proportion of women receiving late or no prenatal care was highest among American Indian or Alaska Native women, non-Hispanic black women, and women of Mexican origin (6–8 percent) (Health, United States, 2004, table 6).

References for figures 8 and 9

1.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for 2002. National vital statistics reports; vol 52 no 10. Hyattsville, Maryland: National Center for Health Statistics. 2003.
2.
Lewis CT, Mathews TJ, Heuser RL. Prenatal care in the United States, 1980–94. Vital Health Stat 21(54). Hyattsville, Maryland: National Center for Health Statistics. 1996.
3.
Rowland D, Salganicoff A, Keenan PS. The key to the door: Medicaid’s role in improving health care for women and children. Annu Rev Public Health. 1999;20:403–26. [PubMed: 10352864]

Vaccination: Adults 65 Years of Age and Over

In the United States influenza resulted in the death of about 36,000 persons 65 years of age and over each year during the 1990s (1). Pneumococcal disease accounts for more deaths than any other vaccine-preventable bacterial disease. Annual influenza vaccination and one dose of pneumococcal polysaccharide vaccine can lessen the risk of illness and subsequent complications among older persons 65 years of age and over.

In 2002, 66 percent of noninstitutionalized adults 65 years of age and over reported an influenza vaccination during the past year, the same percent as in 1999. Between 1989 and 1999 the percent more than doubled to 66 percent and then decreased slightly in 2000 and 2001 (figure 10). Between 1989 and 2002 the percent of adults 65 years of age and over ever having received a pneumococcal vaccine increased sharply from 14 percent to 56 percent. Several factors have been suggested as contributing to these increases: greater acceptance of preventive health care by consumers and practitioners, improved Medicare coverage for these vaccines since 1993, and wider delivery of this care by health care providers other than physicians (2).

Figure 10. Influenza and pneumococcal vaccination among adults 65 years of age over: United States 1989–2002.

Figure 10

Influenza and pneumococcal vaccination among adults 65 years of age over: United States 1989–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for the civilian noninstitutionalized (more...)

Although influenza and pneumococcal vaccination rates have increased for non-Hispanic and Hispanic population groups, substantial gaps persist by race and ethnicity (3). In 2000–2002 vaccinations against influenza were received by two-thirds of non-Hispanic white adults, nearly three-fifths of Asian adults, and approximately one-half of Hispanic and non-Hispanic black older adults. Vaccinations against pneumococcal disease were received by nearly three-fifths of non-Hispanic white, and approximately one-third of Asian, non-Hispanic black, and Hispanic older adults (figure 11). Continued monitoring of vaccination rates for all racial and ethnic groups is needed to apprise efforts to improve rates overall and to reduce disparities in vaccination levels (4).

Figure 11. Influenza and pneumococcal vaccination among adults 65 years of age and over by race and Hispanic origin: United States 2000–2002.

Figure 11

Influenza and pneumococcal vaccination among adults 65 years of age and over by race and Hispanic origin: United States 2000–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Data (more...)

References for figures 10 and 11

1.
Thompson WW. et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003;289(2):179–86. [PubMed: 12517228]
2.
Singleton JA. et al. Influenza, pneumococcal, and tetanus toxoid vaccination of adults—United States, 1993–97. In: CDC Surveillance Summaries. MMWR. 2000;49(SS-9):39–62. [PubMed: 11016877]
3.
Centers for Disease Control and Prevention. Racial/ethnic disparities in influenza and pneumococcal vaccination levels among persons aged 65 years and over—United States, 1989–2001. MMWR. 2003;52(40):958–62. [PubMed: 14534511]
4.
Fedson, DS Adult immunization: Summary of the National Vaccine Advisory Committee report. JAMA. 1994;272(14):1133–7. [PubMed: 7933327]

Health Risk Factors

Smoking

As the leading cause of preventable death and disease in the United States, smoking is associated with significantly increased risk of heart disease, stroke, lung cancer, and chronic lung diseases (1). Smoking during pregnancy contributes to elevated risk of miscarriage, premature delivery, and having a low-birthweight infant. Preventing smoking among teenagers is critical since smoking usually begins in adolescence (2). Decreasing cigarette smoking among adolescents and adults is a major public health objective for the Nation.

Cigarette smoking among adult men and women declined substantially following the first Surgeon General’s Report on smoking in 1964 (figure 12). Since 1990 the percent of adults who smoke has continued to decline but at a slower rate than previously. In 2002, 25 percent of men and 20 percent of women were smokers. Cigarette smoking by adults continues to be strongly associated with educational attainment. Among adults, persons with less than a high school education were almost three times as likely to smoke as those with a bachelor’s degree or more education (Health, United States, 2004, table 61).

Figure 12. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2003.

Figure 12

Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents for men and women (more...)

Among high school students, the percent reporting recent cigarette smoking decreased between 1997 and 2003 after increasing in the early 1990s. During the last decade, a similar percent of male and female students reported smoking. Despite the declines in cigarette smoking rates among high school students, 26 percent of high school students in grade 12 were current smokers in 2003, and 13 percent smoked on 20 or more days in the past month (frequent smokers) (figure 13). Many high school students who were frequent smokers have already become nicotine dependent (3).

Figure 13. Current cigarette smoking among high school students by sex, frequency, and grade level: United States, 2003.

Figure 13

Current cigarette smoking among high school students by sex, frequency, and grade level: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Current cigarette smoking is defined (more...)

Among mothers with a live birth, the percent reporting smoking cigarettes during pregnancy declined between 1989 and 2002 (4,5). Eleven percent of mothers with a live birth in 2002 reported smoking cigarettes during pregnancy. Maternal smoking has declined for all racial and ethnic groups, but differences among these groups persist (Health, United States, 2004, table 11). In 2002 the percent of mothers reporting tobacco use during pregnancy was highest for American Indian or Alaska Native mothers (20 percent), non-Hispanic white mothers (15 percent), and Hawaiian mothers (14 percent).

References for figures 12 and 13

1.
Centers for Disease Control and Prevention. Tobacco use—United States, 1900–1999. MMWR. 1999;48(43):986–93. [PubMed: 10577492]
2.
U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, Georgia: Centers for Disease Control and Prevention. 1994.
3.
Centers for Disease Control and Prevention. Trends in cigarette smoking among high school students—United States, 1991–2001. MMWR. 2002;51(19):409–12. [PubMed: 12033476]
4.
Mathews TJ. Smoking during pregnancy in the 1990s. National vital statistics reports; vol 49 no 7. Hyattsville, Maryland: National Center for Health Statistics. 2001. [PubMed: 11561426]
5.
Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2002. National vital statistics reports; vol 52 no 10. Hyattsville, Maryland: National Center for Health Statistics. 2003.

Physical Activity

Benefits of regular physical activity include a reduced risk of premature mortality and reduced risks of coronary heart disease, diabetes, colon cancer, hypertension, and osteoporosis. In addition physical activity can enhance physical functioning and aid in weight control (1). It also improves symptoms associated with musculoskeletal conditions and mental health conditions such as depression and anxiety. Although vigorous physical activity produces the greatest cardiovascular benefits, moderate amounts of physical activity are associated with lower levels of mortality. Among older persons, even small amounts of physical activity may improve cardiovascular functioning (2).

In 2003, 40 percent of female high school students and 27 percent of male high school students reported a level of physical activity that did not meet the criteria for the recommended amount of either moderate or vigorous physical activity (figure 14, see data table for definition of physical activity levels). The percent that reported not engaging in recommended amounts of moderate and vigorous physical activity was higher among students in 11th and 12th grade than among students in 9th and 10th grade. Between 2001 and 2003 the percent of high school students reporting an insufficient amount of moderate and vigorous physical activity remained stable (3).

Figure 14. High school students not engaging in recommended amounts of physical activity (neither moderate nor vigorous) by grade and sex: United States, 2003.

Figure 14

High school students not engaging in recommended amounts of physical activity (neither moderate nor vigorous) by grade and sex: United States, 2003. Click here for spreadsheet version Click here for PowerPoint (more...)

In 2002 nearly 40 percent of noninstitutionalized adults 18 years of age and over reported that they did not engage in physical activity during leisure time. The trend in leisure-time physical activity among adult men and women has remained stable in recent years (figure 15). Among men and women, the percent that are physically inactive during leisure time increases with age. More than one-half of adults 65 years of age and over indicated being physically inactive during leisure time compared with about one-third of adults 18–44 years of age. Women were more physically inactive during leisure time than men of the same age, consistent with the pattern found among male and female high school students.

Figure 15. Adults not engaging in leisure-time physical activity by age and sex: United States, 1998–2002.

Figure 15

Adults not engaging in leisure-time physical activity by age and sex: United States, 1998–2002. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed, (more...)

Leisure-time physical activity is one component of an active, healthy lifestyle and is reflective of overall activity. A 2000 study that looked at both usual daily activity and leisure-time physical activity showed that, consistent with the pattern found in leisure-time activity, women were more likely than men to never engage in any physical activity overall, and men were more likely than women to engage in a high level of physical activity overall (4).

References for figures 14 and 15

1.
U.S. Department of Health and Human Services. Physical activity and health: A report of the Surgeon General. Atlanta, Georgia: Centers for Disease Control and Prevention. 1996.
2.
Mensink GB, Ziese T, Kok FJ. Benefits of leisure-time physical activity on the cardiovascular risk profile at older age. Int J Epidemiol. 1999;28(4):659–66. [PubMed: 10480693]
3.
Grunbaum JA, Kann L, Kinchen SA, et al. Youth Risk Behavior Surveillance—United States, 2001. In: CDC Surveillance Summaries. MMWR 51(No. SS-4). 2002. [PubMed: 12102329]
4.
Barnes PM, Schoenborn CA. Physical activity among adults: United States, 2000. Advance data from vital and health statistics; no 333. Hyattsville, Maryland: National Center for Health Statistics. 2003.

Overweight and Obesity

Epidemiologic and actuarial studies have shown that increased body weight is associated with excess morbidity and mortality (1). Among adults, overweight and obesity elevate the risk of heart disease, diabetes, and some types of cancer. Overweight and obesity are also factors that increase the severity of disease associated with hypertension, arthritis, and other musculoskeletal problems (2). Among children and adolescents, obesity increases the risk of high cholesterol, hypertension, and diabetes (3). Diet, physical activity, genetic factors, and health conditions all contribute to overweight in children and adults. The potential health benefits from reduction in the prevalence of overweight and obesity are of significant public health importance.

Results from a series of National Health and Nutrition Examination Surveys indicate that the prevalence of overweight and obesity changed little between the early 1960s and 1976–80 (figure 16). Findings from the 1988–94 and 1999–2002 surveys, however, showed substantial increases in overweight and obesity among adults. The upward trend in overweight since 1980 reflects primarily an increase in the percent of adults 20–74 years of age who are obese. In 1999–2002, 65 percent of adults were overweight with 31 percent obese.

Figure 16. Overweight and obesity by age: United States, 1960-2002.

Figure 16

Overweight and obesity by age: United States, 1960-2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents for adults are age adjusted. For adults: “overweight including obese” (more...)

The percent of children (6–11 years of age) and adolescents (12–19 years of age) who are overweight has also risen. Among children and adolescents, the percent overweight increased since 1976–80. In 1999–2002 about 16 percent of children and adolescents were overweight. The prevalence of overweight among adolescents varies by race and ethnicity. In 1999–2002, 14 percent of non-Hispanic white adolescents, 21 percent of non-Hispanic black adolescents, and 23 percent of Mexican-origin adolescents were overweight.

The prevalence of obesity varies among adults by sex, race, and ethnicity (figure 17). In 1999–2002, 28 percent of men and 34 percent of women 20–74 years of age were obese. The prevalence of obesity among women differed significantly by racial and ethnic group; non-Hispanic black women had a higher prevalence of obesity than did non-Hispanic white women. In 1999–2002 one-half of non-Hispanic black women were obese.

Figure 17. Obesity among adults 20-74 years of age by sex, race and Hispanic origin: United States, 1999–2002.

Figure 17

Obesity among adults 20-74 years of age by sex, race and Hispanic origin: United States, 1999–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents are age adjusted. Obese (more...)

References for figures 16 and 17

1.
National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. NIH Pub. No. 98–4083. September 1998. [PubMed: 9813653]
2.
U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, Maryland. 2001.
3.
Dietz WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics. 1998;101(3 Pt 2):518–25. [PubMed: 12224658]

Limitation of Activity

Limitation of Activity: Children

Limitation of activity due to chronic physical, mental, or emotional disorders or deficits is a broad measure of health and functioning that gauges a child’s ability to engage in major age-appropriate activities. Play is the primary activity for preschool children while schoolwork is the primary activity for children 5 years of age and over. Estimates of the number of children with an activity limitation may differ depending on the type of disabilities included and the methods used to identify them (1).

The National Health Interview Survey identifies children with activity limitation through questions about specific limitations in play, self-care, walking, memory, and other activities and through a question about current use of special education or early intervention services. A child is classified as having an activity limitation due to a chronic condition if at least one of the conditions causing limitations is a chronic physical, mental, or emotional problem.

Comparable national data on activity limitation have been available since 1997 (see Appendix I, National Health Interview Survey). Between 1997 and 2002 the percent of children with activity limitation was 6–7 percent (Health, United States, 2004, table 56). The percent of children with limitation of activity has varied consistently by age and sex. In 2001–02 the percent of children with activity limitation was significantly higher among school-age children than among preschoolers, primarily due to the number of school-age children identified solely by participation in special education. Limitation of activity occurred nearly twice as often among boys as among girls (2). Physiological, maturational, behavioral, and social differences between boys and girls have been suggested as explanations for the higher prevalence of activity limitation in boys (3).

In 2001–02 the leading chronic health conditions causing activity limitation in children differed by age (figure 18). Among preschool children, the three chronic conditions most often mentioned were speech problems, asthma, and mental retardation. Among all school-age children, learning disability and Attention Deficit Hyperactivity Disorder (ADHD) were among the top three leading causes of activity limitation. The third leading cause among younger school-age children was speech problems and among older school-age children it was other mental, emotional, and behavioral problems.

Figure 18. Selected chronic health conditions causing limitation of activity among children by age: United States, 2001-02.

Figure 18

Selected chronic health conditions causing limitation of activity among children by age: United States, 2001-02. Click here for spreadsheet version Click here for PowerPoint NOTES: Children with more than one (more...)

References for figure 18

1.
Newacheck PW, Strickland B, Shonkoff JP. et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102(1):117–21. [PubMed: 9651423]
2.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
3.
Gissler M, Jarvelin M-R, Louhiala P, Hemminki E. Boys have more health problems in childhood than girls: Follow-up of the 1987 Finnish birth cohort. Acta Paediatr. 1999;88:310–4. [PubMed: 10229043]

Limitation of Activity: Working-Age Adults

Measuring limitations in everyday activities due to chronic physical, mental, or emotional problems is one way to assess the impact of health conditions on self care and social participation (1). The effect that chronic health conditions have on activity limitation may vary with the availability of supportive and health care services.

In the National Health Interview Survey, limitation of activity in adults includes limitations in handling personal care needs (activities of daily living), routine needs (instrumental activities of daily living), having a job outside the home, walking, remembering, and other activities. Comparable national data on activity limitation have been available since 1997 (see Appendix I, National Health Interview Survey). Between 1997 and 2002 the percent of working-age adults 18–64 years of age reporting any activity limitation caused by a chronic health condition remained relatively stable (Health, United States, 2004, table 56).

In 2000–2002, 6 percent of younger adults 18–44 years of age reported limitation in activity, in contrast to 21 percent of adults 55–64 years of age (figure 19). Differences in limitation of activity by poverty status are substantial; the percent of poor working-age adults reporting a limitation was more than three times that of adults with family income at 200 percent or more of the poverty level. After adjusting for differences in age, limitation of activity was about the same for men and women. Limitation of activity varies modestly by race and Hispanic origin from 8 percent of Hispanic persons to 12 percent of non-Hispanic black persons.

Figure 19. Limitation of activity caused by 1 or more chronic health conditions among working-age adults by selected characteristics: United States, 2000–2002.

Figure 19

Limitation of activity caused by 1 or more chronic health conditions among working-age adults by selected characteristics: United States, 2000–2002. Click here for spreadsheet version Click here for PowerPoint (more...)

Health surveys that measure limitation of activity have typically asked about chronic conditions causing these restrictions. Health conditions usually refer to broad categories of disease and impairment rather than medical diagnoses and reflect the understanding the general public has of factors causing disability or limitation of activity (2). Among working-age adults, arthritis and other musculoskeletal conditions were the most frequently mentioned chronic conditions causing limitation of activity (figure 20). Among persons 18–44 years of age, mental illness was the second most prevalent cause of activity limitation. Among older working-age adults (45–64 years), heart disease was the second most frequently mentioned condition. Persons who reported more than one chronic health condition as the cause of their activity limitation were counted in each category.

Figure 20. Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2000–2002.

Figure 20

Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2000–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Persons (more...)

References for figures 19 and 20

1.
Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in the aging population. Annu Rev Public Health. 1996;17:25–46. [PubMed: 8724214]
2.
Fujiura GT, Rutkowski-Kmitta V. Counting disability. In: Albrecht GL, Seelman KD, Bury M, eds. Handbook of disability studies. Thousand Oaks, California: Sage Publications, 69–96, 2001.

Limitation of Activity: Adults 65 Years of Age and Over

The ability to perform basic activities of daily living (ADL) such as bathing, dressing, and using the toilet, is an indicator of the health and functional well-being of the older population. Being limited in ADLs compromises the quality of life of older persons and often results in the need for informal or formal caregiving services, including institutionalization.

The Medicare Current Beneficiary Survey reports the health and health care utilization of a representative sample of Medicare beneficiaries of all ages and in all types of residences, both institutional and noninstitutional. Respondents are asked about their level of difficulty and the kind of assistance received in performing six ADLs: bathing or showering, dressing, eating, getting in or out of bed or chairs, walking, and using the toilet. The definition of limitation here includes persons who have difficulty and who receive help or supervision performing at least one of the six activities.

From 1992 to 2002 the percent of all Medicare beneficiaries 65 years of age and over who were limited in at least one of six ADLs declined from 16 percent to 14 percent (figure 21). During the same period the percent of Medicare beneficiaries 65 years of age and over who were limited in ADLs ranged between 10–12 percent for noninstitutionalized beneficiaries and between 86–93 percent for institutionalized beneficiaries. In 2002, 11 percent of noninstitutionalized and 90 percent of institutionalized beneficiaries were limited in at least one of six ADLs. About 5 percent of Medicare beneficiaries 65 years of age and over are institutionalized. Over time, the distinction between noninstitutionalized and institutionalized settings has blurred as ‘‘assisted living’’ facilities have become more prominent. Trends in activity limitation for both noninstitutionalized and institutionalized beneficiaries may be affected by the emergence of assisted living and other types of residential settings for older Americans.

Figure 21. Limitation of activities of daily living among Medicare beneficiaries 65 years of age and over: United States, 1992–2002.

Figure 21

Limitation of activities of daily living among Medicare beneficiaries 65 years of age and over: United States, 1992–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Percents are (more...)

Among noninstitutionalized older Medicare beneficiaries, the percent limited in ADLs was higher for women than men and rises with age for both women and men. For the oldest age group, persons 85 years of age and over, 27 percent of women and 24 percent of men received help or supervision with at least one basic activity of daily living in 2002. Among persons in institutions, nearly all, regardless of age, received help or supervision with ADLs (89 percent of men and 90 percent of women) (1).

Some studies show that limitations in certain aspects of disability have declined among the older population, including the ability to perform physical tasks such as walking up steps and reaching arms overhead and the ability to perform instrumental activities of daily living (IADLs) such as shopping and managing money (2–5). Evidence on the trends in ADL limitation is mixed, but a recent study shows declines in certain measures of ADL limitation beginning in the mid-1990s (6). More studies over a longer time period are needed to determine whether a sustained overall decline in ADL limitation is occurring.

References for figure 21

1.
Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey, Access to Care files, unpublished analysis.
2.
Freedman V, Martin L. Understanding trends in functional limitations among older Americans. AJPH. 1998;88:1457–62. [PMC free article: PMC1508476] [PubMed: 9772844]
3.
Lentzner HR, Weeks JD, Feldman JJ. Changes in disability in the elderly population: Preliminary results from the Second Supplement on Aging. Paper presented at the annual meetings of the Population Association of America. Chicago, Illinois: April 1998.
4.
Crimmins E, Saito Y, Reynolds S. Further evidence on recent trends in the prevalence and incidence of disability among older Americans from two sources: The LSOA and the NHIS. J. Gerontol. 1997;52B(2):S59–71. [PubMed: 9060986]
5.
Manton KG, Gu X. Changes in the prevalence of chronic disability in the United States black and nonblack population above 65 from 1982 to 1999. PNAS. 2001;98(11):6354–9. [PMC free article: PMC33472] [PubMed: 11344275]
6.
Freedman VA, Crimmins E, Schoeni RF, Spillman B, Aykan H, Kramarow E, Land K, Lubitz J, Manton K, Martin LG, Shinberg D, Waidmann T. Resolving inconsistencies in old-age disability: Report from a technical working group. Demography 41(3):417–41. August 2004. [PubMed: 15461008]

Mortality

Life Expectancy

Life expectancy is a measure often used to gauge the overall health of a population. As a summary measure of mortality, life expectancy represents the average number of years of life that could be expected if current death rates were to remain constant. Shifts in life expectancy are often used to describe trends in mortality. Life expectancy at birth is strongly influenced by infant and child mortality. Life expectancy later in life reflects death rates at or above a given age and is independent of the effect of mortality at younger ages (1).

During the 20th century, life expectancy at birth increased from 48 to 74 years of age for men and from 51 to almost 80 years of age for women (figure 22). Improvements in nutrition, housing, hygiene, and medical care contributed to decreases in death rates throughout the lifespan. Prevention and control of infectious diseases had a profound impact on life expectancy in the first half of the 20th century (2).

Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 1991–2001.

Figure 22

Life expectancy at birth and at 65 years of age by sex: United States, 1991–2001. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed and additional (more...)

Life expectancy at age 65 years also increased during the last century. Among men, life expectancy at age 65 years rose from 12 to 16 years and among women from 12 to 19 years of age. In contrast to life expectancy at birth, which increased sharply early in the century, life expectancy at age 65 years improved primarily after 1950. Improved access to health care, advances in medicine, healthier lifestyles, and better health before age 65 years are factors underlying decreased death rates among older Americans (3).

While the overall trend in life expectancy for the United States was upward throughout the 20th century, the gain in years of life expectancy for women generally exceeded that for men until the 1970s, widening the gap in life expectancy between men and women. The increasing gap during those years is attributed to increases in male mortality due to ischemic heart disease and lung cancer, both of which increased largely as the result of men’s early and widespread adoption of cigarette smoking (4). After the 1970s the gain in life expectancy for men exceeded that for women and the gender gap in life expectancy began to narrow. Between 1990 and 2001 the total gain in life expectancy for women was 1 year compared with more than 2 years for men, reflecting proportionately greater decreases in heart disease and cancer mortality for men than for women and proportionately larger increases in chronic lower respiratory disease mortality among women (4).

Longer life expectancies at birth in many other developed countries suggest the possibility of improving longevity in the United States (Health, United States, 2004, table 26). Decreasing death rates of less advantaged groups could raise life expectancy in the United States (Health, United States, 2004, table 27).

References for figure 22

1.
Arriaga EE. Measuring and explaining the change in life expectancies. Demography. 1984;21(1):83–96. [PubMed: 6714492]
2.
Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: Control of infectious diseases. MMWR. 1999;48(29):621–9. [PubMed: 10458535]
3.
Fried LP. Epidemiology of aging. Epidemiol Rev. 2000;22(1):95–106. [PubMed: 10939013]
4.
Arias E. United States life tables, 2001. National vital statistics reports; vol 52 no 13. Hyattsville, Maryland: National Center for Health Statistics. 2004.

Infant Mortality

Infant mortality, the risk of death during the first year of life, is related to the underlying health of the mother, public health practices, socioeconomic conditions, and availability and use of appropriate health care for infants and pregnant women. Disorders related to short gestation and low birthweight, and congenital malformations are the leading causes of death during the first month of life (neonatal mortality). Sudden Infant Death Syndrome (SIDS) and congenital malformations rank as the leading causes of infant deaths after the first month of life (postneonatal mortality) (1).

Between 1950 and 2001 the infant mortality rate declined by almost 77 percent (figure 23). In 2002 the infant mortality rate increased to 7.0 infant deaths per 1,000 live births up from 6.8 in 2001 (2,3). This was the first year since 1958 that the rate has not declined or remained unchanged. Based on an analysis of the preliminary data, the rise in infant mortality was attributed to an increase in neonatal infant deaths (infants less than 28 days old). Two-thirds of all infant deaths occur during the neonatal period (Health, United States, 2004, table 22). Provisional counts of infant deaths for the first 9 months of 2003 suggest an improvement in the infant mortality rate for 2003. However, the provisional data are not stable enough to determine if the improvement is large enough to bring the rate down to the historically low level reached in 2001.

Figure 23. Infant, neonatal , and postneonatal mortality rates: United States, 1950–2002.

Figure 23

Infant, neonatal , and postneonatal mortality rates: United States, 1950–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Infant is defined as under 1 year of age, neonatal as (more...)

Declines in infant mortality over the past five decades have been linked to improved access to health care, advances in neonatal medicine, and public health education campaigns such as the ‘‘Back to Sleep’’ campaign to curb fatalities caused by SIDS (4).

Infant mortality rates have declined for all racial and ethnic groups, but large disparities remain (Health, United States, 2004, table 19). During 1999–2001 the infant mortality rate was highest for infants of non-Hispanic black mothers (figure 24) (5). Infant mortality rates were also high among infants of American Indian or Alaska Native mothers, Puerto Rican mothers, and Hawaiian mothers. Infants of mothers of Chinese origin had the lowest infant mortality rates.

Figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999–2001.

Figure 24

Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999–2001. Click here for spreadsheet version Click here for PowerPoint NOTES: Infant is defined as under 1 year of (more...)

References for figures 23 and 24

1.
Anderson RN, Smith BL. Deaths: Leading causes for 2001. National vital statistics reports; vol 52 no 9. Hyattsville, Maryland: National Center for Health Statistics. 2003. [PubMed: 14626726]
2.
Kochanek KD, Martin JA. Supplemental analyses of recent trends in infant mortality. Health E Stats; Hyattsville, Maryland. National Center for Health Statistics. 2004. Available at: www​.cdc.gov/nchs/products​/pubs/pubd/hestats​/infantmort/infantmort.htm.
3.
Kochanek KD, Smith BL. Deaths: Preliminary data for 2002. National vital statistics reports; vol 52 no 13. Hyattsville, Maryland: National Center for Health Statistics. 2004.
4.
American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89(6):1120–6. [PubMed: 1503575]
5.
Data from the 2000–2002 linked birth and infant death file were not available to be included in this report. See www​.cdc.gov/nchs for updated information.

Leading Causes of Death for All Ages

In 2002 a total of 2.4 million deaths were reported in the United States. The overall age-adjusted death rate was 42 percent lower in 2002 than it was in 1950. The reduction in overall mortality during the last half of the 20th century was driven mostly by declines in mortality for such leading causes of death as heart disease, stroke, and unintentional injuries (figure 25).

Figure 25. Death rates for leading causes of death for all ages: United States, 1950–2002.

Figure 25

Death rates for leading causes of death for all ages: United States, 1950–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Rates are age adjusted. Causes of death shown are the five (more...)

Throughout the second half of the 20th century, heart disease was the leading cause of death and stroke was the third leading cause. In 2002 the death rate for heart disease was 59 percent lower than the rate in 1950. The death rate for stroke declined 69 percent since 1950 (Health, United States, 2004, tables 36 and 37). Heart disease and stroke mortality are associated with risk factors such as high blood cholesterol, high blood pressure, smoking, and dietary factors. Other important factors include socioeconomic status, obesity, and physical inactivity. Factors contributing to the decline in heart disease and stroke mortality include better control of risk factors, improved access to early detection, and better treatment and care, including new drugs and expanded uses for existing drugs (1).

Cancer was the second leading cause of death throughout the period. Overall cancer death rates rose between 1960 and 1990 and then reversed direction. Between 1990 and 2002 overall death rates for cancer declined more than 10 percent. In the 1980s cancer death rates for females increased faster and in the 1990s declined more slowly than rates for males, reducing the disparity in cancer death rates. Rates for males were 63 percent higher than rates for females in 1980 and 46 percent higher in 2002. The trend in the overall cancer death rate reflects the trend in the death rate for lung cancer (Health, United States, 2004, tables 38 and 39). Since 1970 the death rate for lung cancer for the total population has been higher than the death rate for any other cancer site. Lung cancer is strongly associated with smoking.

Chronic lower respiratory disease (CLRD) was the fourth leading cause of death in 2002. The death rate for CLRD in 2002 was 54 percent higher than the rate in 1980. The upward trajectory for CLRD death rates is a result of steadily increasing death rates for females, which increased more than 150 percent between 1980 and 2002, while death rates for males increased only 7 percent. The increasing trend for females is most noticeable for females age 55 years and over (Health, United States, 2004, table 41). CLRD is strongly associated with smoking.

The fifth leading cause of death in 2002 was unintentional injuries. Death rates for unintentional injuries declined during the period 1950–1992. Since 1992, however, unintentional injury mortality has increased slightly. Despite recent increases, the death rate for unintentional injuries in 2002 was still 53 percent lower than the rate in 1950. The risk of death due to unintentional injuries is greater for males than females (Health, United States, 2004, table 29) and the risk varies with age. For males age 15–64 years in 2002, the risk of death due to unintentional injuries was 2–3 times the risk for females of those ages. For ages under 15 years and 65 years and over, the gender disparity was smaller. The risk of death due to unintentional injuries increased steeply after age 64 years for both males and females.

Although overall unintentional injury mortality has increased slightly since the early 1990s, the trend in motor vehicle-related injury mortality, which accounts for approximately one-half of all unintentional injury mortality, has been generally downward since the 1970s (Health, United States, 2004, table 44). The decline in death rates for motor vehicle-related injuries is a result of safer vehicles and highways; behavioral changes such as increased use of safety belts, child safety seats, and motorcycle helmets; and decreased drinking and driving (2).

Death rates increase with age for chronic diseases such as heart disease, cancer, stroke, and chronic lower respiratory diseases, as well as for unintentional injuries. Death rates for black persons exceed those for white persons of the same gender for each of these causes. Socioeconomic factors are strongly associated with risk of death. Adult males and females with a high school education or less had death rates more than twice as high as the rates for those with more than a high school education in 2002 (Health, United States, 2004, table 34).

References for figure 25

1.
Centers for Disease Control and Prevention. Decline in deaths from heart disease and stroke—United States, 1900–1999. MMWR. 1999;48(30):649–56. [PubMed: 10488780]
2.
Centers for Disease Control and Prevention. Motor-vehicle safety: A 20th century public health achievement. MMWR. 1999;48(18):369–74. [PubMed: 10369577]

Special Feature: Drugs

Overall Drug Use

Drugs—both prescription and nonprescription—are becoming a more frequently utilized therapy for reducing morbidity and mortality, and improving the quality of life of Americans. Factors affecting the increase in utilization of medications include the growth of third-party insurance coverage for drugs, the availability of effective new drugs, marketing to physicians and increasingly directly to consumers, and clinical guidelines recommending increased use of medications for conditions such as high cholesterol, high blood pressure, chronic asthma, and diabetes (1,2). This increased utilization is reflected in higher expenditures. Between 1995 and 2002 expenditures for prescription drugs grew at a faster rate than expenditures for other types of health care (Health, United States, 2004, table 118).

The National Health and Nutrition Examination Survey (NHANES) collects data on the prescription drug use of survey participants during in-person household interviews. Between 1988–94 and 1999–2000 NHANES data show that the percent of Americans of all ages who reported using any prescribed medication during the past month increased from 39 to 44 percent (age adjusted; figure 26). During the same period the percent of persons who reported using three or more drugs in the past month increased from 12 to 17 percent (age adjusted) of the population. Perhaps most striking is the increase in the percent of older persons who reported taking three or more prescribed medications during a one-month period—almost one-half of those 65 and over in 1999–2000—compared with just over one-third in 1988–94.

Figure 26. Percent of persons reporting prescription drug use in the past month by age: United States, 1988-94 and 1999-2000.

Figure 26

Percent of persons reporting prescription drug use in the past month by age: United States, 1988-94 and 1999-2000. Click here for PowerPoint Click here for Power Point NOTES: All ages data are age adjusted. See (more...)

Prescription drug use is greater among middle-aged and older adults than among younger persons. Prevalence of many chronic conditions and diseases increases with age, as does use of medications designed to help control or prevent complications associated with those conditions. In 1999–2000, about one-quarter of children reported taking at least one prescription medication while more than 60 percent of middle-aged adults and more than 80 percent of older adults reported taking at least one prescription drug during the past month.

Use of prescription drugs differs by race and ethnicity (Health, United States, 2004, table 86). Adults of Mexican origin are less likely to report having taken a prescribed medication in the past month than either non-Hispanic black or non-Hispanic white adults. In part this is because use of medications is strongly related to access to medical care and the ability to pay for medications once prescribed (1,3). Americans of Mexican descent are less likely to have health insurance, which often covers some prescription drug expenses, than those in other racial and ethnic groups (Health, United States, 2004, table 129).

Data on drugs associated with medical visits are available from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS Outpatient Department Component). These data are abstracted from medical records of physician office and hospital outpatient department visits and include information on the number and type of prescription and nonprescription drugs, immunizations, allergy shots, and anesthetics that were prescribed, ordered, supplied, administered, or continued during the visit.

Data from NAMCS and NHAMCS provide information on overall medication prescribing patterns in addition to documenting the burden and complexity that medication management presents to the health care system and to consumers. Estimates of the percent of visits with drugs recorded on the visit record from NAMCS and NHAMCS (figure 27) complement the population-based data from NHANES (figure 26), which provide a snapshot of prescription drugs reported at the time of in-person interviews. Because NAMCS and NHAMCS data include information only on persons who have accessed the medical care system, they do not represent the number or percent of people in the Nation currently taking a specific drug. Rather, the visit-level data provide a snapshot of how drugs are being prescribed or provided to people who receive care from office-based physicians and hospital outpatient departments.

Figure 27. Percent of physician office and hospital outpatient department visits with 5 or more drugs prescribed, ordered, or provided by age: United States, 1995-2002.

Figure 27

Percent of physician office and hospital outpatient department visits with 5 or more drugs prescribed, ordered, or provided by age: United States, 1995-2002. Click here for spreadsheet version Click here for PowerPoint (more...)

Almost two-thirds (62 percent) of visits to physician offices and hospital outpatient departments in 2001–02 had at least one drug associated with the visit (4). Between 1995–96 and 2001–02 the number of drugs recorded during physician office and hospital outpatient department visits increased from 1.1 to 1.5 billion. Rates of visits with at least one drug mentioned are higher for women than men, in part reflecting women’s overall higher rate of visits to physician offices and hospital outpatient departments (Health, United States, 2004, tables 83 and 87) (5).

Between 1995–96 and 2001–02, visits to physician offices and hospital outpatient departments with five or more medications increased from 4 to 7 percent (age adjusted) of all visits. The increase in the percent of visits with five or more drugs recorded during visits varied substantially by age (figure 27). During this period the percent of visits with five or more drugs tripled for children younger than age 18 years, although the percent of children’s visits with five or more drugs mentioned was still small in 2001–02 (less than 3 percent). Between 1995–96 and 2001–02 the percent of adults’ visits with five or more drugs mentioned increased about 60 percent, depending on the age group. The largest absolute percentage point increase was for persons age 75 and over. In 1995–96, 13 percent of visits for persons in this oldest age group had five or more drugs recorded on the visit record; by 2001–02 more than 20 percent of visits had five or more drugs recorded.

The remainder of this special feature on drugs delves further into drug prescribing and utilization patterns by focusing on specific types or therapeutic classes of drugs—that is, drugs generally prescribed for specific conditions or reasons—and how drug use varies by age, gender, and race. Drugs that showed particularly large increases since 1995 are highlighted, as well as drugs commonly used by persons in specific age groups. While not all classes of drugs can be examined in detail in this feature, trends in ambulatory care visits associated with commonly used drugs, as well as trends in the percent of persons who reported taking a drug during a one-month period, show the extent to which large changes in practice patterns and utilization can occur in a relatively short time period.

Several different measures of drug use are presented in this special feature. Data in some figures are presented as visit rates, that is, the number of visits with specific drugs of interest recorded per 100 persons (figures 3235). In some instances information is presented as a percent of visits with specific drugs recorded among visits for a specific diagnosis, asthma (figures 28 and 29). Data in other charts are presented as the percent of persons reporting specific drug use in the past month (figures 30 and 31). Finally, figure 36 presents the percent of visits with a specific class of drugs (selective COX-2 NSAIDs) recorded among visits with a broader class of drugs (all NSAIDs) recorded.

Figure 32. Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults 18 years of age and over by sex: United States, 1995-2002.

Figure 32

Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults 18 years of age and over by sex: United States, 1995-2002. Click here for spreadsheet version Click here for PowerPoint NOTE: (more...)

Figure 35. Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex and age: United States, 1995-2002.

Figure 35

Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex and age: United States, 1995-2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Cholesterol-lowering (more...)

Figure 28. Percent of asthma visits with quick-relief and long-term control drugs prescribed, ordered, or provided: United States, 1995-2002.

Figure 28

Percent of asthma visits with quick-relief and long-term control drugs prescribed, ordered, or provided: United States, 1995-2002. Click here for PowerPoint Click here for spreadsheet version NOTES: Asthma visits (more...)

Figure 29. Percent of asthma visits with selected asthma drugs prescribed, ordered, or provided: United States, 1995-2002.

Figure 29

Percent of asthma visits with selected asthma drugs prescribed, ordered, or provided: United States, 1995-2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Asthma visits are physician office (more...)

Figure 30. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by sex and age: United States, 1988-94 and 1999-2000.

Figure 30

Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by sex and age: United States, 1988-94 and 1999-2000. Click here for spreadsheet version Click here for PowerPoint (more...)

Figure 31. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by race and ethnicity: United States, 1988-94 and 1999-2000.

Figure 31

Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by race and ethnicity: United States, 1988-94 and 1999-2000. Click here for PowerPoint Click here for spreadsheet version (more...)

Figure 36. Percent of nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2 NSAIDs prescribed, ordered, or provided among adults 18 years of age and over by age: United States, 1999-2002.

Figure 36

Percent of nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2 NSAIDs prescribed, ordered, or provided among adults 18 years of age and over by age: United States, 1999-2002. Click here for spreadsheet version (more...)

References for figures 26 and 27

1.
Berndt ER. The U.S. pharmaceutical industry: Why major growth in times of cost containment? Health Aff. 2001;20(2):100–14. [PubMed: 11260932]
2.
Chockley N. The emerging impact of direct-to-consumer prescription drug advertising. Testimony before the Subcommittee on Consumer Affairs, Foreign Commerce and Tourism of the Senate Committee on Commerce, Science and Transportation. July 24, 2001.
3.
Poisal JA, Murray L. Growing differences between Medicare beneficiaries with and without drug coverage. Health Aff. 2001;20(2):74–85. [PubMed: 11260961]
4.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, unpublished data. [PubMed: 10662355]
5.
Weissman CS. Women’s use of health care. In Falik M, Collins K, eds. Women’s Health: The Commonwealth Fund Survey. Baltimore, Maryland: The Johns Hopkins University Press, 1996.

References for figures 28 and 29

1.
National Center for Health Statistics. Asthma prevalence, health care use and mortality, 2000–2001. Available from www​.cdc.gov/nchs/products​/pubs/pubd/hestats/asthma/asthma​.htm accessed on January 6, 2004.
2.
National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. NIH Publication No. 97–4051. Bethesda, MD: National Heart, Lung, and Blood Institute. 1997. Available from www​.nhlbi.nih.gov/guidelines​/asthma/asthgdln.pdf accessed on January 6, 2004.
3.
Weiss KB, Sullivan SD. The health economics of asthma and rhinitis: Assessing the economic impact. J Allergy Clin Immunol. 2001;107(1):3–8. [PubMed: 11149982]
4.
Akinbami LJ, Schoendorf KC. Trends in childhood asthma: Prevalence, health care utilization, and mortality. Pediatrics. 2002;110(2):315–22. [PubMed: 12165584]
5.
NAEPP Expert Panel Report. Guidelines for the diagnosis and management of asthma—update on selected topics 2002. Update 2002: Expert Panel Report. Available from www​.nhlbi.nih.gov/guidelines​/asthma/index.htm.
6.
Stafford RS, Ma J, Finkelstein SN. et al. National trends in asthma visits and asthma pharmacotherapy, 1978–2002. J Allergy Clin Immunol. 2003;111(4):729–35. [PubMed: 12704350]

Asthma Drugs

Asthma is a chronic lung disease that affects breathing. It is characterized by episodes of inflammation and narrowing of small airways in response to ‘‘triggers,’’ which include allergens, infections, exercise, or exposure to respiratory irritants, such as tobacco smoke and pollutants. These attacks or episodes may involve shortness of breath, cough, wheezing, chest pain or tightness, mucus production, or a combination of these symptoms (1,2). Asthma is a leading cause of childhood illness and a leading cause of disability and health care expenditures for adults (3). In 2000 alone, over 10 million visits to private physician offices and hospital outpatient departments, about 2 million visits to hospital emergency departments, and almost half a million hospitalizations with a diagnosis of asthma on the medical record were reported (1).

The proportion of persons reporting that they had at least one asthma episode or attack during the past 12 months (asthma attack prevalence) has remained fairly stable during 1997 to 2001 (39–43 per 1,000 population). Asthma attack prevalence rates decrease with age, and are higher among non-Hispanic black persons than among either non-Hispanic white or Hispanic persons. Among adults, women have a higher asthma attack prevalence rate than men, while among children under 18 years of age, boys have a 30 percent higher rate than girls (1).

Complications and mortality from the disease are largely preventable with adequate medical care, use of medications, and patient and family education about the disease (4). Drugs for asthma are categorized into two general classes: quick-relief (rescue) drugs used to treat acute symptoms and attacks, and long-term control drugs (prevention-focused) for achieving and maintaining control of persistent asthma (2). The types of medicines prescribed for asthma are dictated by the severity of the disease. National Asthma Education and Prevention Program (NAEPP) clinical guidelines issued in 1997, and updated in 2002, recommend some type of daily long-term control drug in addition to quick-relief drugs for persons with all but the least severe type of asthma.

Consistent with NAEPP guidelines, between 1995–96 and 2001–02 utilization of long-term control drugs for asthma increased (figure 28). Between 1995–96 and 1997–98, for patients with a diagnosis of asthma recorded on the visit record, the percent of visits to physician offices and hospital outpatient departments where a long-term control drug was prescribed, provided, or continued surpassed the percent of asthma visits with a quick-relief drug. In 2001–02, 55 percent of visits for asthma patients had a long-term control drug mentioned, compared with only 39 percent in 1995–96. While both quick-relief and long-term control drugs are indicated by the guidelines, the higher rates of long-acting asthma drugs compared with quick-relief drugs may be in part due to reporting practices during asthma visits. Quick-relief asthma drugs may be underreported because nonsymptomatic patients may have a rescue drug but are not currently using it and thus fail to report it during the visit. While asthma may be a condition recorded on the medical record it may not be the primary reason for the specific sampled visit, so physicians may not ask about ‘‘as-needed’’ drugs. In addition, since only six drugs were recorded per visit, infrequently used rescue drugs may be more likely to be omitted.

The types of long-term preventive drugs for asthma that are available has been changing. There was a rapid change in prescribing practices following the availability and marketing of new types or classes of long-acting asthma drugs. Specifically there has been a recent rise in prescribing of two classes of drugs—leukasts (leukotriene modifiers) and inhaled corticosteroids—while cromolyns (cromolyn sodium and nedrocromil) are rarely mentioned on visit records (figure 29).

Leukasts include two recently available brand name drugs: Accolate® and Singulair. Since the approval by the Food and Drug Administration of Accolate® in February 1998 and Singulair® in 1999, recorded use of these drugs in physician office and hospital outpatient visits for asthma patients has increased. By 2001–02 nearly 15 percent of asthma visits had a long-acting leukast drug associated with the visit. Use of leukasts appears to be substituting for the older class of cromolyns, possibly because leukasts are easier to administer. Leukasts are administered in an oral tablet form, while cromolyns are inhaled multiple times per day.

In 2001–02 inhaled corticosteroids were the most commonly prescribed long-term control drug class during physician office and hospital outpatient department visits for asthma patients. The NAEPP considers corticosteroids the most potent and consistently effective long-term control medication for asthma. Inhaled corticosteroids are preferred over oral steroids because they have fewer side-effects than the more systemic oral corticosteroids. NAEPP guidelines state that oral corticosteroids should be used at their lowest effective dose to reduce toxicity (5).

New asthma drugs continue to become available. Advair®, a combination drug including both an inhaled corticosteroid and a long-acting bronchodilator, entered the market in 2001. Data from other drug databases suggest that it is being increasingly prescribed and is in part replacing use of other types of long-acting bronchodilators, consistent with the slight decline in their use in recent years shown on figure 29 (6). In 2001–02 Advair® was prescribed, ordered, provided, or continued during 16 percent of physician office and hospital outpatient department visits that had an asthma diagnosis recorded on the visit record.

Antidepressant Drugs: Adults

Depression and other forms of mental illness are critical public health issues in America today. In 2001–02 more than 1 in 10 noninstitutionalized adult Americans were estimated to have had a major depressive disorder at some point in their lifetime, with 6.6 percent having a major depressive episode during the past 12 months (1). Nearly three-fourths of individuals reporting a major depressive episode in their lifetime also met the criteria for other mental disorders such as anxiety disorder and substance use disorder (1). The detrimental effects of depressive symptoms on quality of life and daily functioning have been estimated to equal or exceed those of heart disease and exceed those of diabetes, arthritis, and gastrointestinal disorders (2). Increased rates of depression and depressive symptoms have been reported for patients with diabetes, chronic pain, gastrointestinal complaints, migraine headaches, cancer, acquired immunodeficiency syndrome, Alzheimer-type dementia, and various neurologic conditions such as Parkinson’s disease and stroke (3).

Prescriptions for antidepressants have been rising. This rise is associated with the introduction of a new class of drugs known as selective serotonin reuptake inhibitors (SSRIs) first marketed in the United States in 1988 (4). SSRIs include the brand names Celexa®, Lexapro®, Luvox®, Paxil®, Prozac®, and Zoloft®. Because of greater ease of use, improved safety, and more manageable side effects, SSRIs have been widely adopted by both psychiatrists and primary care physicians as the first-line treatment for depression (5,6). SSRIs are approved and marketed for the treatment of mental disorders other than depression including obsessive compulsive disorder, panic disorder, anxiety disorders, and premenstrual dysphoric disorder. The substantial increase in the prescription of antidepressants also suggests widespread ‘‘off-label’’ (other than FDA-approved uses) use for subsyndromal mental health conditions and a variety of physical disorders (7,8).

The National Health and Nutrition Examination Survey (NHANES) collects data on the use of prescription drugs during the past month. Between 1988–94 and 1999–2000 the percent of adults in the civilian noninstitutionalized population who reported using an antidepressant during the past month increased from 3 to 7 percent (age adjusted; data table for figure 30). Use among women rose from 3 to 10 percent and use among men from 2 to 4 percent. During this period antidepressant use among adults in all age groups doubled or tripled. In both time periods, antidepressant use by women was greater than for men and greater for adults 45 years of age and over than for younger adults. In 1999–2000, 13 percent of women 45–64 years of age reported antidepressant use in the past month.

Differences in use of antidepressants (both SSRIs and non-SSRIs) varied considerably by race and ethnicity. In both 1988–94 and 1999–2000 a larger percentage of non-Hispanic white adults reported use of antidepressants than non-Hispanic black and Mexican adults. Between the two time periods, differences in the use of antidepressants by non-Hispanic white and non-Hispanic black and Mexican adults widened (figure 31). In 1988–94 the percentage of non-Hispanic white adults using antidepressants was about 1.4 times the percentage among non-Hispanic black and Mexican adults. By 1999–2000 use among non-Hispanic white adults was three times that among non-Hispanic black and Mexican adults. Differences in the types of antidepressant used also varied considerably by race and ethnicity. In 1999–2000 nearly two-thirds of non-Hispanic white adults taking antidepressants reported use of an SSRI in contrast to less than one-half of non-Hispanic black and Mexican adults. Limited access to health care, lower rates of health insurance coverage, and out-of-pocket cost of medical care as well as cultural factors, have been suggested as explanations for the lower percentage of black and Mexican adults reporting use of antidepressants (9,10).

Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Medical Care Survey (NHAMCS-OPD) show that antidepressants rank among the most frequently prescribed drugs for adults treated in physician offices or hospital outpatient clinics. In 2001–02 the average annual number of adult visits with an antidepressant was 57.6 million. Between 1995–96 and 2001–02 the adult antidepressant visit rate (i.e., the number of visits with an antidepressant drug per 100 persons age 18 and over) increased from 17 to 28 per 100 adults (data table for figure 32). This increase in the antidepressant visit rate reflected the rapid rise in visits with an SSRI prescribed, ordered, or provided. Between 1995–96 and 2001–02 the SSRI visit rate among adults doubled and the fraction of antidepressant visits with an SSRI drug increased from 54 to 65 percent. Throughout the period, a very small percentage (0.3–0.5 percent) of antidepressants visits included both an SSRI and a non-SSRI antidepressant.

Between 1995–96 and 2001–02 the antidepressant visit rate among women was double the rate among men (data table for figure 32). During this period women also had higher SSRI visit rates. Trends in the SSRI visit rate for men and women show a widening of the difference between men and women since 1995–96 (data table for figure 32). By 2001–02 the SSRI visit rate of 25 per 100 women was 2.4 times the rate for men. The disparity in the antidepressant and SSRI visit rates of men and women exceeded the difference observed between men and women in the overall rate of visits to office-based physicians and hospital outpatient departments (Health, United States, 2004, table 83).

The rate of visits with an antidepressant increased markedly for adults in all age groups between 1995–96 and 2001–02 data ( table for figure 32). Throughout the period, the antidepressant visit rate was higher among middle aged and older adults than among younger adults. The SSRI visit rate increased among adults in all age groups with the largest change observed among older adults. The lower occurrence of side effects with SSRIs has contributed to the rapid adoption of these drugs for treatment of late-life depression and other disorders in the older population (11).

Since the marketing of Prozac®, the first SSRI, new formulations of anti-depressants have become available. Studies suggest that an even wider array of effective antidepressants will be available in the future for the treatment of depression and other conditions (12).

References for figures 30, 31, and 32

1.
Kessler RC, Berglund P, Demler O. et al. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R) JAMA. 2003;289(23):3095–3105. [PubMed: 12813115]
2.
Wells KB, Stewart A, Hays RD. et al. The functioning and well being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262(7):914–9. [PubMed: 2754791]
3.
Burvill PW. Recent progress in the epidemiology of major depression. Epidemiol Rev. 1995;17(1):21–31. [PubMed: 8521939]
4.
Pincus HA, Tanielian TL, Marcus SC. et al. Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526–31. [PubMed: 9480363]
5.
U.S. Department of Health and Human Services. Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. 1999.
6.
Ornstein S, Stuart G, Jenkins R. Depression diagnoses and antidepressant use in primary care practices: a study from the Practice Partner Research Network (PPRNet) J Fam Pract. 2000;49(1):68–72. [PubMed: 10678342]
7.
Foote SM, Etheredge L. Increasing use of new prescription drugs: A case study. Health Aff. 2000;19(4):165–70. [PubMed: 10916970]
8.
Stone KJ, Viera AJ, Parman CL. Off-label applications for SSRIs. Am Fam Physician. 2003;68(3):498–504. [PubMed: 12924832]
9.
Melfi CA, Croghan TW, Hanna MP, Robinson RL. Racial variation in antidepressant treatment in a Medicaid population. J Clin Psychiatry. 2000;61(1):16–21. [PubMed: 10695640]
10.
Miranda J, Cooper LA. Disparities in care for depression among primary care patients. J Gen Intern Med. 2004;19(2):120–6. [PMC free article: PMC1492138] [PubMed: 15009791]
11.
Sambamoorthi U, Olfson M, Walkup JT, Crystal S. Diffusion of new generation antidepressant treatment among elderly diagnosed with depression. Med Care. 2003;41(1):180–94. [PubMed: 12544554]
12.
Holden C. Future brightening for depression treatments. Science. 2003;302(5646):810–3. [PubMed: 14593164]

Stimulants and Antidepressant Drugs: School-Age Children

Substantial increases have occurred over the past 15 years in the prescription of psychotropic drugs for the treatment of mental disorders in children (1,2). Pediatric use of psychotropic drugs is frequently ‘‘off-label,’’ relying on results from studies of adults due to limited research on the safety and efficacy of these medications in children. Even when the safety and short-term efficacy of psychotropic medications have been established, prescription of these drugs for behavioral and emotional disorders in children has been controversial (3). For all classes of psychotropic drugs, more extensive information is needed to determine the long-term effects of these medications on the health and development of children (4).

Attention Deficit Hyperactivity Disorder (ADHD) is a frequently diagnosed behavioral disorder affecting approximately 3 to 7 percent of the school-age population (5). Children with this disorder experience symptoms related to inattention and hyperactivity-impulsivity, and frequently have significant problems with schoolwork and peer relationships. While a variety of drug and nondrug therapies have been developed to treat children with ADHD, there has been a trend toward more widespread prescription of stimulant drugs (1). The annual number of visits by school-age children 5–17 years of age to physician offices and hospital outpatient departments with a stimulant drug prescribed, ordered, or provided increased from 2.6 million in 1994–96 to over 5.0 million in 2000–2002 (6). The stimulant visit rate among boys was about 2.5–3 times the visit rate among girls reflecting the higher prevalence of identified ADHD in boys compared with girls (figure 33) (7).

Figure 33. Stimulant drug visits among children 5–17 years of age by sex: United States, 1994-2002.

Figure 33

Stimulant drug visits among children 5–17 years of age by sex: United States, 1994-2002. Click here for spreadsheet version Click here for PowerPoint

Depression, an important mood disorder in children, has been estimated to occur in 2 percent of elementary school-aged children and 4 to 8 percent of adolescents (8). Children with depression are at greater risk for suicide, poor academic outcomes, problems with alcohol and illicit drugs, and troubled relationships with their families and peers (3). While psychotherapy has been the traditional treatment for childhood depression, an increasing number of children are now being treated with antidepressants. Between 1994–96 and 2000–2002 the annual number of visits by school-age children 5–17 years of age with an antidepressant increased from 1.1 million to 3.1 million. While the antidepressant visit rate was similar for boys and girls (figure 34), it was more than twice as high among adolescents as younger school-age children. In 2000–2002 the antidepressant visit rate was 3.4 per 100 children 5–11 years of age and 8.8 per 100 adolescents 12–17 years of age (data table for figure 34).

Figure 34. Antidepressant drug visits among children 5–17 years of age by Sex: United States, 1994-2002.

Figure 34

Antidepressant drug visits among children 5–17 years of age by Sex: United States, 1994-2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Stimulant drug visits are physician office (more...)

Between 1994–96 and 2000–2002 the percentage of visits with one of the newer class of antidepressants, selective serotonin reuptake inhibitors (SSRI), increased markedly from 43 to 67 percent of all antidepressant visits (6). Given recent concerns about the safety of some SSRIs for the treatment of childhood and adult depression, monitoring trends in the prescription of these antidepressants is critical (9).

References for figures 33 and 34

1.
Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry. 2002;41(5):514–21. [PubMed: 12014783]
2.
Zito JM, Safer DJ, dosRies S. et al. Rising prevalence of antidepressants among US youths. Pediatrics. 2002;109(5):721–7. [PubMed: 11986427]
3.
U.S. Department of Health and Human Services. Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. 1999.
4.
Jensen PS, Bhatara VS, Vitiello B. et al. Psychoactive medication prescribing practices for U.S. children: gaps between research and clinical practice. J Am Acad Child Adolesc Psychiatry. 1999;38(5):557–65. [PubMed: 10230187]
5.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth Edition, Text revision. Washington D.C.: American Psychiatric Association. 2000.
6.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, unpublished analysis. [PubMed: 10662358]
7.
Bloom B, Cohen RA, Vickerie JL, Wondimu EA. Summary health statistics for U.S. children: National Health Interview Survey, 2001. National Center for Health Statistics. Vital Health Stat 10(216). 2003. Available from www​.cdc.gov/nchs/data​/series/sr_10/sr10_216.pdf accessed on January 9, 2004.
8.
Olfson M, Gameroff MJ, Marcus SC, Waslick BD. Outpatient treatment of child and adolescent depression in the United States. Arch Gen Psychiatry. 2003;60:1236–42. [PubMed: 14662556]
9.
FDA Talk Paper. FDA issues public health advisory on cautions for use of antidepressants in adults and children. March 22, 2004. Available from www​.fda.gov/bbs/topics​/ANSWERS/2004/ANS01283.html accessed on March 24, 2004.

Cholesterol-Lowering Drugs

Heart disease is the leading cause of death in the United States, accounting for about one-half of all deaths. Elevated serum cholesterol is a major risk factor for heart disease (1). National guidelines suggest that the desired serum total cholesterol level is 200 milligrams per deciliter (mg/dL) or lower (1). In the past two decades, public awareness about the importance of measuring and controlling cholesterol levels has grown. In 1999–2002, 17 percent of adults aged 20 and over had high serum cholesterol levels of 240 mg/dL or higher (Health, United States, 2004, table 68).

Cholesterol levels can be reduced by lifestyle modifications, including eating a diet low in saturated fat, losing excess weight, and increasing physical activity. If such modifications do not reduce cholesterol to acceptable levels, or patients are at elevated risk for cardiovascular disease, then drug therapy is warranted. The National Cholesterol Education Panel appointed by the National Heart, Lung, and Blood Institute, issued new recommendations in 2001, and again in 2004, that increased the number of Americans who are candidates for cholesterol-lowering drugs.

There are four major classes of cholesterol-lowering drugs: statins, bile acid sequestrants, nicotinic acid, and fibrates. Statins are generally considered to be safe and effective in reducing cholesterol levels and coronary heart disease mortality and morbidity (2). Because they are effective and well tolerated, statins have become the drug class of choice for cholesterol-lowering drug therapy. Statins include the brand names Lipitor®, Pravachol®, Zocor®, and others.

Physician office and hospital outpatient department visits by adults 45 years and over with cholesterol-lowering drugs prescribed, provided, or continued increased from 16 visits per 100 persons in 1995–96 to 44 per 100 persons in 2001–02. Ninety-one percent of visits where cholesterol-lowering drugs were recorded involved statins in 2001–02. Though statins are effective at reducing cholesterol concentrations, some patients do not reach the target cholesterol levels. Recent research has found that the use of statin drugs with additional cholesterol-lowering drugs (combination therapy) can increase the likelihood of attaining target levels (2). In 2001–02 the visit rate for combination therapy was 1.4 visits per 100 persons aged 45 years and over, a small fraction of the visit rate involving statins (40 visits per 100 persons) (3). It is likely that combination therapy will continue to expand as physicians alter their prescribing patterns based on the recent evidence.

Statin visit rates have grown irrespective of age or gender (figure 35). For both men and women 45–64 years of age, the statin visit rate increased more than three-fold between 1995–96 and 2001–02. The increase in the statin visit rate was greater for women than men for these working-age adults. In 1995–96 the statin visit rates were similar for men and women 65 years of age and over. For men aged 65 years and over, the statin visits rate increased more than 250 percent over this time period while the increase in the rate for women 65 years of age and over was only 180 percent. By 2001–02 statin visit rates for men in this age group were about 25 percent higher than for women.

References for figure 35

1.
National Cholesterol Education Program. . Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) JAMA. 2001;285(19):2486–97. [PubMed: 11368702]
2.
Maron DJ, Fazio S, Linton MF. Current perspectives on statins. Circulation. 2000;101(2):207–13. [PubMed: 10637210]
3.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, unpublished analysis. [PubMed: 10662358]
4.
LaRosa JC. What do the statins tell us? Am Heart J. 2002;144(6, Part 2 Suppl):S21–S26. [PubMed: 12486412]

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs, known as NSAIDs, are used to control pain and reduce inflammation. Their use is widespread; more than 70 million prescriptions are dispensed and billions of nonprescription pills are purchased annually in the United States (1). There are two classes of NSAIDs: nonselective COX inhibitors and selective COX-2 inhibitors. The nonselective COX inhibitors or traditional NSAIDs are effective in controlling pain and reducing inflammation, with the most widely used being ibuprofen and naproxen. For this analysis aspirin was not included as a traditional NSAID because of its common use for cardiac conditions. A small but important proportion of patients with prolonged use of traditional NSAIDs may develop gastrointestinal (GI) side effects, such as bleeding and ulcers. Ulcer complications from traditional NSAID use have been estimated to contribute to as many as 103,000 hospitalizations and 16,500 deaths each year (1).

Since 1999 three new NSAIDs have been introduced—celecoxib (Celebrex®); rofecoxib (Vioxx®); and valdecoxib (Bextra®). These medications, known as COX-2 NSAIDs, are similar in efficacy to traditional NSAIDs but are believed to have a lower incidence of GI side effects (2–4). Because of the lower incidence of GI side effects, COX-2 NSAIDs were heralded as a welcome alternative to traditional NSAIDs. As the use of COX-2 NSAIDs has become widespread, however, a clearer profile of the potential side effects has emerged. The evidence for the lower incidence of side effects is mixed and controversial, and evidence continues to be collected as to their benefit relative to their substantially higher cost (3,5,6).

Since the introduction of COX-2 NSAIDs, their use has become widespread. In 2001–02 COX-2 NSAIDs accounted for 51 percent of NSAID visits to physician offices and hospital outpatient departments among adults 18 years of age and over, surpassing traditional NSAIDs (data table for figure 36). This dramatic growth in COX-2 NSAID prescriptions is evident in all adult age groups in 2001–02. For those 18–44 years of age, about one-third of NSAID visits involved a COX-2 NSAID. For those aged 45–64 years, COX-2 NSAIDs accounted for more than one-half of the NSAID visits. Among those aged 65 years and over, COX-2 NSAIDs accounted for two-thirds of NSAID visits (figure 36).

The use of all classes of NSAIDs has been increasing. Between 1995–96 and 2001–02 NSAID visits among adults increased from 20 to 27 visits per 100 population. Historically, women have higher NSAID use than men (Health, United States, 2004, table 87). In 2001–02 the rate of NSAID use was about 50 percent higher for women than men. Since the introduction of COX-2 NSAIDs, both men and women have increasingly switched to COX-2 from traditional NSAIDs.

The growth in the use of COX-2 NSAIDs is likely due to several factors. Extensive marketing of these new drugs to physicians and consumers may account for some of the increased use. About 80 percent of promotional spending for all drugs is targeted toward physicians. In recent years, spending on direct-to-consumer (DTC) advertising for all drugs tripled, to $2.7 billion in 2001 (7). COX-2 NSAIDs are among the most heavily advertised medications to consumers (7). It is estimated that almost one-third of consumers discussed a DTC advertisement with their physicians, which supports the evidence that spending on DTC ads is having an impact on the quantity of prescriptions dispensed (7).

References for figure 36

1.
Wolfe MM, Lichtenstein DR, Singh G. Medical progress: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999;340(24):1888–99. [PubMed: 10369853]
2.
Silverstein FE, Faich G, Goldstein JL. et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: The CLASS study: A randomized controlled trial. JAMA. 2000;284(10):1247–55. [PubMed: 10979111]
3.
Stichtenoth DO, Frölich JC. The second generation of COX-2 inhibitors: What advantages do the newest offer? Drugs. 2003;63(1):33–45. [PubMed: 12487621]
4.
Lisse JR, Perlman M, Johansson G. et al. Gastrointestinal tolerability and effectiveness of rofecoxib versus naproxen in the treatment of osteoarthritis: A randomized, controlled trial. Ann Intern Med. 2003;139(7):539–46. [PubMed: 14530224]
5.
Juni P, Rutjes A, Dieppe P. Are selective COX 2 inhibitors superior to traditional nonsteroidal anti-inflammatory drugs? Adequate analysis of the CLASS trial indicates that this may not be the case. BMJ. 2002;324(7349):1287–8. [PMC free article: PMC1123260] [PubMed: 12039807]
6.
Wright JM. The double-edged sword of COX-2 selective NSAIDs. Can Med Assoc J. 2002;167(10):1131–7. [PMC free article: PMC134294] [PubMed: 12427705]
7.
U.S. General Accounting Office. Prescription drugs: FDA oversight of direct-to-consumer advertising has limitations. GAO-03–177. Washington, DC: U.S. General Accounting Office. 2002.

Technical Notes

Data Sources and Comparability

Data for The Chartbook on Trends in the Health of Americans come from numerous surveys and data systems and cover a broad range of years. Readers are referred to Appendix I for detailed descriptions of the specific data sources. Readers must be aware that major changes resulting from survey redesign, as well as changes in data collection methodology, the wording and order of questions, interruptions or changes in timing of data collection, and data coding systems may affect data continuity and interpretation of trends. For example, the National Health Interview Survey was redesigned in 1997 to improve its efficiency and flexibility. These changes affect comparisons before and after 1997 for many measures (see Appendix I, National Health Interview Survey).

Data Presentation

Many measures in The Chartbook on Trends in the Health of Americans are shown separately for persons of different ages because of the strong effect age has on most health outcomes. Selected figures in the chartbook also highlight current differences in health and health determinants by variables such as sex, race, and Hispanic origin. Some estimates are age adjusted using the age distribution of the 2000 standard population and this is noted in the excel spreadsheets that accompany each chart (see Appendix II, Age adjustment). Time trends for some measures are not presented because of the relatively short amount of time that comparable national estimates are available. For some charts, data years are combined to increase sample size and reliability of the estimates.

Graphic Presentation

Line charts for which only selected years of data are displayed have dot markers on the data years. Line charts for which data are displayed for every year in the trend are shown without the use of dot markers. Most trends are shown on a linear scale to emphasize absolute differences over time. The linear scale is the scale most frequently used and recognized, and it emphasizes the absolute changes between data points over time (1). The time trend for overall mortality measures is shown on a logarithmic scale to emphasize the rate of change and to enable measures with large differences in magnitude to be shown on the same chart (figure 25). Logarithmic (or log) scales emphasize the relative or percentage change between data points. Readers are cautioned that one potential disadvantage to log scale is that the absolute magnitude of changes may appear less dramatic (2). When interpreting data on a log scale, the following points should be kept in mind:

  1. A sloping straight line indicates a constant rate (not amount) of increase or decrease in the values,
  2. A horizontal line indicates no change,
  3. The slope of the line indicates the rate of increase or decrease, and
  4. Parallel lines, regardless of their magnitude, depict similar rates of change (1).

Tabular Presentation

Following the Technical Notes are data tables that present the data points graphed in each chart. Some data tables contain additional data that were not graphed because of space considerations. Standard errors for data points are provided for many measures. Additional information clarifying and qualifying the data are included in table notes and Appendix II references.

Special Feature: Drugs

Drug data presented in The Chartbook on Trends in the Health of Americans are primarily from three sources: the National Health and Nutrition Examination Survey (NHANES), the National Ambulatory Medical Care Survey (NAMCS), and the National Hospital Ambulatory Medical Care Survey (NHAMCS) Hospital Outpatient Department Component (NHAMCS-OPD). The NHANES provides a snapshot of all prescribed drugs reported by a sample of the civilian noninstitutionalized population for a 1-month period. Drug information from NHANES is collected during an in-person interview conducted in the participant’s home. The NAMCS and NHAMCS-OPD provide a picture of both prescription and nonprescription drugs that are prescribed, ordered, supplied, administered, or continued during physician office and hospital outpatient department visits.

NHANES Prescription Drug Data: NHANES III was conducted from 1988 through 1994. Starting in 1999 the NHANES is continuously in the field. Drug data are currently available for 1999–2000 while other data including obesity, serum cholesterol, and hypertension are available for a 4-year period (1999–2002). The questionnaire administered to all participants included a question on whether they had taken a prescription drug in the past month. Those who answered ‘‘yes’’ were asked to show the interviewer the medication containers for all the prescriptions. For each drug reported, the interviewer entered the product’s complete name from the container. If no container was available, the interviewer asked the participant to verbally report the name of the drug. Additionally, participants were asked how long they had been taking the drug and the main reason for use.

All reported medication names were converted to their standard generic ingredient name. For multi-ingredient products, the ingredients were listed in alphabetical order and counted as one drug (i.e., Tylenol #3 would be listed as Acetaminophen; Codeine). No trade or proprietary names were provided on the data file.

More information on prescription drug data collection and coding in the NHANES 1999–2000 can be found at www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf and more information on NHANES III prescription drug data collection and coding can be found at www.cdc.gov/nchs/data/nhanes/nhanes3/PUPREMED-acc.pdf. Also see Appendix I, National Health and Nutrition Examination Survey.

NAMCS/NHAMCS Drug Data: Data collection in the NAMCS/NHAMCS is from the medical record rather than from individuals and provides an analytic base that complements population-based information on ambulatory care collected through other NCHS surveys. Participating physicians are randomly assigned to a 1-week reporting period. Hospitals are assigned to a 4-week reporting period. During this period, data from a systematic random sample of physician office and hospital outpatient department visits are recorded by the physician or hospital staff on an encounter form provided by NCHS. Additionally, data are obtained on patients’ symptoms and physicians’ diagnoses. The physician, or other health care provider, records medications that were prescribed, ordered, supplied, administered, or continued during the visit. Generic as well as brand name drugs are included, as are nonprescription and prescription drugs. Up to five medications were reported per visit until 1994; in the 1995 and subsequent NAMCS and NHAMCS surveys, up to six medications could be listed.

For more information on drugs collected by the NAMCS/NHAMCS, see the Ambulatory Care Drug Database at www2.cdc.gov/drugs/, ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NAMCS/doc01.pdf, or ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc01.pdf. Also see Appendix I, National Ambulatory Care Medical Survey and National Hospital Ambulatory Medical Care Survey, and Appendix II, Drugs; National Drug Code Directory (NDC).

References

1.
Page RM, Cole GE, Timmreck TC. Basic epidemiological methods and biostatistics: A practical guidebook. Sudbury, Massachusetts: Jones and Bartlett Publishers. 1995.
2.
Jekel JF, Elmore JG, Katz DL. Epidemiology biostatistics and preventive medicine. Philadelphia, Pennsylvania: W.B. Saunders Company. 1996.

Data Tables for Figures 1–36

Data table for figure 1. Total population, population 65 years and over and 75 years and over: United States, 1950–2050Click here for PowerPoint Click here for spreadsheet version

Data table for figure 2. Percent of population in 4 age groups: United States, 1950, 2000, and 2050Click here for PowerPoint Click here for spreadsheet version

Data table for figure 3. Percent of population in selected race and Hispanic origin groups by age: United States, 1980–2000Click here for PowerPoint Click here for spreadsheet version

Data table for figure 4. Poverty rates by age: United States, 1966–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 5. Low income population by age, race, and Hispanic origin: United States, 2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 6. Health insurance coverage among persons under 65 years of age: United States, 1984–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 7. No health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 8. Early prenatal care by race and Hispanic origin of mother: United States, 1980–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 9. Early prenatal care by detailed race and Hispanic origin of mother: United States, 2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 10. Influenza and pneumococcal vaccination among adults 65 years of age and over: United States, 1989–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 11. Influenza and pneumococcal vaccination among adults 65 years of age and over by race and Hispanic origin: United States, 2000–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 12. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2003Click here for PowerPoint Click here for spreadsheet version

Data table for Figure 13. Current cigarette smoking among high school students by sex, frequency, and grade level: United States, 2003Click here for PowerPoint Click here for spreadsheet version

Data table for figure 14. High school students not engaging in recommended amounts of physical activity (neither moderate nor vigorous) by grade and sex: United States, 2003Click here for PowerPoint Click here for spreadsheet version

Data table for figure 15. Adults not engaging in leisure-time physical activity by age and sex: United States, 1998–2002 spreadsheetClick here for PowerPoint Click here for spreadsheet version

Data table for figure 16. Overweight and obesity by age: United States, 1960–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 17. Obesity among adults 20–74 years of age by sex, race, and Hispanic origin: United States, 1999–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 18. Selected chronic health conditions causing limitation of activity among children by age: United States, 2001–02Click here for PowerPoint Click here for spreadsheet version

Data table for figure 19. Limitation of activity caused by 1 or more chronic health conditions among working-age adults by selected characteristics: United States, 2000–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 20. Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2000–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 21. Limitation of activities of daily living among Medicare beneficiaries 65 years of age and over: United States, 1992–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 1901–2001Click here for PowerPoint Click here for spreadsheet version

Data table for figure 23. Infant, neonatal, and postneonatal mortality rates: United States, 1950–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999–2001 versionClick here for PowerPoint Click here for spreadsheet version

Data table for figure 25. Death rates for leading causes of death for all ages: United States, 1950–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 26. Percent of persons reporting prescription drug use in the past month by age: United States, 1988–94 and 1999–2000Click here for PowerPoint Click here for spreadsheet version

Data table for figure 27. Percent of physician office and hospital outpatient department visits with 5 or more drugs prescribed, ordered, or provided by age: United States, 1995–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 28. Percent of asthma visits with quick-relief and long-term control drugs prescribed, ordered, or provided: United States, 1995–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 29. Percent of asthma visits with selected asthma drugs prescribed, ordered, or provided: United States, 1995–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 30. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by sex and age: United States, 1988–94 and 1999–2000Click here for PowerPoint Click here for spreadsheet version

Data table for figure 31. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by race and ethnicity: United States, 1988–94 and 1999–2000Click here for PowerPoint Click here for spreadsheet version

Data table for figure 32 (page 1 of 2; see page 2). Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults 18 years of age and over by sex: United States, 1995–2002Click here for PowerPoint 1/11/2005. Some numbers were revised. See spreadsheet. Click here for spreadsheet version

Data table for figure 32 (page 2 of 2; see page 1). Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults 18 years of age and over by sex: United States, 1995–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 33. Stimulant drug visits among children 5–17 years of age by sex: United States, 1994–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 34. Antidepressant drug visits among children 5–17 years of age by sex: United States, 1994–2002Click here for PowerPoint Click here for spreadsheet version

Data table for figure 35. Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex and age: United States, 1995–2002Click here for PowerPoint 1/11/2005. Some numbers were revised. see spreadsheet Click here for spreadsheet version

Data table for figure 36. Percent of nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2 NSAIDs prescribed, ordered, or provided among adults 18 years of age and over by age: United States, 1999–2002Click here for PowerPoint Click here for spreadsheet version

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