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National Center for Health Statistics (US) . Health, United States, 2005: With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics (US); 2005 Nov.

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Health, United States, 2005: 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 2004 the total resident population of the United States increased from 150 million to 294 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 twice as rapidly and increased from 12 to 36 million persons. The population 75 years of age and over grew 2.9 times as quickly as the total population, increasing from 4 to 18 million persons. Projections indicate that the rate of population growth from now to 2050 will be 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 and older population: United States, 1950–2050.

Figure 1

Total population and older population: United States, 1950–2050. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed and additional notes.

Between 1950 and 2004, the U.S. population grew older (figure 2). From 1950 to 2004 the population under 18 years of age fell from 31 to 25 percent of the total population, while persons 55–64 years increased from 9 to 10 percent of total persons, persons 65–74 years remained at about 6 percent, and persons 75 years and over increased from 3 to 6 percent of the total.

Figure 2. Percent of population in five age groups: United States, 1950, 2004, and 2050.

Figure 2

Percent of population in five age groups: United States, 1950, 2004, and 2050. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed and additional notes.

From 2004 to 2050 it is anticipated that the percent of the population 55 years and over will increase substantially. The population age 55–64 years of age, featured in this chartbook, is projected to be the fastest growing segment of the adult population during the next 10 years (figure 30). In future decades both the population age 55–64 and the population age 65 years and over will increase dramatically as the baby boomers, born in the post-World War II period of 1946 through 1964, age. By 2029, all of the baby boomers will be age 65 and over. Between 2004 and 2050 the population 65–74 years of age will increase from 6 to 9 percent of the total 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.

Figure 30. Aging of the population 45 years of age and over: United States, 2004, 2014, and 2024.

Figure 30

Aging of the population 45 years of age and over: United States, 2004, 2014, and 2024. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed and additional notes. (more...)

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.

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, 2005, 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 that is of Hispanic origin or Asian has more than doubled (figure 3). In 2004 nearly 30 percent of adults and almost 40 percent of children identified themselves as Hispanic, black, Asian, American Indian or Alaska Native, or Native Hawaiian or Other Pacific Islander.

Figure 3. Percent of population in selected race and Hispanic origin groups by age: United States, 1980–2004.

Figure 3

Percent of population in selected race and Hispanic origin groups by age: United States, 1980–2004. Click here for spreadsheet version Click here for PowerPoint 1 Not Hispanic

In the 1980 and 1990 decennial censuses, Americans could choose only one racial category to describe their race (1). Beginning with 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, the percent of children described as being of more than one race was more than twice as high as the percent of adults. The number of American adults identifying themselves or their children as multiracial is expected to increase in the future (2).

The percent of persons reporting two or more races varies considerably among racial groups. For example, the percent of persons reporting a specified 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 in 2000 (3).

Poverty

Children and adults in families with incomes below or near the Federal poverty level have poorer health outcomes 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 2003 the overall percent of Americans living in poverty increased to 12.5 percent, up from 12.1 percent in 2002, 11.7 percent in 2001, and 11.3 percent in 2000. The increases in the poverty rate in 2001–03 were the first 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. In 2002 the poverty rate increased for all ages. Although the poverty rate increased overall in 2003, there was little effect on adults. A slight increase among working age adults was counterbalanced by a slight decrease among those age 65 and over.

Children under 18 years of age bore the brunt of the 2003 increase, which was added to an already high poverty rate for children (2). Starting in 1974 children became 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 16.2 percent in 2000 but had increased to 17.6 percent by 2003. In 2003, 12.9 million children lived in poverty (data table for figure 5).

Figure 4. Poverty by age: United States, 1966–2003.

Figure 4

Poverty by age: United States, 1966–2003. 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 Data Table for (more...)

Figure 5. Low income by age, race and Hispanic origin: United States, 2003.

Figure 5

Low income by age, race and Hispanic origin: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Poor is defined as family income less than 100 percent of the poverty level and near (more...)

Prior to 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 to 9.7 percent in 1999 (3). From 2000 to 2002 the poverty rate among persons 65 years of age and over increased to 10.4, but in 2003 it decreased to 10.2 percent.

In 2003 the percent of persons living in poverty also continued to differ significantly by race and ethnicity (figure 5). At all ages, a higher percent of Hispanic and black persons than non-Hispanic white persons were poor. In 2003, 30–34 percent of Hispanic and black children were poor compared with 10–13 percent of Asian and non-Hispanic white children. The 2003 increase in the poverty rate among children from 16.7 to 17.6 percent had a larger impact on black and Hispanic children than on non-Hispanic white children. Similarly, among persons 65 years of age or over one-fifth of Hispanic and nearly one-quarter of black persons were poor, compared with eight percent of non-Hispanic white persons and 14 percent of Asians. In 2001–03, more than one in five American Indian and Alaska Native persons lived in poverty. Poverty estimates for American Indian and Alaska Native persons are based on 3 years of data combined for all age groups in order to produce an estimate (2).

In the first years of this century the burden of poverty appears to be increasing for those who are least able to bear it, namely those with already very high poverty rates (children, and black and Hispanic persons). The record pace of immigration combined with higher poverty levels among immigrants and the present upward trend in the poverty rate may lead to even higher poverty rates over the next few years (4).

Health Insurance and Expenditures

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, 2005, tables 75, 79, 80, and 82). Uninsured persons are more likely to forego 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 is generally more costly 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 1998 the 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 69–73 percent (figure 6). In 2002 and 2003 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, 1984–2003.

Figure 6

Health insurance coverage among persons under 65 years of age: United States, 1984–2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed, standard (more...)

In 2003, 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 2003 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, 2005, table 132). The growing number of Hispanic immigrants of which Mexicans are the largest group (31 percent of all United States immigrants in 2004 were from Mexico) may be expected to further reduce the percent of the population with health insurance through employment and increase the percent with no coverage (3).

Figure 7. No health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2003.

Figure 7

No health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Persons of Hispanic origin (more...)

Health Care Expenditures

In 2003 the United States spent 15 percent of its Gross Domestic Product (GDP) on health care, a greater share than any other developed country for which data are collected by the Office of Economic Cooperation and Development (figure 8, Health, United States, 2005, table 118). After almost a decade of stability from 1992 to 2000, a period of robust economic growth, the share of GDP devoted to health increased sharply from 2000 to 2003, although the 7.7 percent rate of spending increased more slowly in 2003 than in 2002.

Figure 8. National health expenditures as a percent of Gross Domestic Product: United States, 1960–2003.

Figure 8

National health expenditures as a percent of Gross Domestic Product: United States, 1960–2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed (more...)

In 2003 the United States spent $1.7 trillion on health, an average of $5,671 per person (Health, United States, 2005, table 119). Personal health care expenditures include spending for therapeutic goods or services to treat or prevent a specific disease or condition in an individual and comprised 86 percent of national health expenditures in 2003. The remaining 14 percent was spent on administration, government public health activities, research, and construction (Health, United States, 2005, table 123) (1).

Overall, private health insurance paid for 36 percent of total personal health expenditures in 2003, the Federal Government 33 percent, State and local government 11 percent, and out-of-pocket payments paid for 16 percent (figure 9). Since 1980 the share of total expenditures paid out-of-pocket declined by 11 percentage points (Health, United States, 2005, table 123). This decline resulted from an expansion of benefits in both private health insurance plans and in government programs.

Figure 9. Personal health care expenditures according to source of funds and type of expenditures: United States, 2003.

Figure 9

Personal health care expenditures according to source of funds and type of expenditures: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed (more...)

In 2003, more than one-third of personal health care expenditures were for hospital care, one-quarter for physician care, one-eighth for prescription drugs, 8 percent for nursing home care, and the remaining one-fifth for "other" personal health care including visits to non-physician medical providers, medical supplies, and other health services (figure 9). Since 1980 the share of total personal health care expenditures devoted to hospital care has decreased from 47 percent to 36 percent and the prescription drug expenditure share has doubled, reflecting the shift in health care from inpatient to ambulatory care settings and the increasing contribution of prescription drugs to health care (Health, United States, 2005, table 123).

The source of payment for personal health care varies according to type of care provided. In 2003, government sources were the primary payers of hospital and nursing home care, paying for about three-fifths of these types of services (data table for figure 9). Thirty percent of hospital expenditures were paid by Medicare (the Federal health program for persons 65 years of age and over and the disabled) and 17 percent by Medicaid (the joint Federal and State program for the poor). Nearly one-half of nursing home care was paid by Medicaid, while Medicare paid for only a small part (12 percent in 2003) of nursing home care, primarily short-stays and rehabilitative services. Private health insurance paid for almost one-half of physician services and prescription drugs.

In 2003, 30 percent of expenditures for prescription drugs were paid by recipients out-of-pocket compared with more than twice that percent in 1980 (69 percent) (Health, United States, 2005, table 123). Out-of-pocket expenditures for physician services declined to 10 percent in 2003, from 30 percent in 1980. Declines in out-of-pocket expenditures for nursing home services since 1980 have been accompanied by a concurrent increase in government (primarily Medicaid) and private health insurance expenditures through 2003. However, the inflation in health care costs over recent years means that consumers may still have significant out-of-pocket expenditures for their health care. This is the case especially for older persons with worse health and higher total expenditures and persons with large prescription drug expenses, since drug expenses are less likely to be covered by health insurance than hospital and physician expenses. In 2002, more than 40 percent of noninstitutionalized adults 65 years of age and over with medical expenses spent at least $1,000 out-of-pocket (Health, United States, 2005, table 126).

Health Risk Factors

Tobacco Use

Smoking is associated with a significantly increased risk of heart disease, stroke, lung and other types of cancer, and chronic lung diseases (1). Decreasing cigarette smoking among adolescents and adults is a major public health objective for the Nation. Preventing smoking among teenagers and young adults is critical because smoking usually begins in adolescence (2). Smoking during pregnancy contributes to elevated risk of miscarriage, premature delivery, and having a low birthweight infant (3).

Cigarette smoking among adult men and women declined substantially following the first Surgeon General's Report on smoking in 1964 (figure 10). Since 1990 the percent of adults who smoke has continued to decline but at a slower rate than previously. During the 1990s declines in the percent of adults 18 years and over who smoke were the result of increasing rates of never smoking. In contrast, the percent of former smokers remained relatively stable during that time (4). By 2003, 24 percent of men and 19 percent of women were smokers, down from one-half of men and one-third of women in 1965. Cigarette smoking by adults continues to be strongly associated with educational attainment. Adults 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, 2005, table 64).

Figure 10. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2003.

Figure 10

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 (more...)

Among mothers with a live birth, the percent reporting smoking cigarettes during pregnancy declined between 1989 and 2002 (3,5). 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, 2005, table 12 includes 2003 data for 47 States and the District of Columbia). 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).

Antismoking efforts have entailed a two-prong approach; encouraging young persons not to begin smoking and helping current smokers to quit smoking. Cigarette smoking among high school students in grades 9–12 decreased between 1997 and 2003 after increasing in the early 1990s (figure 10). In 2003, 22 percent of high school students reported smoking cigarettes on one or more days of the 30 days preceding the survey and 10 percent reported smoking frequently that is, on 20 days or more in the 30 days preceding the survey (data table for figure 11). Cigarette smoking and frequent cigarette smoking for high school girls were more prevalent among non-Hispanic white girls than among Hispanic or non-Hispanic black girls (figure 11). Among high school boys, current and frequent cigarette smoking were generally similar by race and ethnicity. Cigarette smoking—and especially frequent cigarette smoking—was more common in upper grades than lower grades. By grade 12, 29 percent of boys and 23 percent of girls were current smokers with about one-half of them smoking on a frequent basis. Many high school students who were frequent smokers have already become nicotine dependent (6). In 2003 almost 7 percent of students had used smokeless tobacco (e.g., chewing tobacco, snuff, or dip), and 15 percent of students had smoked cigars on one or more days of the 30 days preceding the survey (7).

Figure 11. Current and frequent cigarette smoking among high school students by sex, race and Hispanic origin, and grade level: United States, 2003.

Figure 11

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

Teenagers and Cars

Between 1970 and 2002 death rates for motor vehicle-related injuries for teenagers and young adults 15–24 years of age decreased by 40 percent. Yet, teenagers and young adults have among the highest death rates for motor vehicle-related injuries of any age group; one-third of deaths for 15–24 year-olds were the result of motor vehicle-related injuries in 2002 (Health, United States, 2005, table 44 and (1)). Research has shown that seatbelts, when properly used reduce the risk of fatal injury to front-seat passenger car occupants by 45 percent and the risk of moderate to critical injury by 50 percent (2). In States with strong seatbelt laws teenage seatbelt use is consistently higher (3). Alcohol use and cars are a deadly combination. In 2003 one-fifth of young drivers 16–20 years of age involved in fatal motor vehicle traffic-related crashes were intoxicated (4). In 2002 three-quarters of young drivers who had been drinking and were killed in a crash were not wearing seatbelts (5).

Between 1991 and 2003 the percent of high school students in grades 9–12 who never or rarely wore seatbelts while riding in a car driven by someone else decreased from 26 percent to 18 percent (data table for figure 12). Although the percent not wearing a seatbelt declined for both male and female students, 22 percent of male high school students compared with 15 percent of female high school students rarely or never used a seatbelt in 2003 (figure 12).

Figure 12. Seatbelt use and drinking and driving among high school students by sex: United States, 1991–2003.

Figure 12

Seatbelt use and drinking and driving among high school students by sex: United States, 1991–2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points graphed, (more...)

Among high school students, riding with a driver who had been drinking was more common than lack of seatbelt use or drinking and driving. The percent of high school students in grades 9–12 who rode with a driver who had been drinking alcohol decreased from 40 percent to 30 percent between 1991 and 2003. In 2003 male and female high school students were equally as likely to ride with a driver who had been drinking.

The percent of 11–12th grade high school students who drove after drinking alcohol declined from almost 25 percent to 18 percent between 1991 and 2003. Although the percent drinking and driving declined for both males and females, in 2003 male students in grades 11–12 were nearly twice as likely as female students to drink and drive (22 percent compared with 12 percent).

Physical Activity

Most diseases result from a complex interaction between inherited risk factors and environmental risk factors such as diet, lifestyle, and social factors (1). Adopting a healthy lifestyle, which includes being physically active, eating nutritiously, and avoiding tobacco, can prevent or help to control many diseases. 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. Regular physical activity also improves symptoms associated with musculoskeletal conditions and mental health conditions such as depression and anxiety. In addition physical activity can enhance physical functioning and aid in weight control (2). Physical activity, along with a healthy diet, plays an important role in the prevention of overweight and obesity. Monitoring levels of regular physical activity is of particular concern due to the increasing prevalence of overweight and obesity in the United States.

Although vigorous physical activity produces the greatest cardiovascular benefits, moderate amounts of physical activity are also associated with lower levels of mortality. Among older persons, even small amounts of physical activity may improve cardiovascular functioning (3). National recommendations for physical activity encourage all Americans to engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. Current 2005 recommendations are for adolescents to engage in at least 60 minutes of physical activity and for adults to engage in at least 30 minutes of moderate physical activity on most days of the week. Additional recommendations target older age groups and weight loss or weight maintenance goals (4).

Physical activity for high school students includes physical education classes, sports teams, and other forms of activity. Between 1999 and 2003 the percent of high school students nationwide who participated in regular physical activity declined slightly from 70 percent to 67 percent (see figure 13 data table for definition of regular physical activity). Male students are more likely than female students to be physically active. In 2003, 73 percent of male high school students and 60 percent of female high school students reported regular physical activity. Among female non-Hispanic black students, only 50 percent were active (figure 13). The percent participating in regular physical activity declines with advancing grade in school. In 2003, 72 percent of 9th graders compared with 60 percent of 12th graders engaged in regular physical activity. The decline in regular physical activity with advancing age is explained in part by patterns of enrollment in high school physical education (PE) classes. In 2003, 71 percent of 9th graders were enrolled in PE classes compared with 40 percent of 12th graders (5). Nationwide, only 28 percent of high school students attended daily PE classes in 2003 while 38 percent of high school students watched at least 3 hours of television on an average school day.

Figure 13. High school students engaging in regular physical activity by sex, race and Hispanic origin, and grade: United States, 2003.

Figure 13

High school students engaging in regular physical activity by sex, race and Hispanic origin, and grade: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Regular physical (more...)

School is one place where teenagers can participate in organized exercise and sports activities and learn the benefits of physical activity to health. Childhood and adolescence may be pivotal times for developing the habit of regular physical activity and preventing sedentary behavior among adults. Positive experiences with physical activity at a young age help lay the basis for being regularly active throughout life (2).

The trend in leisure-time physical activity among adult men and women has remained stable in recent years (Health, United States, 2005, table 72). In 2003, 3 in 10 adults engaged in regular leisure-time activity (see figure 14 data table for definition of leisure-time activity continuum), 3 in 10 had some leisure-time activity, and nearly 4 in 10 adults were inactive in their leisure time. Men were more likely than women to have regular leisure-time activity. While regular leisure-time activity decreases substantially with age from its peak of 42 percent among young adults 18–24 years of age, significant portions of older adults maintain an active lifestyle. More than one-quarter of noninstitutionalized adults 65–74 years of age and nearly one-fifth of adults 75 years of age and over reported regular leisure-time physical activity.

Figure 14. Leisure-time physical activity among adults 18 years of age and over by poverty status: United States, 2003.

Figure 14

Leisure-time physical activity among adults 18 years of age and over by poverty status: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for the civilian noninstitutionalized (more...)

Leisure-time physical activity patterns also vary by poverty status, with adults living below or near poverty less likely to have regular leisure-time physical activity and more likely to be inactive (figure 14). In 2003 about one-half of adults who were poor or near poor were inactive in leisure time compared with about one-third of adults living in families with income more than twice poverty. Conversely, about one-quarter of adults living in or near poverty had regular leisure-time physical activity compared with more than one-third of adults living in families with higher incomes (percents are age adjusted).

Leisure time presents one opportunity for engaging in sufficient physical activity to maintain good health. Other opportunities include physical activity associated with occupation or transportation (for example, walking or biking to work and school). Adults who are inactive in leisure time may compensate for it by being physically active at work. However, an analysis of type of work among adults who are inactive in leisure time showed that only a small proportion—about 1 in 5 adults—reported a category of employment that involved physical activity (6).

Overweight and Obesity

Epidemiologic and actuarial studies have shown that surplus 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). Obesity also has serious health consequences among younger persons. Among children and adolescents, obesity increases the risk of high cholesterol, hypertension, and diabetes (3). Diet, physical activity, genetic factors, environment, 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.

National Health and Nutrition Examination Surveys (NHANES) collect data from physical exams in a mobile examination center. Results from a series of NHANES indicate that the prevalence of overweight and obesity changed little between the early 1960s and 1976–80 (figure 15). 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 15. Overweight and obesity by age: United States, 1960–2002.

Figure 15

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 is defined (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 has 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 (4).

The prevalence of obesity varies among adults by sex, race, and ethnicity (Health, United States, 2005, table 73). 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. In 1999–2002 one-half of non-Hispanic black women were obese compared with nearly one-third of non-Hispanic white women. In contrast, the prevalence of obesity among men differed little by race and ethnicity (28–29 percent).

The rise in overweight and obesity is reflected in the average weight of adult men and women in the United States (5). Adult men and women are roughly an inch taller than they were in 1960–62, but are nearly 25 pounds heavier on average. The average weight of men age 20–74 years increased from 166 pounds in 1960–62 to 191 pounds in 1999–2002 and the average weight of women increased from 140 pounds to 164 pounds during the same period.

Morbidity and Limitation of Activity

Asthma in Children Age 3–17

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 disability although childhood deaths from asthma are rare (1,3). Attacks can cause considerable discomfort and anxiety in both children and their families, and may limit athletic and other activities. Children under the age of 3 years may experience wheezing, which can later develop into asthma, but in the majority of cases the wheezing is associated with diminished airway function at birth or other respiratory diseases (4). Therefore, a definitive diagnosis of asthma is difficult to make in children less than 3 years of age.

In 2002–03, about 6 percent of children 3–17 years of age, more than 3.6 million children, had an asthma attack within the past year (5). Racial and ethnic disparities in prevalence of and health care utilization for the disease have been documented and have persisted over time (6). Non-Hispanic black children 3–10 years of age have higher asthma attack prevalence rates than either non-Hispanic white or Hispanic children, and this disparity has been increasing in recent years (figure 16). In 2002–03 attack prevalence rates among children age 3–10 years were 9 percent for non-Hispanic black children, compared with about 5 percent for Hispanic and non-Hispanic white children. Additional years of data will be required to see if this gap continues to increase over time. In 2002–03 the race and ethnic differentials in asthma attack prevalence were smaller in older children age 11–17 years.

Figure 16. Asthma attack among children by age, race and Hispanic origin: United States, 1998–2003.

Figure 16

Asthma attack among children by age, race and Hispanic origin: United States, 1998–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Asthma attack in past 12 months. See Data Table (more...)

In 2003 there were approximately 132,000 hospital discharges for children age 3–17 years with a first-listed diagnosis of asthma, 475,000 emergency department visits, and 4.6 million visits to office-based physicians and hospital outpatient clinics with a first-listed diagnosis of asthma (7,8,9). Nearly 70 percent of asthma hospitalizations among children age 3–17 years were for young children 3–10 years of age, although this age group comprised about one-half of all children age 3–17 years (7,10).

Despite an increased number of asthma medications that help prevent the onset of attacks, new clinical practice guidelines, and intervention programs designed to improve asthma management among children, asthma attack prevalence rates among young black children are rising. Poor black children are at the highest risk of asthma-associated morbidity (6). Poor outcomes associated with asthma attacks can generally be prevented if families and children are properly educated and have access to quality health care (3). Disparities by race and poverty status in attack rates may be due to social, cultural, or environmental differences between races that disproportionally affect poor families' ability to effectively identify and manage children's asthma (6).

Headache and Low Back Pain

Headache and low back pain are two common sources of pain and constitute a significant public health concern. They interfere with an individual's ability to work, enjoy social activities, and negatively affect quality of life (1). These conditions have considerable medical and economic consequences for society by placing a large burden on the health care system in terms of diagnosis, treatment, and medication management. In addition there are substantial indirect costs associated with reduced productivity. Americans spend at least $50 billion a year on low back pain, the most common cause of job-related disability and a leading contributor to missed work (2). The cost to American employers due to missed work and reduced productivity associated with migraine headaches is estimated at $13 billion per year (3).

Headache can be classified into three major types: tension, migraine, and cluster (3,4). Tension headache, the most common form of headache, is of mild to moderate intensity and occurs on both sides of the head. Migraine is described as an intense pulsing or throbbing pain in one area of the head often accompanied by extreme sensitivity to light and sound, nausea, and vomiting. Cluster, so named because of the characteristic grouping or clustering of headache, is one of the least common types of headache. With typical cluster headache, the pain is almost always one-sided and usually localized in the eye region.

Low back pain is the second most common neurological ailment in the United States—only headache (when all types and severity levels are considered) is more common (2). Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis, or other causes. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position can also contribute to low back pain.

In the National Health Interview Survey, the presence of pain is measured by asking adult respondents 18 years of age and over about "severe headache or migraine," "low back pain," and other selected types of pain during the past 3 months. Respondents are instructed to report pain that lasted a whole day or more and not to include minor aches or pains. Respondents who reported both severe headache or migraine and low back pain were counted separately for each condition. Comparable national data on pain have been available since 1997 (see Appendix I, National Health Interview Survey). Between 1997 and 2003 the percent of adults 18 years of age and over reporting severe headache or migraine and low back pain remained relatively stable (Health, United States, 2005, table 57).

In 2003, 15 percent of adults suffered with severe headache or migraine during the past 3 months (figure 17 and data table for figure 17). Severe headache or migraine was more than twice as common among women as men (21 percent compared with 9 percent). The presence of severe headache or migraine diminished with age; rates among men and women 65 years of age and over were less than one-half the level reported among younger men and women.

Figure 17. Adults 18 years of age and over with severe headache or migraine or low back pain in the past 3 months by age and sex: United States, 2003.

Figure 17

Adults 18 years of age and over with severe headache or migraine or low back pain in the past 3 months by age and sex: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See (more...)

In 2003, 27 percent of adults reported low back pain—nearly double the level of adults with severe headache or migraine (figure 17 and data table for figure 17). Low back pain was slightly more common among women than men (30 percent compared with 25 percent). In contrast to the pattern for severe headache or migraine, which diminished with age for men and women, the prevalence of low back pain increased with age. Among men low back pain peaked in the 45–64 year age group and then decreased at older ages while for women the prevalence of low back pain was similar for middle-aged and older women.

Diagnosis, treatment, and medication management of headache and low back pain have considerable impact on the ambulatory health care system (5,6). In 2003 adults 18 years of age and over made 3.5 million visits to physician offices and hospital outpatient departments with a patient's stated reason for visit (up to three reasons were recorded) of headache or migraine, and 3.6 million visits with a reason for visit of back pain (which includes low back pain) (7). Visit rates were higher for women than for men; more than twice as high for headache or migraine and for back pain. Ambulatory care visits for headache or migraine and back pain reflect only a portion of total health care costs for these conditions as they include care only for persons who access the health care system. Additional medical costs are born by persons who self-treat these conditions with over-the-counter drugs or utilize complementary and alternative medicine (CAM) therapies (8).

Children

Limitation of activity due to chronic physical, mental, or emotional conditions is a broad measure of health and functioning that gauges a child's ability to undertake major age-appropriate activities. Play is the primary activity for preschool children, whereas schoolwork is the primary activity for children 5 years of age and over.

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. 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).

Comparable national data on activity limitation have been available since 1997 (see Appendix I, National Health Interview Survey). Between 1997 and 2003, 6–7 percent of children were reported to have limitation of activity (Health, United States, 2005, table 58). The percent of children with limitation of activity varies by age and sex. In 2002–03 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. About three-quarters of school-age children with an activity limitation were identified as having a limitation solely by participation in special education. Limitation of activity occurred more often among boys than 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 2002–03 the leading chronic health conditions causing activity limitation in children differed by age (figure 18). Among preschool children, the chronic conditions most often mentioned were speech problems, asthma, and mental retardation or other developmental problems. Among school-age children, learning disability and Attention Deficit Hyperactivity Disorder (ADHD) were among the most frequently mentioned causes of activity limitation.

Figure 18. Selected chronic health conditions causing limitation of activity among children by age: United States, 2002–03.

Figure 18

Selected chronic health conditions causing limitation of activity among children by age: United States, 2002–03. Click here for spreadsheet version Click here for PowerPoint NOTES: Children with more than (more...)

Approximately 20 percent of school-age children with an activity limitation had more than one condition causing activity limitation. Among school-age children, the most common combinations of causal conditions were learning disability and ADHD; learning disability and speech problems; and ADHD and other mental, emotional, or behavioral problems (2).

Working-Age and Older Adults

Chronic physical, mental, or emotional conditions can cause limitations in one's ability to function and carry out normal activities, such as working, keeping house, raising children, or even functioning independently. Limitation of activity increases with age and the impact of activity limitations may vary by age (1). For working-age adults 18–64 years, the most significant effect of limitations may be on their ability to work or keep house. For older adults 65 years of age and over, the impact of activity limitations on quality of life and independence may be the chief concerns. Limitations in activity are more common among older persons due to their greater likelihood of having disabling chronic conditions. However, examination of trends in conditions causing limitation of activity in younger populations provides important information on their current and projected health care needs and associated costs (2).

In the National Health Interview Survey, limitation of activity in adults is defined as 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 2003 the percent of noninstitutionalized working-age adults reporting any activity limitation caused by a chronic health condition remained relatively stable (Health, United States, 2005, table 58). In 2003, 6 percent of younger adults 18–44 years of age reported activity limitation, in contrast to 21 percent of adults 55–64 years of age.

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 (3). In figure 19, persons who reported more than one chronic health condition as the cause of their activity limitation were counted in each category. Among working-age adults, arthritis and other musculoskeletal conditions were the most frequently mentioned chronic conditions causing limitation of activity in 2002–03. Among persons 45–64 years of age, heart and other circulatory conditions were the second most common cause of activity limitation. Other common conditions causing activity limitation included mental illness and diabetes.

Figure 19. Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2002–03.

Figure 19

Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2002–03. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for (more...)

For younger working adults 18–44 years of age, mental illness was the second leading cause of activity limitation and fractures and joint injury were the third most common causes of activity limitation.

In 2003 more than one-third of noninstitutionalized adults 65 years of age and over living in the community reported limitation of activity (Health, United States, 2005, table 58). The percent with limitation of activity was more than twice as high among the oldest adults 85 years of age and over compared with adults 65–74 years of age (64 percent compared with 26 percent) (4).

For both older and working-age adults, the most common chronic conditions causing activity limitation were similar, though the rates were higher among older adults. Arthritis and other musculoskeletal conditions were the most frequently mentioned chronic conditions causing any limitation of activity among noninstitutionalized older persons in 2002–03 (figure 20). Heart disease and other circulatory conditions, including stroke, were the second most commonly reported conditions. For the oldest age group, adults 85 years and over, senility (which likely encompasses Alzheimer's disease and other types of dementia), vision, and hearing were commonly reported causes of limitation in activity.

Figure 20. Selected chronic health conditions causing limitation of activity among older adults by age: United States, 2002–03.

Figure 20

Selected chronic health conditions causing limitation of activity among older adults by age: United States, 2002–03. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for the (more...)

Needing help with personal care needs such as eating, bathing, dressing, or getting around inside the home, known as activities of daily living or ADLs, is a more severe type of limitation (see related Health, United States, 2005, table 58). The percent of adults 65 years of age and over who reported needing help with ADLs increased with age from 3 percent of persons 65–74 years to 10 percent of persons 75 years and over. Among older adults, the percent reporting ADL limitations was higher among Hispanic and non-Hispanic black than non-Hispanic white elders. ADL limitations were more common among those living in institutions. Over 90 percent of institutionalized Medicare beneficiaries were limited in ADLs (5).

Twelve percent of noninstitutionalized older persons reported limitations in instrumental activities of daily living (IADLs) in 2003. IADLs are activities related to independent living and include preparing meals, managing money, shopping for groceries, performing housework, and using a telephone. Like other types of activity limitation, limitations in IADLs increase with age. Seven percent of those age 65–74 reported IADL limitations, compared with 18 percent of those 75 years and over (Health, United States, 2005, table 58). Among those 65 years of age and over, IADL limitation was higher for women than men, higher for the poor than the nonpoor, and higher for non-Hispanic black than non-Hispanic white adults.

Health Care Utilization

Mammography

Breast cancer is the most common type of newly diagnosed cancer among women and the second leading cause of cancer deaths for women. In 2002 approximately 204,000 women in the United States were diagnosed with breast cancer and nearly 42,000 women died from the disease (1,2). Rates of newly diagnosed breast cancer, breast cancer survival rates, and death rates vary among race and ethnic groups (Health, United States, 2005, tables 40, 53, 54). Breast cancer incidence and death rates are higher among white and black women than among Asian and Hispanic women. Although breast cancer survival rates have been improving, race differentials in survival persist. Between 1974–79 and 1992–2000, the 5-year relative survival rate for white women increased from 75 to 88 percent and for black women, from 63 to 74 percent. Death rates from breast cancer have been declining since the early 1990s but the percentage decrease in mortality has been substantially greater among white women than among black women.

Regular mammography screening has been shown to be effective in reducing breast cancer mortality. In 2002 the U.S. Department of Health and Human Services released its updated recommendation from the U.S. Preventive Services Task Force (USPSTF) that called for screening mammography, with or without clinical breast examination, every 1 to 2 years for women age 40 years and over. The USPSTF, with concurrence from the National Cancer Institute, lowered the recommended age for initiating routine screening from 50 to 40 years of age, but found that the strongest evidence of the mortality benefit for women undergoing mammography screening was among women age 50–69 years (3).

Between 1999 and 2003, 70 percent of women age 40 years and over had a recent mammogram within the past 2 years, more than double the percent in 1987 (age-adjusted, Health, United States, 2005, table 86). During the period 1987–99, the percent of women with a recent mammogram increased substantially for most race and ethnic groups, except for Asian women, for whom mammography rates have been relatively stable since 1993 (figure 21). In the early 1990s, compared with other racial and ethnic groups, non-Hispanic white women had the highest recent mammography rates. Starting in 1993, recent mammography rates for non-Hispanic black and white women have been similar and generally higher than for other race and ethnic groups. In 2003 mammography rates for non-Hispanic white and black women (71 percent) were higher than rates for Asian and Hispanic women (58 and 65 percent).

Figure 21. Use of mammography within the past 2 years for women 40 years of age and over by race and Hispanic origin: United States, 1987–2003.

Figure 21

Use of mammography within the past 2 years for women 40 years of age and over by race and Hispanic origin: United States, 1987–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: (more...)

Barriers to mammography for Asian and Hispanic women may include language and acculturation, cultural beliefs, and health system barriers such as lack of insurance and no usual source of regular medical care. Several studies report lower rates of screening mammography among Spanish-speaking Hispanic patients compared with English-proficient Hispanics and non-Hispanics (4,5). With the growing number of recent immigrants in the United States, including large numbers of Asian and Hispanic immigrants, identification of potential barriers to mammography screening is critical to improving screening rates in these populations.

Disparities in mammography screening among underserved women with low income or less education also continue to exist. In 2003 poor women remained less likely than women with higher incomes to have a recent mammogram (55 percent compared with 74 percent, data table for figure 21). Women age 40 years and over with no high school diploma or GED also remained much less likely than women with at least some college education to have a recent mammogram (58 percent compared with 75 percent).

Reducing death rates from breast cancer is contingent on increasing mammography screening rates to detect the disease at an early stage and providing access to followup treatment for women who are diagnosed with breast cancer (6). Many public and private initiatives, including the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) help low income, uninsured, and underserved women obtain access to both screening and followup care (7). The Breast Cancer Treatment and Prevention Act, passed in 2000, also helps to make treatment more available to women screened by the NBCCEDP and allowed States the option of providing Medicaid coverage to low-income women enrolled in NBCCEDP who have a diagnosis of breast cancer, cervical cancer, or a related precancerous condition. Other efforts to increase mammogram usage include mammography coverage for Medicaid and Medicare enrollees, endorsement of screening by professional associations and health plan guidelines, and inclusion as a quality of care measure.

Pap Smear

A Pap smear is a microscopic examination of cells scraped from the cervix that is used to detect cancerous or precancerous conditions of the cervix and other medical conditions. If detected, precancerous conditions can be treated before they become malignant. Between 1975 and 2001 use of the Pap smear is credited with cutting the age adjusted cervical cancer incidence in half, from 14.8 to 7.9 cases per 100,000 women; and with reducing the age adjusted cervical cancer death rate from 5.6 to 2.7 deaths per 100,000 women (1). In 2002 cervical cancer was the reported cause of death for 4,000 women in the United States (2). The U.S. Preventive Services Task Force, the American Cancer Society, and the American College of Obstetricians and Gynecologists all recommend regular Pap smear screening for cervical cancer, although recommendations vary as to the frequency, timing, risk factors, and age of women to be screened (35).

Between 1987 and 2003 the percent of women 18 years of age and over with a Pap smear within the past 3 years increased from 74 percent to 79 percent, with increases occurring among women of all race and ethnic groups (figure 22). However, Pap smear screening rates vary considerably by race and ethnicity. In 2003 non-Hispanic black women had the highest rate of screening, 84 percent. Both non-Hispanic black and non-Hispanic white women were considerably more likely to report having a recent Pap smear than Asian and Hispanic women in 2003. Screening rates for both Asian and Hispanic women increased between 1987 and 1993, but have remained fairly stable through 2003. Pap smear screening rates remained lower for Asian and Hispanic women than for non-Hispanic black and non-Hispanic white women.

Figure 22. Use of Pap smear within the past 3 years for women 18 years of age and over by race and Hispanic origin: United States, 1987–2003.

Figure 22

Use of Pap smear within the past 3 years for women 18 years of age and over by race and Hispanic origin: United States, 1987–2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Persons (more...)

Several studies have examined barriers to cervical cancer screening for Hispanic and Asian women. Demographic and socioeconomic variables were found to be important predictors of Pap smear screening for Hispanic and Asian women, as they are for the general U.S. population (6). In addition, language and acculturation has been shown to predict Pap smear utilization among Hispanic and Asian women, with more recent immigrants and those with English language barriers, fatalistic views on cancer, and culturally-based embarrassment reporting less frequent receipt of Pap smear (79).

Incidence rates of cervical cancer were highest for Hispanic women and rates for black women were also higher than the average for all women (10). Despite their high Pap smear screening rates, black women had the highest death rates from cervical cancer in 1997–2001, 5.6 deaths per 100,000 women. Hispanic women also had cervical cancer death rates higher than that of non-Hispanic white and Asian women. In contrast, both the incidence rate of cervical cancer and the death rate for Asian women—who had the lowest screening level—were in line with the average rates for women of all races and ethnicities combined. The reasons for the higher death rates among black women despite their high screening rates are not fully understood. This higher mortality among black women may be in part due to diagnosis at more advanced cancer stages and lower socioeconomic status (11).

For women in whom precancerous lesions have been detected through Pap smears, the likelihood of survival is nearly 100 percent with appropriate evaluation, treatment, and followup (12). The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and other initiatives help low income, uninsured, and underserved women to obtain access to both screening and followup care for cervical cancer.

Injury-Related Emergency Department Visits Among Children and Adolescents

Injuries are a substantial and preventable public health concern. Injury-attributable medical expenditures cost as much as $117 billion in 2000 (1). Whereas the most severe injuries can result in death, nonfatal injuries cause substantial pain and disability. Injuries account for a significant proportion of deaths among young persons. In 2002 injuries accounted for about 45 percent of deaths for children 1–9 years, 50 percent at 10–14 years, and 78 percent of deaths for persons age 15–19 years (2,3). In 2003 there were nearly 20 million visits with a first-listed diagnosis of injury to hospital emergency departments (EDs), hospital outpatient departments (OPDs), and physician offices for children and young adults less than 20 years of age (4). Forty-six percent of visits to these three sites for injury care were made in physicians' offices, an additional 46 percent in EDs, and 8 percent to OPDs.

EDs are often the initial site of care for serious injuries. Many injury-related visits to physician offices and OPDs are for care and observation following treatment of an initial injury. Over 60 percent of ED injury visits by persons of all ages resulted in a referral to another physician or hospital outpatient clinic (5). A larger proportion of ED visits by children and adolescents are for injuries than ED visits by middle-age and older adults. In 2003 almost 30 percent of ED visits by children and adolescents under 20 years of age were for injury diagnoses compared with 19 percent of ED visits for persons 45 years and over (4).

The National Hospital Ambulatory Medical Care Survey collects information on injury-related visits from medical records of hospital EDs. For injury-related visits two important pieces of information are coded from the medical record—the medical diagnosis and the external cause of injury. The external cause of injury, which is defined as the classification of environmental events, circumstances, and conditions that were the cause of injury, provides important public health information in terms of injury prevention. For example, an injury diagnosis might be contusions or fracture, and the external cause of injury might be cut or a fall.

In 2000–2003 the most common external causes of injury for visits to EDs for children and adolescents under 20 years of age were falls, being struck by or against a person or object, motor vehicle traffic-related injuries, and cuts. The likelihood of ED visits for these four external causes of injury varied considerably by age (figure 23 and data table for figure 23). Young children under 10 years of age were more likely to have ED visits from falls than from other causes (figure 23). Falls were the most common cause of ED injury visits among infants under 1 year of age with visit rates peaking in the toddler years. Children 10 years of age and over were more likely to have ED injury visits due to being struck by or against an object or person, often occurring during sports activities. Sports and recreation are the most common activities associated with pediatric injury-related ED visits in the United States (6). Visit rates for motor vehicle traffic-related injuries rise rapidly as teenagers begin to reach driving age, with motor vehicle traffic-related injury visit rates peaking at age 18. Most injury visits in the ED are classified as unintentional rather than intentional. However, it is noteworthy that with increasing age among teenagers, the proportion of visits coded to intentional `struck by or against' increases from 23 percent at age 15 years to 30 percent at age 19 years (4).

Figure 23. Injury-related visits to hospital emergency departments among children under 20 years of age by first-listed external cause and age: United States, average annual 2000–2003.

Figure 23

Injury-related visits to hospital emergency departments among children under 20 years of age by first-listed external cause and age: United States, average annual 2000–2003. Click here for spreadsheet version Click (more...)

Visits to Physician Offices and Hospital Outpatient Departments

Americans of all ages visit physician offices and hospital outpatient departments (OPDs) to receive preventive and screening services, diagnosis and treatment of health conditions, medical counseling, and other types of ambulatory health care. In 2002–03 there were, on average, 1 billion visits per year to physician offices and OPDs (data table for figure 24). Many OPD clinics provide preventive services and primary care very similar to the services received in private physicians' offices. About 8 percent of these visits were made in OPDs overall, but OPDs were more frequently used sites of care for certain population groups. Visit rates to OPDs were nearly twice as high for black persons as for white persons (Health, United States, 2005, table 88). Physician expenditures are a major component of all personal health care expenditures and their price tag continues to increase (Health, United States, 2005, table 119).

Figure 24. Visits to physician offices and hospital outpatient departments by sex and age: United States, 1996–2003.

Figure 24

Visits to physician offices and hospital outpatient departments by sex and age: United States, 1996–2003. Click here for spreadsheet version Click here for PowerPoint NOTE: See Data Table for data points (more...)

Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, which are abstracted from medical records, provide a snapshot of care from office-based physicians and hospital outpatient departments. Visit rates to physician offices and hospital OPDs have increased since the mid-1990s. Between 1996–97 and 2002–03 the average number of ambulatory care visits for persons of all ages rose from 3.1 to 3.6 visits per person (data table for figure 24). This increase was driven by rising visit rates among men 65 years of age and over and women 45 years of age and over (figure 24).

Gender differences in visits to physician offices and hospital OPDs vary by age. The largest gender difference in visit rates occurs among adults 18–44 years of age. In this age group visit rates for women were twice as high as for men, largely due to care associated with female reproduction. This gender difference continues to narrow among middle-age adults and disappears among the oldest age group. In 2002–03 among adults 45–54 years of age visit rates for women were 45 percent higher than for men, 35 percent higher among adults 55–64 years, 10 percent higher among adults 65–74 years, and visit rates were similar among men and women 75 years of age and over.

Clinical advances; new medications and increased use of existing medications; rising burden of risk factors such as overweight and obesity; and increasing prevalence of chronic diseases such as asthma, diabetes, and hypertension contribute to rising visit rates (15). Medical advances such as identifying the benefits of lower cholesterol, blood pressure, and blood sugar levels lead to more visits for screening and treatment including drug monitoring. Contributing to the rise in visit rates is the increased use of both prescription and over-the-counter drugs. Drugs are becoming a more frequently utilized therapy for reducing morbidity and mortality and improving the quality of life of Americans. Almost two-thirds (62 percent) of visits to physician offices and hospital OPDs in 2001–02 had at least one drug associated with the visit; among adults 65 years of age and over nearly 20 percent of visits had 5 or more drugs associated with the visit (6). The prevalence of many chronic conditions and diseases increases with age, and as the baby boom generation continues to age its impact on the ambulatory care system will be felt more strongly (Health, United States, 2005, figures 3037).

Figure 37. Total prescribed medicine expense per person per year among adults 55–64 years of age by source of payment and sex: United States, 1997 and 2002.

Figure 37

Total prescribed medicine expense per person per year among adults 55–64 years of age by source of payment and sex: United States, 1997 and 2002. Click here for spreadsheet version Click here for PowerPoint (more...)

Hospital Procedures: Cardiac Stents

Heart disease is the leading cause of morbidity and mortality in the United States. Blockages to the coronary arteries (coronary artery disease) are a major cause of heart disease and heart attacks and their associated disability and mortality. Technological advances in treatment of blocked arteries include the introduction of coronary artery bypass graft (CABG) surgery (also called cardiac revascularization) in the late 1960s, percutaneous transluminal coronary angioplasty (PTCA, also called balloon angioplasty), introduced in the late 1970s and now often called percutaneous coronary intervention (PCI). Both procedures are preceded by cardiac catheterization, which measures the location and extent of coronary artery blockage. Whether CABG, PTCA, or some other alternative procedure is used depends on various factors such as where the blockage is, how many blockages there are, and the extent of the blockage (1,2).

The code for coronary artery stenting was introduced in 1996. Stenting is performed in combination with the PTCA procedure. A stent is a wire mesh tube used to prop open an artery that has recently been cleared using angioplasty. Since the mid-1990s angioplasty has increasingly been used with the insertion of stents because of lower rates of renarrowing of opened arteries (restenosis) (2). According to the American Heart Association, 70–90 percent of percutaneous transluminal coronary angioplasty (PTCA) procedures involve the placement of a stent (3).

Among adults 45 years of age and over, there were more than half a million hospital discharges with at least one coronary stent insertion procedure performed in 2002–03 (data table for figure 25). Between 1996–97 and 2002–03 the rate of coronary stent insertion procedure for adults age 45 years and over more than doubled from 22 to 49 per 10,000 population (data table for figure 25). Among adults age 75 years and over, the rate of hospitalizations that included this procedure more than tripled from 23 per 10,000 population in 1996–97 to 73 in 2002–03 (figure 25). For persons 45–64 years the rate of stent procedures per population stabilized after 1999, but for persons 65 years and over the rate continued to rise, in part because PTCA and stenting are considerably less invasive than CABG and can be performed on older persons who are likely to have other medical conditions that preclude more extensive open-heart CABG surgery (4,5). In contrast to rising rates of stent insertions, rates for CABG procedures declined among adults 45–64 years of age and remained stable for adults 75 years and over (Health, United States, 2005, table 100).

Figure 25. Hospital inpatient procedures for insertion of coronary artery stent(s) among adults 45 years of age and over by age: United States, 1996–2003.

Figure 25

Hospital inpatient procedures for insertion of coronary artery stent(s) among adults 45 years of age and over by age: United States, 1996–2003. Click here for spreadsheet version Click here for PowerPoint (more...)

Together, medical innovations such as CABG, PTCA, the intracoronary stent, and other procedures developed during the last 30 years have contributed to improved survival for heart attack patients. It is estimated that around 70 percent of survival improvement in heart attack mortality is a result of these technological changes (2). New drug-eluting stents show promise of reducing restenosis and subsequent heart attacks still further (6).

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).

From the turn of the 20th century through 2002, life expectancy at birth increased from 48 to 75 years for men and from 51 to 80 years for women (figure 26). 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 26. Life expectancy at birth and at 65 years of age by sex: United States, 1901–2002.

Figure 26

Life expectancy at birth and at 65 years of age by sex: United States, 1901–2002. 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 has also increased since the beginning of the 20th century. Among men, life expectancy at age 65 rose from 12 to 17 years and among women from 12 to 20 years. In contrast to life expectancy at birth, which increased sharply early in the century, life expectancy at age 65 improved primarily after 1950. Improved access to health care, advances in medicine, healthier lifestyles, and better health before age 65 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 rose 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 2002 the total gain in life expectancy for women was 1.1 year compared with 2.7 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, 2005, table 26). Decreasing death rates of less advantaged groups could raise life expectancy in the United States (Health, United States, 2005, table 27).

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 neonatal period (less than 28 days of life). Sudden Infant Death Syndrome (SIDS) and congenital malformations rank as the leading causes of infant deaths during the postneonatal period (28 days through 11 months of life) (1).

Between 1950 and 2001 the infant mortality rate declined by almost 77 percent (figure 27 and Health, United States, 2005, table 22). 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 had not declined or remained unchanged. The rise in infant mortality in 2002 was concentrated among neonatal deaths occurring in the first week of life. A special analysis of the 2002 linked birth/infant death data set found that the increase in infant mortality was due to an increase in the number of infants born weighing less than 750 grams (1 lb 10 1/2 oz), the majority of whom die during the first year of life (4).

Figure 27. Infant, neonatal, and postneonatal mortality rates: United States, 1950–2002.

Figure 27

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 under (more...)

Preliminary 2003 data indicated a small, but nonsignificant, decline in the infant mortality rate (5). More information on infant mortality patterns in 2003 will be available when the final mortality data and the linked birth/infant death data set for 2003 are available.

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 (6).

Infant mortality rates have declined for all racial and ethnic groups, but large disparities remain (Health, United States, 2005, table 19). During 2000–2002 the infant mortality rate was highest for infants of non-Hispanic black mothers (figure 28). 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 28. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 2000–2002.

Figure 28

Infant mortality rates by detailed race and Hispanic origin of mother: United States, 2000–2002. Click here for spreadsheet version Click here for PowerPoint NOTES: Infant is defined as under 1 year of (more...)

Leading Causes of Death for All Ages

In 2002 a total of 2.4 million deaths were reported in the United States (Health, United States, 2005, table 31). 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 twentieth century was driven mostly by declines in mortality for such leading causes of death as heart disease, stroke, and unintentional injuries (figure 29).

Figure 29. Death rates for leading causes of death for all ages: United States, 1950–2002.

Figure 29

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 (more...)

Throughout the second half of the twentieth century, heart disease was the leading cause of death and stroke was the third leading cause. In 2002 the age-adjusted death rate for heart disease was 59 percent lower than the rate in 1950. The age-adjusted death rate for stroke declined 69 percent since 1950 (Health, United States, 2005, 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 age-adjusted death rates for cancer 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, 2005, 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 diseases (CLRD) was the fourth leading cause of death in 2002. The age-adjusted 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 150 percent between 1980 and 2002, whereas 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, 2005, table 41). CLRD is strongly associated with smoking.

The fifth leading cause of death in 2002 was unintentional injuries. Age-adjusted death rates for unintentional injuries declined during the period 1950–92 (Health, United States, 2005, table 29). Since 1992, however, unintentional injury mortality has gradually increased. 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 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 ages 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 (2).

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, 2005, 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 (3).

Death rates generally increase with age for chronic diseases such as heart disease, cancer, stroke, and CLRD, as well as for unintentional injuries. Age-adjusted death rates for black persons exceed those for white persons of the same gender for heart disease, stroke, and cancer. 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, 2005, table 34).

Special Feature: Adults 55–64 Years of Age

Introduction

As they approach age 65, many Americans eagerly anticipate the day when they can have more leisure time. This "preretirement age" population, defined in this Special Feature as all adults 55–64 years of age, is projected to be the fastest growing segment of the adult population during the next 10 year period. In 2004 there were about 29 million persons in this age group. The 55–64 age group is projected to increase by 11 million persons over the 2004–14 period, to 40 million persons by 2014 (figure 30). Persons born during the explosive rise in population following World War II, between 1946 and 1964, are referred to as "baby boomers." In 2004 the oldest baby boomers were 55–58 years of age and are just beginning to enter the preretirement age group, with many more boomers aging into the 55–64 age group in the next 10 year period. In future decades the population age 65 years and over will increase dramatically—yet the population age 55–64 will not decline for the next few decades—because more boomers will replace the ones that age into older age groups. By 2029, the youngest of the baby boomers will have reached age 65.

Adults age 55–64 have more frequent and more severe health problems than younger people. The prevalence of diabetes, hypertension, heart disease, and other chronic diseases increase with age (Health, United States, 2005, tables 55, 69, 70). In addition, hypertension and obesity have been increasing over time for this age group. Between 1988–94 and 1999–2002 hypertension prevalence rose from 42 to 50 percent and obesity increased from 31 to 39 percent among adults 55–64 years (1).

Between 1997 and 2003 the percent of adults 55–64 years of age who had at least one health care visit in the past year rose from 85 to 89 percent and the percent with 4 or more visits rose from 43 to 50 percent (Health, United States, 2005, table 75). Strengthened efforts to identify and modify risk factors for chronic diseases may contribute to this greater use of health care services. This increased vigilance in screening and modifying risk factors is intended to reduce morbidity and improve quality of life. All Americans, including those age 55–64 years, are targeted for identification and intervention of heart disease risk factors (e.g., high serum cholesterol, high blood sugar, overweight, and high blood pressure) and cancer screening (25). Clinical guidelines have also increased the number of candidates for hypertension-lowering therapy and blood sugar control. Rates of office visits with prescribed cholesterol-lowering and blood glucose regulating drugs have increased dramatically in recent years (figure 36).

Figure 36. Blood glucose regulators and cholesterol-lowering drugs prescribed during medical visits among adults 55–64 years of age by sex: United States, 1995–96 and 2002–03.

Figure 36

Blood glucose regulators and cholesterol-lowering drugs prescribed during medical visits among adults 55–64 years of age by sex: United States, 1995–96 and 2002–03. Click here for spreadsheet version (more...)

Health insurance coverage is an important determinant of access to health services and is of particular importance for people with chronic conditions that require ongoing care. Whereas Americans age 55–64 years are more likely to be insured than other working-age adults under age 65, preretirement age adults do not have the guarantee of health insurance coverage that Medicare offers to almost all older adults age 65 and over (Health, United States, 2005, table 134). The 11 percent of 55–64 year olds who have no health insurance may find it difficult to buy insurance in the private market (data table for figure 33). Private nongroup health insurance is generally considerably more expensive than employer-sponsored health insurance, and preexisting health conditions often increase premiums in the nongroup market (6).

Figure 33. Health insurance coverage among adults 55–64 years of age by marital status: United States, 2002-03.

Figure 33

Health insurance coverage among adults 55–64 years of age by marital status: United States, 2002-03. Click here for spreadsheet version Click here for PowerPoint NOTES: Public includes Medicare, Medicaid, (more...)

Uninsured persons may postpone or not receive care that could have prevented or delayed the progression of various diseases and conditions. Those uninsured due to disability or the inability to work because of a health condition are at particular risk of not obtaining needed services or of incurring high out-of-pocket expenditures. When they do become eligible for Medicare they may use more health care resources as a result of deferring health care that was needed at earlier ages (7).

The changing health insurance market is also affecting people age 55–64 who currently have health insurance. Among employed persons age 55–64 years with health care coverage, the need for health insurance can affect the timing of their retirement. Planned retirement may be postponed to maintain individual or dependent health insurance coverage. Many employers that continue to offer retirees health benefits have reduced benefits, particularly prescription drug coverage, and many have shifted costs they previously paid to their retirees through expenditure caps and various increases in cost-sharing provisions such as increased premiums, copayments and deductibles (8,9). Future cuts in retiree health insurance benefits have implications both for currently employed 55–64 year olds, as well as for the growing number of aging baby boomers entering that age group.

While many Americans age 55–64 are in good health and relatively well off financially, minorities, primarily African Americans, American Indians, and persons of Hispanic origin, are more likely than non-Hispanic white Americans to have chronic health problems, live in poverty, lack insurance coverage, and be unable to work because of a disability (figure 31, figure 32, figure 33) (10,11). The percent of the population that is black or Hispanic is increasing. If current racial and ethnic disparities do not narrow, this trend could indicate even higher prevalence of obesity, diabetes, hypertension, and other diseases more common in minorities and a corresponding higher burden on the health care system.

Figure 31. Employment status among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2002–03.

Figure 31

Employment status among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2002–03. Click here for spreadsheet version Click here for PowerPoint NOTES: Data are for the (more...)

Figure 32. Low income among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2003.

Figure 32

Low income among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2003. Click here for spreadsheet version Click here for PowerPoint NOTES: Poor is defined as family income less (more...)

This special feature focuses on the health care use and its determinants for the population age 55–64 years including their employment status, income, health insurance, heart disease risk factors, and health care utilization and expenses. Focusing on this age group may provide insight into program and policy interventions that could both improve access and quality of care for Americans age 55–64 years as well as to highlight implications for the Medicare system as this large age group looms at its doorstep.

Employment Status

In 2002–03, 58 percent of adults 55–64 years of age were employed (data table for figure 31) compared with nearly 80 percent of younger adults 35–54 years of age (1). Adults 55–64 years of age who were not working were either retired, unemployed due to disability, keeping house, looking for work, or not working for some other reason. Employment, or past employment, is a determinant of access to health care both in terms of supplying income to pay for care and also because employer-sponsored health insurance is frequently offered to employees. Persons who are not working because of a disability often have considerable medical expenditures and thus have a greater need for health insurance than less disabled persons.

Men 55–64 years of age were more likely to be working at a job or business for pay than women (figure 31). Data from the National Health Interview Survey show that about two-thirds of men 55–64 years of age were working for pay in 2002–03 compared with about one-half of women in that age group (data table for figure 31). Although men were more likely than women to be working, the percent of women 55–64 years in the labor force has increased substantially over the past 20 years. Between 1982 and 2002 the percent of women 55–64 years who were employed increased 32 percent, whereas the percent of men 55–64 years who were employed decreased slightly (2). In 2002–03 there was no difference between men and women in the percent who were retired (17 percent) or who said they were unemployed due to disability (12 percent) when asked the reason they had not been working for pay at a job or business the previous week. Women were more likely to be taking care of house or family than were men.

In 2002–03 employment status differed by race and ethnicity. Non-Hispanic white men and Hispanic men were more likely to be working (about 65 percent) than non-Hispanic black men (57 percent). Among women, a little over one-half of non-Hispanic white women were working compared with 46 percent of non-Hispanic black women and 41 percent of Hispanic women. Hispanic women in this age group were more likely to be taking care of home or family than non-Hispanic women. Hispanic men and women were less likely to be retired than non-Hispanic adults 55–64 years. Unemployment due to disability was higher for non-Hispanic black men and women age 55–64 years than for other racial and ethnic groups. In 2002–03, about one-fifth of non-Hispanic black men and one-quarter of non-Hispanic black women were unemployed due to a disability compared with 15 percent of Hispanic adults and 10 percent of non-Hispanic white adults. This self-reported higher prevalence of unemployment because of disability among black adults is confirmed by data on Medicare enrollment for the disabled, which includes those with end-stage renal disease. In 2001, 16 percent of the disabled Medicare enrollees age 45–64 years were black adults, higher than would be expected given that they represent 11 percent of the population in this age group (Health, United States, 2005, tables 1 and 141). African Americans have higher rates of enrollment in the Medicare End-Stage Renal Disease Program, which is in part explained by their higher prevalence of diabetes and hypertension, risk factors for kidney disease (3,4). Hispanic adults accounted for 11 percent of disabled Medicare beneficiaries age 45–64 years, though they represented only 8 percent of the population in this age group in 2001. Higher rates of unemployment due to disability for black and Hispanic adults may be explained in part by higher prevalence of heart, kidney, and other diseases (5). In addition, health problems are more often disabling for Hispanic and black workers because their jobs are more likely to be physically demanding than the jobs of white workers and less likely to be able to accommodate a disabled or partially disabled worker (6).

Low Income

People with low income are more likely to be in poor health and have a higher prevalence of many serious chronic diseases than those with higher incomes (Health, United States, 2005, tables 56, 57, 60, 61, 85). Their worse health is a result of many factors including a higher prevalence of health risk factors, poor nutrition and housing, occupational and environmental hazards, and other social ills (1). Poor health may also contribute to poverty by reducing the ability to earn income. People living below or near the poverty level are also more likely to lack health insurance, which, combined with their low incomes reduces their access to health care (Health, United States, 2005, tables 75, 134, figure 7).

In general the preretirement age population 55–64 years has higher incomes than older persons age 65 and over. In 2003 more than one-fifth of the population age 55–64 had incomes below 200 percent of poverty, compared with almost two-fifths of older persons age 65 years and over. More older adults than preretirement age adults had incomes in the 100–199 percent of poverty range. The percent living below 100 percent of poverty, however, was similar for the two groups (about 10 percent) (2).

There is large variation in the poverty distribution by gender and race and Hispanic origin for the preretirement age population (figure 32). In 2003 women 55–64 years of age were more likely than men to be living in poverty (10 percent compared with 8 percent). Both non-Hispanic black and Hispanic men and women were about twice as likely to be living in or near poverty as non-Hispanic white adults. In addition, non-Hispanic black and Hispanic women were more likely to be poor than their male counterparts.

It is unclear how the poverty distribution for this age group will change in the future. The baby boom generation is better educated and wealthier than previous generations and it is likely that as they age they will maintain their economic advantage compared with current retirees (3,4). However, beginning in 2001 the poverty rate for the total population has been rising. In addition, because poverty rates differ by population subgroup, differential population growth and immigration rates may affect future disparities in income (5).

Income for persons age 55–64 is not likely to increase and will probably decrease upon retirement. Persons 55–64 currently living in poverty most often cannot expect future increases in their employment-based incomes (3,6). Employment prospects at this age for poor and near poor persons diminish and are most often limited to low income jobs with few fringe benefits (6).

Health Insurance Coverage

Adults 55–64 years of age are reaching a time of life when health problems are likely to become more frequent and more serious. Consequently, persons of this age group are likely to have greater health care needs, on average, than younger persons. Unless adults 55–64 years are disabled or suffer from certain serious chronic conditions, they are not eligible for Medicare, the Federal health program for the disabled and those 65 years of age and over. Some people in this group may have incomes low enough to qualify for Medicaid, the joint Federal and State program serving the poor, or may qualify for other coverage such as from the Department of Veterans Affairs, which is available for persons who have served in the military. However, most adults 55–64 years of age do not qualify for public health insurance coverage and are heavily reliant on private health insurance to finance their health care needs.

Employer-sponsored private health insurance is usually preferable to individually-purchased private health insurance both in terms of more generous benefits and the lower costs resulting from group plan underwriting rates and the financial contributions by employers to the health plan (13). Post-retirement health insurance offers by large private-sector firms have been declining (4). Among employers that are continuing to offer retirees health benefits, most have made changes to their benefit packages, including dropping retiree coverage for new employees and shifting costs onto others. Sixty-four percent of firms reported that they are very likely to increase retiree contributions to premiums, and 54 percent are very likely to increase cost sharing (5). This trend is likely to affect both currently employed 55–64 year olds as well as those who will enter the 55–64 year old age group in the future.

In 2002–03 among persons 55–64 years there was a strong relationship between marital status and health insurance regardless of gender. Married persons often have two opportunities to obtain health insurance—through their own employment or their spouse's. Among married preretirement age adults 83 percent were covered by private health insurance compared with about 60 percent of widowed, separated or divorced, and single adults (figure 33). Levels of public coverage were over 2 times as high for unmarried adults as married adults. Among those who were widowed, separated or divorced, or single the percent with no health insurance ranged from 16–18 percent compared with 9 percent for married adults.

Although there was little difference between men and women in the relationship between health insurance coverage and marital status, there were significant differences in marital status for men and women. In 2002–03 preretirement age men were more likely to be married than women (79 percent compared with 66 percent). Women were more than 3 times as likely to be widowed as men (11 percent compared with 3 percent), reflecting both the greater longevity of women and the tendency for women to be a few years younger than their husbands. Women were also more likely to be separated or divorced than men (19 percent compared with 14 percent). These differences were even more pronounced by sex and race and Hispanic origin. Forty-one percent of non-Hispanic black women were currently married compared with 80 percent of non-Hispanic white men (6). Because being married is associated with higher rates of health insurance, minority women, in particular, are more at risk for being uninsured than other groups, as well as more likely to live in poverty (figure 32).

Cardiovascular Risk Factors

Hypertension, obesity, and high cholesterol are all independent risk factors for the leading causes of death in the United States—heart disease and stroke (1,2). Hypertension is also a major risk factor for congestive heart failure and kidney failure. Being obese is associated with increased risk of morbidity and mortality (3). High cholesterol increases the likelihood of developing heart disease and raises the risk of heart attacks among those with heart disease (4).

Previous research has found that the prevalence rates for obesity, hypertension, and cholesterol abnormalities are higher at older ages and that having each of these three risk factors substantially increases the risk for cardiovascular morbidity (2,5). People with multiple risk factors are at higher jeopardy for coronary heart disease and stroke than those with a single risk factor and the likelihood of heart disease and stroke increases as the number of risk factors increases.

The National Health and Nutrition Examination Survey (NHANES) collects information on hypertension, high cholesterol, and obesity through in-person household interviews, and physical exams and blood work conducted in a mobile examination center. Hypertension is defined as having either elevated blood pressure (systolic pressure of at least 140 mmHg or diastolic pressure of at least 90 mmHg) or taking antihypertensive medication. High serum cholesterol is defined as having total serum cholesterol greater than or equal to 240 mg/dL. Obesity is defined as having a body mass index greater than or equal to 30 (see Appendix II, Body mass index).

The percent of adults 55–64 years of age who have hypertension increased from 42 to 50 percent between 1988–94 and 1999–2002 (data table for figure 34). During the same time period, obesity increased from 31 to 39 percent of adults in this age group. In contrast, the percent of Americans age 55–64 with elevated cholesterol decreased between 1988–94 and 1999–2002, in part due to growing awareness about the risks of high cholesterol and the increased use of cholesterol-lowering medications.

Figure 34. Cardiovascular risk factors (hypertension, obesity, and high cholesterol) among adults 55–64 years of age by sex: United States, 1988–94 and 1999–2002.

Figure 34

Cardiovascular risk factors (hypertension, obesity, and high cholesterol) among adults 55–64 years of age by sex: United States, 1988–94 and 1999–2002. Click here for spreadsheet version Click here (more...)

Between 1988–94 and 1999–2002 the percent of adults 55–64 years of age with one or more of the three cardiovascular risk factors examined remained level at about 70 percent (data table for figure 34). However, the pattern differed for men and women (figure 34). In 1988–94 women 55–64 years of age were more likely than men to have one or more risk factor for cardiovascular disease (73 percent compared with 64 percent). By 1999–2002 the percent of men with one or more risk factors had risen to the level for women.

In 1999–2002 women in this age group were more likely than men to have elevated cholesterol and hypertension and the more serious condition of combinations of two or three cardiovascular risk factors. In 1999–2002, 39 percent of women and 24 percent of men age 55–64 years had two or three of these risk factors (data table for figure 34). Almost one-half of non-Hispanic black adults had two or three of the risk factors, compared with just under one-third of non-Hispanic white and Mexican adults (6).

Use of Health Care Services

People seek care from health professionals to receive preventive and screening services, diagnosis and treatment, counseling, and other health care services. Visits run the continuum from emergency and critical care to services designed to maintain quality of life and functioning. Visits to health professionals are influenced by factors in addition to medical need. Health insurance coverage, ability to pay for services not covered by health insurance, capability to travel to the services, availability of services, and compliance with health care professionals' recommendations to obtain tests or treatment all influence visit patterns (1). These factors vary by race and Hispanic origin, sex, and marital status (figures 3133). In 2002–03, nearly 90 percent of the population 55–64 years of age had at least one visit to a health care provider such as a primary care physician, specialist physician, therapist, eye doctor, or mental health professional in the past 12-month period (2).

Persons age 55–64 years who have Medicare coverage are eligible primarily through being permanently disabled or having end-stage renal disease. Persons in this age group who have Medicaid coverage also qualify primarily through medical need as well as poverty status (see Appendix II, Medicare and Medicaid). Because of these eligibility criteria, persons age 55–64 years with public coverage have worse health status than the general population age 55–64. A greater percent of persons 55–64 years of age with public coverage reported at least one visit to a general physician, specialist physician, physical or other therapist, or mental health professional than those with private coverage or the uninsured, in part reflecting the higher disease burden in this group (figure 35).

Figure 35. Visits to health professionals in the past 12 months among adults 55–64 years of age by health insurance status: United States, 2002–03.

Figure 35

Visits to health professionals in the past 12 months among adults 55–64 years of age by health insurance status: United States, 2002–03. Click here for spreadsheet version Click here for PowerPoint (more...)

Uninsured persons 55–64 years of age were considerably less likely to have ambulatory health care visits from many types of health care providers in the past year than persons with private insurance. About one-half of the uninsured saw a general physician compared with more than three-quarters of those with private insurance. The percent with a visit to an eye doctor was similar for those with public and private insurance coverage but lower for those without insurance. The uninsured were about one-half as likely to report visits to specialist physicians, eye doctors, and physical or other therapists compared with those with private insurance.

Uninsured persons age 55–64 were about as likely as those with private coverage to report being told by a health care professional that they have one of several common chronic conditions, including arthritis, hypertension, diabetes, heart disease, and serious psychological distress (2). Because the uninsured are less likely to obtain medical care, prevalence rates of diagnosed conditions may be underestimated for many conditions such as hypertension and diabetes that are difficult to diagnose without medical tests.

There is evidence that lack of health insurance among midlife adults discourages routine care that may delay or reduce the future impact of chronic conditions (3,4). Previously uninsured persons may increase their use of clinical services once they reach age 65 and became eligible for Medicare (5). "Catch-up" use of Medicare services by newly-eligible participants has implications for future Medicare expenditures.

Blood Glucose Regulators and Cholesterol-Lowering Drugs Prescribed During Medical Visits

Drugs—both prescription and over the counter—are becoming a more frequently utilized therapy for reducing morbidity and mortality and improving the quality of life of Americans (1). Prevalence of many chronic conditions and diseases increases with age, with concurrent use of medications designed to help control or prevent complications associated with those conditions. In 1999–2002, 73 percent of adults 55–64 years of age reported taking at least one prescription drug during the past month compared with 62 percent in 1988–94 (2).

Factors contributing to 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 more aggressive clinical guidelines recommending increased use of medications for conditions such as high cholesterol, high blood pressure, chronic asthma, and diabetes (3,4). A greater emphasis on screening for common conditions and beginning medication therapy before permanent damage to body systems occurs has also contributed to greater use of drug therapy.

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 surveys abstract information from medical records of physician office and hospital outpatient department visits, including information on the number and type of prescription and over-the-counter drugs, immunizations, allergy injections, and anesthetics that were prescribed during the in-person visit. Until 2002, up to six medications could be recorded on the visit record. Beginning in 2003, up to eight medications may be recorded. A visit with drugs is defined as a visit where at least one drug was prescribed, ordered, supplied, administered, or continued. Drug rates are presented as drugs per 100 population, which is calculated as the number of drugs recorded during visits for the 2-year period divided by the sum of the population estimates for both years, times 100. If more than one drug in a selected drug class was recorded on the visit record, then that drug class was counted multiple times. 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.

The prevalence of diagnosed diabetes among adults 55–64 years of age has been increasing (5). Diabetes is associated with numerous serious health complications, including amputations, heart disease, eye disease and blindness, and kidney disease (6,7). Improved glucose control decreases the risk of complications. Diabetes treatment may include dietary management, increased physical activity, oral medications, and insulin. New and better types of oral diabetes medications have been introduced over the past two decades. The rate of blood glucose regulators prescribed during physician and hospital outpatient department visits increased between 1995–96 and 2002–03, for both men and women (figure 36). In 2002–03 the rates of these drugs prescribed were similar for men and women age 55–64 at 45–48 drugs per 100 persons.

High cholesterol is a known risk factor for heart disease. Updated national guidelines and growing awareness about the risks of high cholesterol have contributed to greater diagnosis and treatment of elevated serum cholesterol (8). Cholesterol levels can be reduced by lifestyle modifications, including losing excess weight and increasing physical activity. If such modifications do not reduce cholesterol to target levels, then drug therapy may be warranted. Between 1995–96 and 2002–03 the rate of cholesterol-lowering drugs prescribed during medical visits among those 55–64 years of age more than doubled (data table for figure 36). By 2002–03 the rate of cholesterol-lowering drugs prescribed among men age 55–64 years had increased to 57 drugs per 100 men. Over the same time period, the rate of cholesterol-lowering drugs prescribed for women increased from 15 to 49 drugs per 100 women (figure 36).

Total Health Care Expense and Prescribed Medicine Expense

As people age their health care needs increase, resulting in higher health care expenses for adults 55–64 years of age than for younger adults. These higher expenses are financed by third party payers (private health insurers, publicly-financed health programs and other miscellaneous sources), as well as by individuals through out-of-pocket payments. Between 1997 and 2002 the out-of-pocket portion of health care expenses in real (2002) dollars increased from 17 percent to 20 percent and rose on average from $753 to $971 per person per year (data table for figure 37). By contrast, the amount of health expenses per person paid by all other sources remained stable during the period. Increased average out-of-pocket payments for all health services may particularly burden poorer, sicker (especially chronically ill), and uninsured adults 55–64 years of age and may result in their foregoing needed services (1).

Drugs—both prescription and over the counter—are becoming a more frequently utilized therapy for reducing morbidity and mortality among adults 55–64 years of age (figure 36). Between 1997 and 2002 prescription drug expenses as a percent of total health care expenses increased from 14 to 23 percent (data table for figure 37). In 2002 average expenses for prescription drugs were about $1,100 per person, a 75-percent increase over 1997 (figure 37). Women had higher average prescribed medicine expenses per person per year than men in both time periods.

The percent of prescription drug expenses paid out-of-pocket declined from 1997 to 2002 (45 percent compared with 38 percent) indicating increased coverage of drug expenses by private health insurance and publicly-funded health programs. Despite expanded coverage of prescription drugs by third party payers, the use of more drugs and the use of more expensive drugs resulted in average out-of-pocket expenses for prescription drugs that were about 50 percent higher in 2002 than in 1997 (figure 37). In some cases high out-of-pocket costs may deter people from obtaining needed prescription drugs, which may result in deteriorating health status (1,2).

References

Figures 1 and 2: Age

1.
Wolf DA. Population change: Friend or foe of the chronic care system Health Aff 20(6):28–42.2001. Available at content.healthaffairs.org/cgi/content/abstract/20/6/28 accessed on February 17, 2005. [PubMed: 11816669]
2.
Goulding MR, Rogers ME, Smith SM. Public health and aging: Trends in aging—United States and worldwide. MMWR 52(06):101–6. 2003. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5206a2.htm accessed on February 17, 2005.

Figure 3: Race and Ethnicity

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.

Figures 4 and 5: Poverty

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics. 1998.
2.
DeNavas-Walt C, Proctor B, Mills R. Income, poverty, and health insurance coverage in the United States: 2003. Current population reports, series P-60 no 226. Washington: U.S. Government Printing Office. 2004. Available at www​.census.gov/prod/2004pubs​/p60–226.pdf accessed on February 23, 2005.
3.
Hungerford T, Rassette M, Iams H, Koenig M. Trends in the economic status of the elderly. Soc Sec Bull. 2001–02.;64(no 3) [PubMed: 12655738]
4.
Camarota SA. Economy slowed, but immigration didn't: The foreign-born population 2000–2004. Center for Immigration Studies, November 2004. Available at www​.cis.org/articles/2004/back1204.html accessed on January 7, 2005.

Figures 6 and 7: Health Insurance

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: 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]
3.
Camarota, SA. Economy slowed, but immigration didn't: The foreign-born population 2000–2004. Center for Immigration Studies, November 2004. Available at www​.cis.org/articles/2004/back1204.pdf accessed on January 7, 2005.

Figures 8 and 9: Health Care Expenditures

1.
Smith C, Cowan C, Sensenig A. et al. Trends: Health spending growth slows in 2003 Health Affairs 24(1):185–94.2005. Available at content.healthaffairs.org/cgi/reprint/hlthaff.24.1.185v1 accessed on January 26, 2005. [PubMed: 15644387]

Figures 10 and 11: Tobacco Use

1.
U.S. Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. 2004. Atlanta, GA: Centers for Disease Control and Prevention. 2004. Available at www​.cdc.gov/tobacco/sgr/sgr_2004/index​.htm accessed on May 2, 2005.
2.
U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention. 1994. Available at www​.cdc.gov/tobacco/sgr/sgr_1994/ accessed on March 17, 2005.
3.
Mathews TJ. Smoking during pregnancy in the 1990s. National vital statistics reports; vol 49 no 7. Hyattsville, MD: National Center for Health Statistics. 2001. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr49/nvsr49_07.pdf accessed on February 17, 2005.
4.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
5.
Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2002. National vital statistics reports; vol 52 no 10. Hyattsville, MD: National Center for Health Statistics. 2003. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr52/nvsr52_10.pdf accessed on February 17, 2005.
6.
Centers for Disease Control and Prevention Trends in cigarette smoking among high school students—United States, 1991–2001 MMWR 51(19):409–12.2002. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5119a1.htm accessed on March 17, 2005. [PubMed: 12033476]
7.
Centers for Disease Control and Prevention Youth Risk Behavior Surveillance—United States, 2003 MMWR 53SS021–96.2004. Available at www​.cdc.gov/tobacco/research_data​/youth/YRBS_ss5302a1.htm accessed on March 17, 2005.

Figure 12: Teenagers and Cars

1.
Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final data for 2002. National vital statistics reports; vol 53 no 5. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_05.pdf accessed on March 18, 2005.
2.
National Highway Traffic Safety Administration. Motor Vehicle Traffic Crash Fatality and Injury Estimates for 2000; U.S. Department of Transportation, Washington: 2001.
3.
McCartt AT, Shabanova VI. Teenage Seat belt Use: White Paper. The National Safety Council's Air Bag & Seat Belt Safety Campaign. 2002. Available at www​.nsc.org/public/teen0702.pdf accessed on March 28, 2005.
4.
Subramanian R. Alcohol Involvement in Fatal Motor Vehicle Traffic Crashes, 2003. National Highway Traffic Safety Administration, U.S. Department of Transportation, Washington: DOT HS 809 822, March 2005. Available at www​.nrd.nhtsa.dot.gov​/pdf/nrd-30/NCSA/Rpts/2005/809822.pdf accessed on March 28, 2005.
5.
National Highway Traffic Safety Administration. Motor Vehicle Occupant Protection FACTS. Available at www​.nhtsa.dot.gov/people​/injury/airbags/OccupantProtectionFacts/young_adults.htm accessed on March 28, 2005.

Figures 13 and 14: Physical Activity

1.
Centers for Disease Control and Prevention, Office of Genomics and Disease Prevention. Genomics and Population Health: United States, 2003. Atlanta, GA. 2004. Available at www​.cdc.gov/genomics accessed on August 12, 2004.
2.
U.S. Department of Health and Human Services. Physical activity and health: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention. 1996. Available at www​.cdc.gov/nccdphp/sgr/sgr.htm accessed on January 10, 2005.
3.
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]
4.
U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. Available at www​.healthierus.gov/dietaryguidelines/ accessed on March 3, 2005.
5.
Grunbaum JA, Kann L, Kinchen S. et al. Youth Risk Behavior Surveillance—United States, 2003. In: CDC Surveillance Summaries MMWR 53SS-2.2004. Available at www​.cdc.gov/mmwr accessed on January 10, 2005.
6.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.

Figure 15: Overweight and Obesity

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. 1998. Available at www​.nhlbi.nih.gov/guidelines​/obesity/ob_gdlns.htm accessed on March 18, 2005.
2.
U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD. 2001. Available at www​.surgeongeneral.gov/topics/obesity/ accessed on March 18, 2005.
3.
Dietz WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics. 1998;101(3 Pt 2):518–25. [PubMed: 12224658]
4.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, unpublished analysis.
5.
Ogden CL, Fryar CD, Carroll MD, Flegal KM. Mean body weight, height, and body mass index, United States 1960–2002. Advance data no 347. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data/ad/ad347.pdf accessed on March 18, 2005.

Figure 16: Asthma in Children Age 3–17

1.
National Center for Health Statistics. Asthma prevalence, health care use and mortality, 2002. Available at www​.cdc.gov/nchs/products​/pubs/pubd/hestats/asthma/asthma​.htm accessed on February 3, 2005.
2.
National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma: Update on selected topics 2002. NIH pub no 02–5074. Bethesda, MD: National Heart, Lung, and Blood Institute. 2003. Available at www​.nhlbi.nih.gov/guidelines​/asthma/asthupdt.htm accessed on March 17, 2005.
3.
Akinbami LJ, Schoendorf KC. Trends in childhood asthma: Prevalence, health care utilization, and mortality. Pediatrics. 2002;110(2):315–22. [PubMed: 12165584]
4.
Martinez FD, Wright AL, Taussig LM. et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995;332(3):133–8. [PubMed: 7800004]
5.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
6.
Akinbami LJ, LaFleur BJ, Schoendorf KC. Racial and income disparities in childhood asthma in the United States. Ambulatory Pediatrics. 2002;2:382–7. [PubMed: 12241134]
7.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Discharge Survey, unpublished analysis.
8.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, unpublished analysis. [PubMed: 10662358]
9.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey, unpublished analysis.
10.
U.S. Census Bureau. Monthly postcensal resident populations by single year of age, sex, race, and Hispanic origin [file for July 1, 2003]. Available at www​.census.gov/popest​/national/asrh/2003_nat_res.html accessed on May 13, 2005.

Figure 17: Headache and Low Back Pain

1.
Bingefors K, Isacson D. Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain—a gender perspective. Eur J Pain. 2004;8(5):435–50. [PubMed: 15324775]
2.
National Institute of Neurological Disorders and Stroke. Low Back Pain Fact Sheet. Available at www​.ninds.nih.gov/health_and_medical​/pubs/back_pain.htm accessed on October 18, 2004.
3.
National Institute of Neurological Disorders and Stroke, in Cooperation with the American Academy of Neurology, American Headache Society and National Headache Foundation. 21st century prevention and management of migraine headaches. Clinical Courier 19(8), 2001. Available at www​.ninds.nih.gov/doctors​/OP129D_Clinical_Courier_fa.pdf accessed on October 25, 2004.
4.
National Headache Foundation. Headache fact sheet. Available at www​.headaches.org/consumer​/presskit/NHAW04​/Categories%20of%20Headache.pdf accessed on October 28, 2004.
5.
American Academy of Neurology. Practice Parameter: Evidence-based guidelines for migraine headache (an evidence-based review). Available at www​.neurology.org/cgi/reprint/55/6/754​.pdf accessed on November 1, 2004.
6.
American Academy of Orthopaedic Surgeons (AAOS). AAOS clinical guideline on low back pain/sciatica (acute) (phases I and II). Rosemont, IL: American Academy of Orthopaedic Surgeons (AAOS); 2002. Available at www​.guideline.gov/summary/summary​.aspx?ss​=15&doc_id=5369&nbr​=3672 accessed on January 11, 2005.
7.
Centers for Disease Control and Prevention, National Center for Health Statistics. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (OPD), unpublished analysis.
8.
Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Advance data; no 343. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data/ad/ad343.pdf accessed on November 1, 2004. [PubMed: 15188733]

Figure 18: Morbidity and Limitation of Activity: Children

1.
Newacheck PW, Strickland B, Shonkoff JP. et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102(1):117–23. [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]

Figures 19 and 20: Morbidity and Limitation of Activity: Working-age and Older Adults

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.
Bhattacharya J, Cutler DM, Goldman DP, et al. Disability forecasts and future Medicare costs. Chapter 3 in Frontiers in health policy research, volume 7. Cutler DM and Garber AM, editors. Boston: the MIT Press, 2004. [PubMed: 15612336]
3.
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.
4.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
5.
Federal Interagency Forum on Aging-Related Statistics. Older Americans 2004: Key indicators of well-being. Washington. 2004.

Figure 21: Mammography

1.
American Cancer Society. Cancer Facts and Figures 2002. Available at www​.cancer.org/downloads​/STT/CancerFacts&Figures2002TM.pdf accessed on May 17, 2005.
2.
Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final data for 2002. National vital statistics reports: vol 53 no 5. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_05.pdf accessed on February 18, 2005.
3.
U.S. Preventive Services Task Force. Screening for breast cancer: Recommendations and rationale. February 2002. Agency for Healthcare Research and Quality, Rockville, MD. Available at www​.ahrq.gov/clinic/3rduspstf​/breastcancer/brcanrr.htm accessed on September 29, 2004.
4.
Fiscella K, Franks P, Doescher MP. et al. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002;40:52–59. [PubMed: 11748426]
5.
Goel MS, Wee CC, McCarthy EP. et al. Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care. J Gen Intern Med. 2003;18:1028–35. [PMC free article: PMC1494963] [PubMed: 14687262]
6.
Lawson HW, Henson R, Bobo JK, Kaeser MK. Implementing recommendations for the early detection of breast and cervical cancer among low-income women MMWR Recomm Rep 49RR-237–55.2000. Available at www​.cdc.gov/mmwr/PDF/RR/RR4902.pdf accessed on January 26, 2005. [PubMed: 15580731]
7.
National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention. The national breast and cervical cancer early detection program: saving lives through screening, 2004/2005 fact sheet. Available at cdc.gov/cancer/nbccedp/about2004.htm accessed on January 21, 2005.

Figure 22: Pap Smear

1.
Ries LAG, Eisner MP, Kosary CL, et al. (eds). SEER Cancer Statistics Review, 1975–2001. Table V-3. National Cancer Institute. Bethesda, MD. 2004. Available at seer.cancer.gov/csr/1975_2001/ accessed on January 5, 2005.
2.
Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final data for 2002. National vital statistics reports; vol 53 no 5. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_05.pdf accessed on February 18, 2005.
3.
U.S. Preventive Services Task Force. Screening for cervical cancer: Recommendations and rationale. AHRQ pub no 03–515A. January 2003. Agency for Healthcare Research and Quality. Rockville, MD. Available at www​.ahrq.gov/clinic/3rduspstf​/cervicalcan/cervcanrr.htm accessed on January 3, 2005.
4.
Saslow D, Runowicz CD, Solomon D. et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52(6):342–62. [PubMed: 12469763]
5.
The American College of Obstetricians and Gynecologists. ACOG News Release: Revised cervical cancer screening guidelines require reeducation of women and physicians. Available at www​.acog.org/from_home​/publications/press_releases​/nr05–04-04–1​.cfm accessed on January 5, 2005.
6.
Swan J, Breen N, Coates RJ. et al. Progress in cancer screening practices in the United States: Results from the 2000 National Health Interview Survey. Cancer. 2003;97(6):1528–40. [PubMed: 12627518]
7.
Chaudhry S, Fink A, Gelberg L, Brook R. Utilization of Papanicolaou smears by South Asian women living in the United States. J Gen Intern Med. 2003;18:377–84. [PMC free article: PMC1494856] [PubMed: 12795737]
8.
Alba D, Sweningson JM, Chandy C, Hubbell FA. Impact of English language proficiency on receipt of Pap smears among Hispanics. J Gen Intern Med. 2004;19(9):967–70. [PMC free article: PMC1492513] [PubMed: 15333062]
9.
Austin LT, Ahmad F, McNally MJ, Stewart DE. Breast and cervical cancer screening in Hispanic women: A literature review using the health belief model. Women's Health Issues. 2002;12(3):122–8. [PubMed: 12015184]
10.
Ries LAG, Eisner MP, Kosary CL, et al. (eds). SEER Cancer Statistics Review, 1975–2001. Table V-7. National Cancer Institute. Bethesda, MD. 2004. Available at seer.cancer.gov/csr/1975_2001/results_merged/topic_race_ethnicity.pdf accessed on January 6, 2005.
11.
Schwartz KL, Crossley-May H, Vigneau, FD et al. Race, socioeconomic status and stage at diagnosis for five common malignancies. Cancer Causes Control. 2003;14:761–6. [PubMed: 14674740]
12.
Lawson HW, Henson R. recommendations for the early detection of breast and cervical cancer among low-income women MMWR Recomm Rep 49RR-237–55.2000. Available at www​.cdc.gov/mmwr/PDF/RR/RR4902.pdf accessed on January 26, 2005. [PubMed: 15580731]

Figure 23: Injury-related Emergency Department Visits Among Children and Adolescents

1.
Centers for Disease Control and Prevention Medical expenditures attributable to injuries—United States, 2000 MMWR Jan 1653(1):1–4.2004. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5301a1.htm accessed on February 18, 2005.
2.
Anderson RN, Minino AM, Fingerhut LA, et al. Deaths: Injuries, 2002. National vital statistics reports, forthcoming. [PubMed: 16485447]
3.
Kochanek KD, Murphy SL, Anderson RN, et al. Deaths: Final data for 2002. National vital statistics reports; vol 53 no 5. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_05.pdf accessed on February 18, 2005.
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 analysis.
5.
Burt CW, Fingerhut LA. Injury visits to hospital emergency departments: United States, 1992–95. National Center for Health Statistics Vital Health Stat 13(131)1998. Available at www​.cdc.gov/nchs/data​/series/sr_13/sr13_131.pdf accessed on February 18, 2005.
6.
Simon TD, Bublitz C, Hambidge SJ. External causes of pediatric injury-related emergency department visits in the United States. Acad Emer Med. 2004;11:1042–8. [PubMed: 15466146]

Figure 24: Visits to Physician Offices and Hospital Outpatient Departments

1.
NAEPP Expert Panel Report. Guidelines for the diagnosis and management of asthma—Update on selected topics 2002. Update 2002: Expert panel report. Available at www​.nhlbi.nih.gov/guidelines​/asthma/index.htm accessed on January 10, 2005.
2.
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]
3.
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. Available at www​.nhlbi.nih.gov/guidelines​/obesity/ob_gdlns.htm accessed on February 18, 2005.
4.
U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD. 2001. Available at www​.surgeongeneral.gov/topics/obesity/ accessed on February 18, 2005.
5.
National Institutes of Health. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. NIH pub no 04–5230. August 2004. Available at www​.nhlbi.nih.gov/guidelines​/hypertension/ accessed on February 18, 2005.
6.
National Center for Health Statistics. Health, United States, 2004 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics. 2004. [PubMed: 20698065]

Figure 25: Hospital Procedures: Cardiac Stents

1.
Holubkov R, Detre KM, Sopko G. et al. Trends in coronary revascularization 1989 to 1997: The bypass angioplasty revascularization investigation (BARI) survey of procedures. Am J of Cardiol. 1999;84:157–61. [PubMed: 10426332]
2.
Cutler DM, McClellan MM. Is technological change in medicine worth it? Health Affairs. 2001;20(5):11–29. [PubMed: 11558696]
3.
Heart and Stroke Encyclopedia, American Heart Association online encyclopedia. Available at www​.americanheart.org​/downloadable/heart​/1056719919740HSFacts2003text.pdf accessed on November 30, 2004.
4.
Cohen HA, Williams DO, Holmes DR, et al. Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty: A report from the NHLBI Dynamic Registry. American Heart Journal. September 2003. [PubMed: 12947372]
5.
MacGillivray TE, Vlahakes GJ. Perspective: Angioplasty versus minimally invasive bypass surgery. N Engl J Med. 2002;347(8):5551–2. [PubMed: 12192012]
6.
Michaels AD, Chatterjee K. Angioplasty versus bypass surgery for coronary artery disease. Circulation. 2002;106:e187–e190. [PubMed: 12460885]

Figure 26: Life Expectancy

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 48(29):621–9.1999. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm4829a1.htm accessed on February 18, 2005.
3.
Fried LP. Epidemiology of aging. Epidemiol Rev. 2000;22(1):95–106. [PubMed: 10939013]
4.
Arias E. United States life tables, 2002. National vital statistics reports; vol 53 no 6. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_06.pdf accessed on February 18, 2005.

Figures 27 and 28: Infant Mortality

1.
Anderson RN, Smith BL. Deaths: Leading causes for 2002. National vital statistics reports; vol 53 no 17. Hyattsville, MD: National Center for Health Statistics. 2005. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_17.pdf accessed on April 1, 2005.
2.
Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: Final data for 2002. National vital statistics reports; vol 53 no 5. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_05.pdf accessed on April 1, 2005.
3.
Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period linked birth/infant death data set. National vital statistics reports; vol 53 no 10. Hyattsville, MD: National Center for Health Statistics. 2004. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_10.pdf accessed on April 1, 2005. [PubMed: 15622996]
4.
MacDorman MF, Martin JA, Mathews TJ, Hoyert DL, Ventura SJ. Explaining the 2001–02 infant mortality increase: Data from the linked birth/infant death data set. National vital statistics reports; vol 53 no 12. Hyattsville, MD: National Center for Health Statistics. 2005. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_12.pdf accessed on April 1, 2005. [PubMed: 15712582]
5.
Hoyert DL, Kung H, Smith BL. Deaths: Preliminary data for 2003. National vital statistics reports; vol 53 no 15. Hyattsville, MD. National Center for Health Statistics. 2005. Available at www​.cdc.gov/nchs/data​/nvsr/nvsr53/nvsr53_15.pdf accessed on April 1, 2005.
6.
American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics. 1996;98(6 Pt 1):1216–8. [PubMed: 8951285]

Figure 29: Leading Causes of Death for All Ages

1.
Centers for Disease Control and Prevention Decline in deaths from heart disease and stroke—United States, 1900–1999 MMWR 48(30):649–56.1999. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm4830a1.htm accessed on February 18, 2005. [PubMed: 10488780]
2.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, table 250R. Available at www​.cdc.gov/nchs/data​/dvs/mortfinal2002_work250r.pdf accessed on May 16, 2005.
3.
Centers for Disease Control and Prevention Motor-vehicle safety: A 20th century public health achievement MMWR 48(18):369–74.1999. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm4818a1.htm accessed on February 18, 2005. [PubMed: 10369577]

Figure 30: Adults 55–64 Years of Age: Introduction

1.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, unpublished analysis.
2.
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]
3.
Screening for type 2 diabetes mellitus in adults: recommendations and rationale. United States Preventive Services Task Force—Independent Expert Panel. 1996 (revised 2003 Feb). Available at www​.guideline.gov/summary/summary​.aspx?doc_id=3523 accessed on February 18, 2005.
4.
Screening for hypertension in adults. Available at www​.guideline.gov/summary/summary​.aspx?ss​=15&doc_id=3226&nbr​=2452 accessed on January 10, 2005.
5.
U.S. Preventive Services Task Force. Guidelines for screening for colorectal cancer. Available at www​.ahrq.gov/clinic/3rduspstf​/colorectal/ accessed on January 10, 2005.
6.
U.S. Government Accountability Office. Private health insurance: Millions relying on individual market face cost and coverage trade-offs. GAO/HEHS-97–8. Washington: U.S. General Accounting Office. 1996.
7.
McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Impact of Medicare coverage on basic clinical services for previously uninsured adults. JAMA. 2003;290(6):757–64. [PubMed: 12915428]
8.
Stuart B, Singhal PK, Fahlman CF, Doshi J, Briesacher B. Employer-Sponsored Health Insurance and Prescription Drug Coverage for New Retirees: Dramatic Declines in Five Years. Health Aff (web exclusive) July 23:W3–334-W3–341. 2003. Available at content.healthaffairs.org/cgi/content/full/hlthaff.w3.334v1/DC1 accessed on February 18, 2005. [PubMed: 15506136]
9.
Claxton G, Gil I, Finder B, et al. Employer Health Benefits, 2004 Annual Survey. Report by the Henry J. Kaiser Family Foundation and the Health Research & Educational Trust (HRET). 2004. Available at www​.kff.org/insurance/7148/index.cfm accessed on January 10, 2005.
10.
Zsembik BA, Peek MK, Peek CW. Race and ethnic variation in the disablement process. J Aging Health. 2000;12(2):229–49. [PubMed: 11010698]
11.
Liao Y, Tucker P, Giles WH. Health status of American Indians compared with other racial/ethnic minority populations—Selected states, 2001–02 MMWR 52(47):1148–52.. Available at www​.cdc.gov/mmwr/preview​/mmwrhtml/mm5247a3.htm accessed on March 14, 2005. [PubMed: 14647016]

Figure 31: Adults 55–64 Years of Age: Employment Status

1.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
2.
Toossi M. Labor force projections to 2012: the graying of the U.S. workforce. Mon Labor Rev (February):37–57:2004.
3.
Medicare and Medicaid Statistical Supplement, 2001. Health Care Financ Rev. Available at www​.cms.hhs.gov/review​/supp/2001/table6a.pdf accessed on November 24, 2004.
4.
Sowers JR, Ferdinand KC, Bakris GL, Douglas JG. Hypertension-related disease in African Americans: Factors underlying disparities in illness and its outcome. Postgrad Med. 2002;112(4):24–48. [PubMed: 12405099]
5.
Choi NG, Schlichting-Ray L. Predictors of transitions in disease and disability in pre- and early-retirement populations. J Aging Health. 2001;13(3):379–409. [PubMed: 11813732]
6.
Flippen C, Tienda M. Pathways to retirement: patterns of labor force participation and labor market exit among the pre-retirement population by race, Hispanic origin, and sex. J Geront: Social Sciences. 2000;55B(1):S14–S27. [PubMed: 10728126]

Figure 32: Adults 55–64 Years of Age: Low Income

1.
Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic status and health chartbook. Health, United States, 1998. Hyattsville, MD. 1998.
2.
DeNavas-Walt C, Proctor BD, Mills RJ. Income, poverty, and health insurance coverage in the United States: 2003. Current population reports, series P-60 no 226. Washington: U.S. Government Printing Office. 2004.
3.
Butrica BA, Iams HM, Smith KE. It's all relative: understanding the retirement prospects of baby-boomers. Center for Retirement Research at Boston College, CRRWP 2003–21. November 2003.
4.
U.S. Government Accountability Office. Older Workers: Demographic Trends Pose Challenges for Employers and Workers. GAO-02–85, November 2001.
5.
Camarota SA. Economy slowed, but immigration didn't: the foreign-born population 2000–2004. Center for Immigration Studies, November 2004. Available at www​.cis.org/articles/2004/back1204.html accessed on June 6, 2005.
6.
Rubin RM, White-Means SI. Income Distribution of older Americans. Mon Labor Rev. 2000 November;2000;123:19–30.

Figure 33: Adults 55–64 Years of Age: Health Insurance Coverage

1.
Holahan J. Health insurance coverage of the near elderly. The Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, pub no 7114, July 2004. Available at www​.kff.org/uninsured/7114.cfm accessed on January 10, 2005.
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Monheit AC, Vistnes JP, Eisenberg JM. Moving to Medicare: Trends in the health insurance status of near-elderly workers, 1987–1996. Health Aff. 2001;20(2):204–13. [PubMed: 11260945]
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Jensen GA. Health insurance of the near elderly: A growing concern. Med Care. 1998;36(2):107–9. [PubMed: 9475466]
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Claxton G, Gil I, Finder B, et al. Employer health benefits, 2004 annual survey. Kaiser Family Foundation and Health Research and Educational Trust (HRET). 2004. Available at www​.kff.org/insurance/7148/index.cfm accessed on January 10, 2005.
5.
Fronstin P, Salisbury D. Retiree health benefits: Savings needed to fund health care in retirement. EBRI Issue Brief No 254, February 2003. [PubMed: 12778631]
6.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.

Figure 34: Adults 55–64 Years of Age: Cardiovascular Risk Factors

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]
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Yusuf HR, Giles WH, Croft JB. et al. Impact of multiple risk factor profiles on determining cardiovascular disease risk. Prev Med. 1998;27(1):1–9. [PubMed: 9465349]
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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. Available at www​.nhlbi.nih.gov/guidelines​/obesity/ob_gdlns.htm accessed on February 18, 2005.
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National Cholesterol Education Program. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Final Report. NIH pub no 02–5215. 2002. Available at www​.nhlbi.nih.gov/guidelines​/cholesterol/atp3full.pdf accessed on May 13, 2005.
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Brown CD, Higgins M, Donato KA. et al. Body mass index and the prevalence of hypertension and dyslipidemia. Obes Res. 2000;8(9):605–19. [PubMed: 11225709]
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Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, unpublished analysis.

Figure 35: Adults 55–64 Years of Age: Use of Health Care Services

1.
Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions. Arch Intern Med. 2000;160(9):1269–74. [PubMed: 10809029]
2.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, unpublished analysis.
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Johnson RW, Crystal S. Uninsured status and out-of-pocket costs at midlife. Health Serv Res. 2000;35(5):911–32. [PMC free article: PMC1089176] [PubMed: 11130804]
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Sudano Jr JJ, Baker DW. Intermittent lack of health insurance coverage and use of preventive services. Am J Public Health. 2003;93(1):130–7. [PMC free article: PMC1447707] [PubMed: 12511402]
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McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Impact of Medicare coverage on basic clinical services for previously uninsured adults. JAMA. 2003;290(6):757–64. [PubMed: 12915428]

Figure 36: Adults 55–64 Years of Age: Blood Glucose Regulators and Cholesterol-lowering Drugs Prescribed During Medical Visits

1.
National Center for Health Statistics. Health, United States, 2004 with Chartbook on trends in the health of Americans. Hyattsville, MD. 2004. [PubMed: 20698065]
2.
Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, unpublished analysis.
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Berndt ER. The U.S. pharmaceutical industry: Why major growth in times of cost containment? Health Aff. 2001;20(2):100–14. [PubMed: 11260932]
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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. Available at commerce.senate.gov/hearings/072401Chockley.pdf accessed on February 18, 2005.
5.
National Center for Health Statistics. Health, United States, 2003 with Chartbook on trends in the health of Americans. Hyattsville, MD. 2003.
6.
National Diabetes Data Group. Diabetes in America, 2nd Edition. Bethesda, MD: National Institutes of Health, 1995. (NIH pub no 95–1468).
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Ross SA. Controlling diabetes: the need for intensive therapy and barriers in clinical management. Diabetes Res Clin Pract. 2004;65S(1):S29–S34. [PubMed: 15315868]
8.
National Cholesterol Education Program. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Final Report. NIH pub no 02–5215. 2002. Available at www​.nhlbi.nih.gov/guidelines​/cholesterol/atp3full.pdf. [PubMed: 12485966]

Figure 37: Adults 55–64 Years of Age: Total Health Expense and Prescribed Medicine Expense

1.
Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;e94(10):1782–87. [PMC free article: PMC1448534] [PubMed: 15451750]
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Heisler M, Langa KM, Eby EL. et al. The health effects of restricting prescription medication use because of cost. Med Care. 2004;42(7):626–34. [PubMed: 15213486]

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. Detailed descriptions of data sources are contained in Appendix I. Interpretation of trend data is affected by major changes such as periodic survey redesign, changes in data collection methodology, changes in wording and order of questions, interruptions or changes in timing of data collection, and changes in data coding systems. Comparability issues are discussed in the notes that accompany each figure and data table, and in the survey description in Appendix I. For example, the National Health Interview Survey was redesigned in 1997 to improve its efficiency and flexibility. The survey redesign affects comparisons before and after 1997 for many measures.

Data Presentation

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

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 (or log) scale to emphasize the rate of change and to enable measures with large differences in magnitude to be shown on the same chart. 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 I and II references.

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 1–37

Data table for figure 1. Total population and older population: United States, 1950–2050Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 2. Percent of population in five age groups: United States, 1950, 2000, 2004, and 2050Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 3. Percent of population in selected race and Hispanic origin groups by age: United States, 1980–2004Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 4. Poverty by age: United States, 1966–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 5. Low income by age, race and Hispanic origin: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 6. Health insurance coverage among persons under 65 years of age: United States, 1984–2006Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 7. No health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2007Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 8. National health expenditures as a percent of Gross Domestic Product: United States, 1960–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 9. Personal health care expenditures according to source of funds and type of expenditures: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 10. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 11. Current and frequent cigarette smoking among high school students by sex, race and Hispanic origin, and grade level: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 12. Seatbelt use and drinking and driving among high school students by sex: United States, 1991–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 13. High school students engaging in regular physical activity by sex, race and Hispanic origin, and grade: United States, 1999, 2001, and 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 14. Leisure-time physical activity among adults 18 years of age and over by poverty status: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 15. Overweight and obesity by age: United States, 1960–2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 16. Asthma attack among children by age, race and Hispanic origin: United States, 1998–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 17. Adults 18 years of age and over with severe headache or migraine or low back pain in the past 3 months by age and sex: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 18. Selected chronic health conditions causing limitation of activity among children by age: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 19. Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 20. Selected chronic health conditions causing limitation of activity among older adults by age: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 21. Use of mammography within the past 2 years for women 40 years of age and over by selected characteristics: United States, selected years 1987–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 22. Use of Pap smears within the past 3 years for women 18 years of age and over by selected characteristics: United States, 1987–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 23. Injury-related visits to hospital emergency departments among children under 20 years of age by first-listed external cause and age: United States, average annual 2000–2003Revised March 2006Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 24. Visits to physician offices and hospital outpatient departments by sex and age: United States, 1996–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 25. Hospital inpatient procedures for insertion of coronary artery stent(s) among adults 45 years of age and over by age and sex: United States 1996–2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 26. Life expectancy at birth and at 65 years of age by sex: United States, 1900–1902 through 2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 27. Infant, neonatal, and postneonatal mortality rates: United States, 1950–2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 28. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 2000–2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 29. Death rates for leading causes of death for all ages: United States, 1950–2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 30. Aging of the population 45 years of age and over: United States, 2004, 2014, and 2024Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 31. Employment status among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 32. Low income among adults 55–64 years of age by sex, race and Hispanic origin: United States, 2003Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 33. Health insurance coverage among adults 55–64 years of age by marital status: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 34. Cardiovascular risk factors (hypertension, obesity, and high cholesterol) among adults 55–64 years of age by sex: United States, 1988–94 and 1999–2002Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 35. Visits to health professionals in the past 12 months among adults 55–64 years of age by health insurance status: United States, 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 36. Blood glucose regulators and cholesterol-lowering drugs prescribed during medical visits among adults 55–64 years of age by sex: United States, 1995–96 and 2002–03Click here for spreadsheet versionClick here for PowerPoint

Data table for figure 37. Total health care expense and prescribed medicine expense per person per year among adults 55–64 years of age by source of payment and sex: United States, 1997 and 2002Click here for spreadsheet versionClick here for PowerPoint

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