spotlight on chronic diseases, part a · spotlight on chronic diseases, part a. a. height and...

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Center onSocietyand Health

Steven H. Woolf, MD, MPH*Laudan Aron, MA**Derek A. Chapman, PhD*Lisa Dubay, PhD**Emily Zimmerman, PhD*Lauren C. Snellings, MPH, CHES*Lindsey Hall, MPH*Amber D. Haley, MPH*Nikhil Holla, BA**Kristin Ayers, MPH*Christopher Lowenstein, BA**Timothy A. Waidmann, PhD**

*Center on Society and Health, Virginia Commonwealth University, Richmond, Virginia **Urban Institute, Washington, DC

Supplement 8, December 2017

SPOTLIGHT ON CHRONIC DISEASES, PART A

The

The Health of the States study, funded by the Robert Wood Johnson Foundation,

was a systematic examination of health disparities in the U.S. across the 50 states

and the District of Columbia. The study was conducted in 2014 – 2016 by the Virginia

Commonwealth University Center on Society and Health and the Urban Institute.

The goal was to take a “deep dive” into the available data on the health of the

states and the factors that shape health. The project examined how 123 potential

determinants of health, drawn from five broad domains, correlated with 39 different

health outcomes that span mortality and illness/injury across the life course.

The results were issued in a series of reports: a summary report1 released in October

2016, which was followed by a series of supplements. This report, the eighth of

nine supplements, focuses on how rates of chronic disease vary across the states.

Please refer to the first supplement 2 for details on the data sources and analytic

methods used to produce these results.

Virginia Commonwealth UniversityCenter on Society and Healthand the Urban Institute

December 2017

THE HEALTH OF THE STATES Supplement 8:

Spotlight on Chronic

Diseases, Part A

Overweight and Obesity, Diabetes, and Cardiovascular Conditions

4

in the state, and the accuracy of self-report

(versus clinical diagnosis). According

to BRFSS data, the prevalence of diabetes

in 2010 ranged 2.5 fold across the states,

from 5.4 percent in Alaska to 13.5 percent

in Alabama (Figure 1). Data on diabetes

mortality from the Centers for Disease

Control and Prevention (CDC) are more

precise because death is a discrete outcome

and based on state vital records data.

CDC data on 2013 diabetes mortality rates

also ranged 2.4 fold, from 14.1 deaths

per 100,000 in Massachusetts to 34.1 deaths

per 100,000 in West Virginia (Figure 1).

As with adult overweight/obesity,

states with the most favorable diabetes

statistics were concentrated in the Mountain

states and in New England (Figures 3–4).

Colorado and Wyoming ranked in the Top

10 on both measures — diabetes prevalence

and mortality — however Alaska had the

nation’s lowest diabetes prevalence

and Massachusetts reported the lowest

diabetes mortality rate.

States with the highest diabetes rates

were concentrated in the South and West

South Central regions. Four Southern states

Alabama, Mississippi, Tennessee, and

West Virginia — ranked in the Bottom 10

for diabetes prevalence and mortality,

as did the West South Central states of

Louisiana and Oklahoma. Alabama and

West Virginia had the nation’s highest

diabetes prevalence and mortality rates,

In 2010, the prevalence of overweight/

obesity ranged from 56.3 percent in the

District of Columbia to 69.9 percent in

Alabama (Figure 1).a The Top 10 states —

which had the nation’s lowest overweight/

obesity rates — were concentrated in the

Pacific, Mountain, and New England regions

of the country (Figure 2). The Bottom 10,

with the highest rates of overweight

and obesity, were primarily in the South

and West South Central regions.

DIABETES

Data from the Behavioral Risk Factor

Surveillance System (BRFSS) also support

estimates of the prevalence of adult

diabetes based on respondents’ answers

as to whether they have ever been told

by a doctor that they have the disease.

Statistics based on this answer can be

skewed by such factors as access to health

care, the intensity of diabetes screening

Spotlight on Chronic Diseases, Part A

a. Height and weight data

from the Behavioral

Risk Factor Surveillance

System (BRFSS) were

used to compute the

body mass index (BMI)

of adults. An overweight/

obese indicator was

computed as having a

BMI of 25.0 kg/m2 or

greater, which combined

the thresholds for over

weight (BMI = 25.0–29.9

kg/m2) and obesity

(BMI > 30.0 kg/m2).

5

Overweight/obesity

prevalence (%)

Diabetes prevalence (%)

Diabetes mortality (per

100,000)

Angina or CHD*

prevalence (%)

Heart disease mortality (per

100,000)

Stroke prevalence (%)

Stroke mortality (per

100,000)

FIGURE 1OVERWEIGHT/OBESITY, DIABETES, AND CARDIOVASCULAR CONDITIONS (PER 100,000), BY STATE

DC 56.3 AK 5.4 MA 14.1 HI 2.3 MN 166.5 CT 1.7 NY 26.3HI 57.2 CO 6.1 WY 14.2 DC 2.6 CO 172.0 CO 1.8 NH 27.6

CO 57.6 UT 6.6 CT 14.8 AK 2.6 MA 182.6 MN 1.9 MA 27.7UT 57.7 MN 6.8 NV 14.8 UT 2.8 HI 185.3 WY 1.9 RI 27.7VT 58.4 VT 6.9 CO 15.0 CO 3.1 AZ 186.7 WI 2.0 CT 28.3

MA 60.1 SD 7.0 HI 15.5 WA 3.4 AK 186.9 AK 2.0 AZ 28.6NV 60.2 MT 7.2 VT 17.4 GA 3.5 WA 188.5 MA 2.1 NM 30.0CT 60.6 WI 7.2 NY 17.8 CA 3.6 NH 188.8 SD 2.1 DC 30.1

NM 60.7 WY 7.3 DC 17.9 CT 3.6 OR 189.6 NH 2.2 FL 30.6OR 60.9 OR 7.3 VA 18.4 ID 3.6 NM 190.6 UT 2.2 VT 31.7VA 61.3 CT 7.4 WI 18.5 OR 3.6 CT 192.3 VT 2.2 CO 32.0MT 61.3 ND 7.6 NH 18.7 MN 3.6 FL 195.2 NY 2.2 MN 32.0NY 61.5 MA 7.6 MN 18.8 MT 3.7 ID 196.4 ID 2.2 ND 32.4NJ 61.5 IA 7.7 RI 18.9 MD 3.7 VT 196.9 WA 2.3 NJ 32.4CA 61.6 NE 7.8 IA 19.0 VT 3.7 ME 198.4 CA 2.3 NV 33.3WA 61.8 WA 7.8 MD 19.1 WI 3.8 UT 199.3 ND 2.4 ME 33.4

ID 62.9 RI 8.1 FL 19.2 NJ 3.9 ND 200.1 NE 2.4 IA 33.9MN 63.1 ID 8.1 DE 19.4 IL 3.9 NE 200.9 NJ 2.4 HI 34.8NH 63.1 NH 8.1 NJ 19.4 WY 3.9 WY 201.3 RI 2.4 CA 34.9

IL 63.2 DC 8.4 IL 19.7 NV 4.0 SD 202.3 MD 2.5 WY 35.1RI 63.5 HI 8.5 MT 19.7 NE 4.0 RI 202.7 OR 2.5 ID 35.4

WI 63.6 NM 8.6 KS 19.8 IA 4.0 CA 205.0 HI 2.5 WA 35.5ME 63.7 KS 8.6 AK 20.1 NM 4.0 MT 206.2 KS 2.6 WI 36.0WY 63.8 NV 8.7 ME 20.4 VA 4.1 WI 209.7 NM 2.6 MD 36.1DE 64.0 CA 8.9 MO 20.5 AZ 4.1 VA 209.9 VA 2.7 MI 36.3KS 64.6 ME 8.9 CA 20.6 MA 4.1 DE 217.1 IL 2.7 NE 36.4

ND 64.8 VA 8.9 WA 21.3 KS 4.1 NJ 217.3 GA 2.8 IL 36.7AZ 64.8 DE 8.9 TX 21.6 RI 4.2 KS 217.6 MT 2.8 DE 37.0NE 64.9 IL 8.9 NE 21.7 OH 4.3 IA 218.6 ME 2.8 PA 37.2FL 65.0 NY 9.0 NC 21.8 ND 4.4 IL 222.7 IA 2.8 OR 37.3

NC 65.3 AZ 9.2 ND 22.3 NY 4.4 MD 223.1 TX 2.8 MT 37.6OH 65.7 NJ 9.4 SC 22.5 MS 4.4 NC 223.1 MI 2.9 SD 38.0SD 65.7 MD 9.5 PA 22.6 NH 4.4 TX 225.0 IN 2.9 KS 38.1PA 65.7 MO 9.7 SD 22.7 TX 4.4 NY 227.2 DE 3.0 UT 38.2

GA 65.8 AR 9.8 GA 23.0 DE 4.5 PA 230.3 OH 3.0 VA 38.6MO 65.8 GA 9.9 OR 23.4 MO 4.6 GA 240.1 NC 3.1 OH 39.9AK 65.9 TX 9.9 AZ 23.5 IN 4.6 SC 243.1 NV 3.1 TX 40.2

MD 66.0 NC 10.0 ID 23.7 SC 4.6 NV 244.0 AZ 3.2 MO 40.6IA 66.2 IN 10.0 MI 23.8 SD 4.6 IN 244.7 PA 3.4 AK 40.7IN 66.5 KY 10.3 KY 24.1 NC 4.6 OH 245.6 LA 3.4 IN 40.7LA 66.5 MI 10.3 AR 24.2 PA 4.7 MO 249.3 DC 3.4 WV 40.7TX 66.6 OH 10.4 AL 24.3 TN 4.8 MI 254.1 TN 3.5 GA 41.4MI 66.8 LA 10.5 TN 24.8 AR 5.1 WV 257.7 WV 3.5 KY 41.7AR 67.1 PA 10.5 UT 25.3 ME 5.2 KY 261.1 KY 3.5 NC 42.4OK 67.2 FL 10.6 OH 25.4 MI 5.3 DC 261.3 FL 3.5 LA 44.0SC 67.4 OK 10.7 IN 26.3 LA 5.3 TN 265.8 AR 3.6 TN 44.4KY 67.5 SC 11.0 LA 26.9 OK 5.4 LA 275.5 SC 3.7 OK 44.5TN 67.8 WV 11.8 NM 27.6 FL 5.5 AR 278.3 MO 3.9 MS 47.2WV 67.9 TN 11.9 OK 29.9 AL 5.6 OK 289.5 MS 4.1 AR 47.6MS 68.8 MS 12.6 MS 32.9 KY 5.8 AL 297.1 OK 4.2 SC 47.6AL 69.9 AL 13.5 WV 34.1 WV 6.0 MS 308.3 AL 4.7 AL 48.1

6

CARDIOVASCULAR DISEASE

Cardiovascular disease was measured

in terms of prevalence and mortality.

The BRFSS asks respondents about heart

disease — whether they have ever been

told by a doctor that they had angina

or [coronary] heart disease — as well as

cerebrovascular diseases (e.g., stroke).

In contrast, CDC mortality data measure

the death rate from cardiovascular

diseases, a category that encompasses

heart disease and other vascular conditions,

such as cerebrovascular disease (e.g.,

stroke). Cerebrovascular disease, a form

of cardiovascular disease that damages

the brain and is itself a leading cause

of death, was also measured in terms of

prevalence and mortality.

respectively (Figure 1). In the Midwest,

Ohio also ranked in the Bottom 10 on

both measures.

Utah, which ranked in the Top 10

for low obesity rates (see above), ranked

in the Bottom 10 for diabetes mortality.

This is all the more surprising given

that Utah ranked in the Top 10 for its low

diabetes prevalence; it also ranked in

the Top 10 for 20 other health outcomes

examined in this report, a total matched

only by Massachusetts. The District of

Columbia, which struggles with other

health disadvan tages, achieved the Top 10

for both obesity and diabetes mortality.

Several Southern states had distinctly

higher diabetes prevalence and mortality

rates than other states in the Bottom 10

(Figure 1).

FIGURE 2PREVALENCE OF ADULT OVERWEIGHT/OBESITY (PERCENT), BY STATE (2010)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW

. No. CentralE. No. CentralNew EnglandM

iddle AtlanticSouth

TOP 10 STATES: LOWEST RATES OF ADULT OVERWEIGHT / OBESITY

Washington, D.C. (1) xHawaii (2) xColorado (3) xUtah (4) xVermont (5) xMassachusetts (6) xNevada (7) xConnecticut (8) xNew Mexico (9) x Oregon (10) xBOTTOM 10 STATES: HIGHEST RATES OF

ADULT OVERWEIGHT/OBESITYAlabama (51) xMississippi (50) xWest Virginia (49) xTennessee (48) xKentucky (47) xSouth Carolina (46) xOklahoma (45) xArkansas (44) xMichigan (43) xTexas (42) x

Adult overweight/ obes ity, 2010

56.3 – 61.3

61.4 – 63.5

63.6 – 65.3

65.4 – 66.5

66.6 – 69.9

7

Alabama (Figure 1). States with the lowest

prevalence of angina and coronary heart

disease and the lowest cardiovascular

mortality rates were primarily in the Pacific,

Mountain, and New England regions

(Figures 5–6). States in these regions also

had among the lowest rates of strokes and

cerebrovascular mortality (Figures 7–8).b

Pacific RegionAlaska and Washington ranked in

the Top 10 for their low prevalence of heart

disease and cardiovascular mortality.

Alaska ranked for its low prevalence of

strokes. Hawaii ranked in the Top 10 for

its low cardiovascular and cerebrovascular

mortality rates; it also had the nation’s

lowest prevalence of heart disease (Figure 1).

b. We also note the

following findings

elsewhere in the country:

The District of Columbia

ranked in the Top 10

on two measures —

low prevalence of heart

disease and low cerebro

vascular mortality.

Minnesota had the

lowest cardiovascular

mortality rate in the

nation, whereas New

York had the lowest

cerebrovascular mortality

rate in the nation.

In the 2010 BRFSS survey, the prevalence

of heart disease ranged almost three-fold

across the states, from 2.3 percent in

Hawaii to 6.0 percent in West Virginia,

and the prevalence of stroke varied from

1.7 percent in Connecticut to 4.7 percent

in Alabama (Figure 1). As with diabetes,

comparing prevalence rates is problematic

because these measures may in fact be

reflecting differences across states in

access to health care and disease screening

rather than true differences in prevalence.

Death rates in 2013 from cardiovascular

disease ranged from 166.5 deaths per

100,000 in Minnesota to 308.3 deaths per

100,000 in Mississippi (Figure 1); cardio-

vascular deaths due to cerebrovascular

disease ranged from 26.3 per 100,000 in

New York to 48.1 deaths per 100,000 in

FIGURE 3DIABETES PREVALENCE (PERCENT), BY STATE (2010)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW


iddle AtlanticSouth

TOP 10 STATES: LOWEST DIABETES PREVALENCE

Alaska (1) x Colorado (2) xUtah (3) xMinnesota (4) xVermont (5) xSouth Dakota (6) xMontana (7) xWisconsin (8) xWyoming (9) x Oregon (10) x

BOTTOM 10 STATES: HIGHEST DIABETES PREVALENCE

Alabama (51) xMississippi (50) xTennessee (49) xWest Virginia (48) xSouth Carolina (47) xOklahoma (46) xFlorida (45) xPennsylvania (44) xLouisiana (43) xOhio (42) x

Diabetes P revalence 2010

5.4 – 7.4

7.5 – 8.5

8.6 – 9.2

9.3 – 10.3

10.4 – 13.5

8

FIGURE 4DIABETES MORTALITY (PER 100,000), BY STATE (2013)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW


iddle AtlanticSouth

TOP 10 STATES: LOWEST DIABETES MORTALIT Y

Massachusetts (1) x Wyoming (2) xNevada (3) xConnecticut (3) xColorado (5) xHawaii (6) xVermont (7) xNew York (8) xWashington, D.C. (9) xVirginia (10) x

BOTTOM 10 STATES: HIGHEST DIABETES MORTALIT Y

West Virginia (51) xMississippi (50) xOklahoma (49) xNew Mexico (48) xLouisiana (47) xIndiana (46) xOhio (45) xUtah (44) xTennessee (43) xAlabama (42) x

Diabetes morta lity per 100,000 2013

14.1 – 18.5

18.6 – 19.7

19.8 – 22.3

22.4 – 24.2

24.3 – 34.1

FIGURE 5PREVALENCE OF ANGINA/CORONARY HEART DISEASE (PERCENT), BY STATE (2010)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW


iddle AtlanticSouth

TOP 10 STATES: LOWEST PREVALENCE OF ANGINA OR CORONARY HEART DISEASE

Hawaii (1) xWashington, D.C. (2) xAlaska (3) xUtah (4) xColorado (5) xWashington (6) xGeorgia (7) xCalifornia (8) xConnecticut (8) x Idaho (10) xBOTTOM 10 STATES: HIGHEST PREVALENCE OF ANGINA OR CORONARY HEART DISEASE

West Virginia (51) xKentucky (50) xAlabama (49) xFlorida (48) xOklahoma (47) xLouisiana (46) xMichigan (45) xMaine (44) xArkansas (43) xTennessee (42) xSee Supplement 1: The Health of the States: Spotlight on

Methods for our protocol for handling tied rankings.

Heart Dis eas e prevalence 2010

2.3 – 3.6

3.7 – 4.0

4.1 – 4.4

4.5 – 4.7

4.8 – 6.0

9

FIGURE 6CARDIOVASCULAR DISEASE MORTALITY (PER 100,000), BY STATE (2013)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW


iddle AtlanticSouth

TOP 10 STATES: LOWEST CARDIOVASCUL AR DISEASE MORTALIT Y

Minnesota (1) xColorado (2) xMassachusetts (3) xHawaii (4) xArizona (5) xAlaska (6) xWashington (7) xNew Hampshire (8) xOregon (9) x New Mexico (10) x

BOTTOM 10 STATES: HIGHEST CARDIOVASCUL AR DISEASE MORTALIT Y

Mississippi (51) xAlabama (50) xOklahoma (49) xArkansas (48) xLouisiana (47) xTennessee (46) xWashington, D.C. (45) xKentucky (44) xWest Virginia (43) xMichigan (42) x

C ardiovas cular mortality per 100,000 2013

166.5 – 192.3

192.4 – 202.7

202.8 – 223.1

223.2 – 254.1

254.2 – 308.3

FIGURE 7PREVALENCE OF STROKE (PERCENT), BY STATE (2010)

CENSUS REGIONS

STATE (Rank)

Pacifi c

Mountain

W. So. Central

W. No. Central

E. No. Central

New England

Middle Atlantic

South

TOP 10 STATES: LOWEST STROKE PREVALENCE

Connecticut (1) xColorado (2) xMinnesota (3) xWyoming (4) xWisconsin (5) xAlaska (6) xMassachusetts (7) xSouth Dakota (8) xNew Hampshire (9) x Utah (10) xVermont (10) x

BOTTOM 10 STATES: HIGHEST STROKE PREVALENCE

Alabama (51) xOklahoma (50) xMississippi (49) xMissouri (48) xSouth Carolina (47) xArkansas (46) xFlorida (45) xKentucky (44) xWest Virginia (43) xTennessee (42) xPercentage of persons age 18 years and older who

reported ever having had a stroke. Top 10 for this

outcome includes 11 states, Bottom 10 includes 10 states.

See Supplement 1: The Health of the States: Spotlight on


S troke prevelance 2010

1.7 – 2.2

2.3 – 2.5

2.6 – 2.8

2.9 – 3.4

3.5 – 4.7

10

and cerebrovascular mortality and stroke

prevalence).

Sixteen states, dominated by Southern and

West South Central states in the “stroke

belt,” ranked in the Bottom 10 for at least

one of the four measures: the prevalence

of heart disease, cardiovascular mortality,

stroke prevalence, or cerebrovascular

mortality. Alabama, Arkansas, Oklahoma,

Tennessee, and Kentucky ranked in the

Bottom 10 on all four measures.c Figure 1

also reveals the following:

• Alabama had the nation’s highest

rates of stroke prevalence and cere-

brovascular mortality, and the second

highest cardiovascular mortality.

c. Michigan, an East North

Central state, ranked

in the Bottom 10 for

its prevalence of heart

disease and cardio

vascular death rate.

Mountain Region Colorado ranked in the Top 10 for three

measures (the low prevalence of heart

disease and strokes and low cardiovascular

mortality), whereas Utah ranked in the

Top 10 for two measures (low prevalence

of heart disease and strokes), as did

Arizona and New Mexico (low cardiovas-

cular and cerebrovascular mortality).

New England Region New England states performed better

around cerebrovascular disease

than cardiovascular disease overall.

Connecticut had the lowest prevalence

of strokes in the nation. New Hampshire

and Massachusetts ranked in the Top

10 on three measures (cardiovascular

FIGURE 8CEREBROVASCULAR MORTALITY (PER 100,000), BY STATE (2013)

CENSUS REGIONS

STATE (Rank)

Pacifi cM

ountainW

. So. CentralW


iddle AtlanticSouth

TOP 10 STATES: LOWEST CEREBROVASCUL AR MORTALIT Y

New York (1) xNew Hampshire (2) xRhode Island (3) xMassachusetts (3) xConnecticut (5) xArizona (6) xNew Mexico (7) xWashington, D.C. (8) xFlorida (9) xVermont (10) x

BOTTOM 10 STATES: HIGHEST CEREBROVASCUL AR MORTALIT Y

Alabama (51) xSouth Carolina (49) xArkansas (49) xMississippi (48) xOklahoma (47) xTennessee (46) xLouisiana (45) xNorth Carolina (44) xKentucky (43) xGeorgia (42) xSee Supplement 1: The Health of the States: Spotlight on


C erebrovascular morta lity per 100,000 2013

26.3 - 32.0

32.1 - 35.5

35.6 - 38.0

38.1 - 41.4

41.5 - 48.1

11

• Mississippi had the nation’s

highest cardiovascular death rate.

It also ranked in the Bottom 10

on stroke prevalence and cerebro-

vascular mortality.

• West Virginia had the nation’s

highest prevalence of heart disease.

It also ranked in the Bottom 10

on stroke prevalence and cardio-

vascular mortality.

• South Carolina ranked in the Bottom

10 on stroke prevalence and cerebro-

vascular mortality.

• Florida ranked in the Bottom 10 only

for the prevalence of heart disease

and stroke but, as noted above,

achieved a Top 10 ranking for low

cerebro vascular morality.

Some geographic patterns were noteworthy

for their discrepancies. For example, some

Pacific states with Top 10 standing for

cardio vascular disease and heart disease

prevalence did not always report the lowest

rates for cerebrovascular disease. As just

noted, Florida reported a high prevalence

of strokes but low stroke mortality. The

neighboring state of Georgia reported a low

prevalence of heart disease but ranked in

the Bottom 10 for its high cerebrovascular

mortality. The District of Columbia —

which ranked in the Top 10 for its low

prevalence of obesity and heart disease,

and its low mortality rates for diabetes and

FIGURE 9

WHAT CORRELATES WITH ADULT OVERWEIGHT/OBESITY? THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS

Physical inactivity (adult) 0.83 Any breastfeeding -0.70

Soda intake (youth) 0.70 Bicycle helmet use (youth) -0.65

Current smokers 0.68 Physical activity (children) -0.54

Sexual activity before age 18 0.55 Fruit intake (youth) -0.53

PHYSICAL AND SOCIAL ENVIRONMENT

Commuting by motor vehicle 0.78 Neighborhood resources for children -0.74

Smokers in household (child present) 0.73 Neighborhoods that

are walkable -0.64

Proximity to parks -0.58

SOCIAL AND ECONOMIC FACTORS

Severe housing disrepair 0.65 Bachelor’s degree/higher -0.68

Poverty (adults) 0.53 Median household income -0.64

Higher educated household head -0.53

HEALTH SYSTEM

Avoidable hospitalization 0.73 Annual dental visit (adult) -0.54

Primary care shortage 0.63

PUBLIC POLICIES AND SPENDING

Unemployment benefits ÷ pop. <100% FPL -0.55

State income support ÷ pop. <100% FPL -0.54

Mass transit spending per capita -0.51

*Correlation coefficients range from zero to 1.0 and measure how strongly one variable correlates with another. Factors on the right (negative coefficients) are inversely related (e.g., one goes up when the other goes down).

High correlations were also noted for other measures of Physical and Social Environment: Neighborhoods that are walkable (rs= -0.58), Commuting by public transit (-0.56); Social and Economic Factors: Poverty (children) (0.59), Residents in very concentrated (>40%) poverty (0.52); and Public Policies and Spending: State/Federal income support ÷ pop. <100% FPL (-0.57); Unemployment benefits ÷ pop. <200% FPL (-0.55), State income support ÷ pop. <200% FPL (-0.54); Public welfare workers ÷ pop. <200% FPL (-0.53).

See Supplement 1: The Health of the States: Spotlight on methods for definitions of terms, data sources, and methods for calculating the correlation coefficients.

x

x

x

xxx

12

cerebrovascular disease, ranked in the

Bottom 10 for cardiovascular mortality.

Although cardiovascular and cerebro-

vascular conditions share many common

risk factors (e.g., smoking, hypertension,

obesity) and would be expected to share

similar geographic patterns, other factors

could explain discrepancies. For example,

geographic differences in cerebrovascular

mortality may be due to the speed with

which stroke victims receive treatment.

Whether these discrepancies reflect a

difference in treatment success rates or in

access to care is unclear.

What correlates the most

with obesity, diabetes, and

cardiovascular conditions?

As reported widely in the literature,

the prevalence of overweight/obesity,

diabetes, and cardiovascular conditions

correlated with unhealthy behaviors

(see Figures 9–15). For example, states

that ranked highly on physical inactivity

had higher rates of overweight/obesity,

diabetes prevalence and mortality, angina/

coronary heart disease, cardiovascular

mortality, strokes, and cerebrovascular

mortality. The prevalence of adult physical

inactivity was 29.4 percent in Bottom 10

states for adult overweight/obesity, com-

pared with 19.7 percent in Top 10 states.

Cigarette smoking also correlated with the

prevalence and mortality rates for these

diseases. For example, the percentage of

FIGURE 10

WHAT CORRELATES WITH DIABETES PREVALENCE? THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS

Physical inactivity (adult) 0.78 Exclusive breastfeeding -0.76

Screen time (youth) 0.65 Bicycle helmet use (youth) -0.66

Sexual activity before age 18 0.58 Fruit intake (youth) -0.59

Soda intake (youth) 0.55 Physical activity (children) -0.59

Current nonsmokers -0.57


Commuting by motor vehicle 0.63 Safe schools (parent report) -0.68

Indoor smoking (child present) 0.57 Neighborhood resources for children -0.67

Dating violence (youth) 0.53 Residents in walkable neighborhoods -0.56



Poverty (children) 0.69 Employment -0.77

Poverty (adults) 0.67 Higher educated household head -0.59

Residents in concentrated (>20%) poverty 0.64 Median household income -0.57

Single-parent households 0.62 Proficient in math (grade 8) -0.53Poor living in concentrated (>20%) poverty 0.61 Bachelor’s degree/higher -0.50

Food insecurity (households) 0.54

Income inequality 0.53

HEALTH SYSTEM

Avoidable hospitalization 0.73 Private insurance -0.61

Could not afford doctor 0.65 Annual dental visit (adult) -0.53

Rehospitalization 0.59 Electronic health record system -0.51

PUBLIC POLICIES AND SPENDINGState income support ÷ pop. <100% FPL -0.53

Libraries (per capita) -0.50


High correlations were also noted for Health Behaviors: Any breastfeeding (rs= -0.69); Physical and Social Environment: Smoke-free homes (-0.54), Commuting by walking/cycling (-0.74), Smoking in home (nonsmokers present) (0.54), Neighborhoods that are walkable (-0.52); Social and Economic Factors: Residents in very concentrated (>40%) poverty (0.56), Children with employed parents (-0.55), Poverty (supplemental def.) (0.51); Health Systems: Rehospitalization (heart failure) (0.60), Rehospitalization (pneumonia) (0.58), Rehospitalization (heart attack) (0.52). Diabetes prevalence correlated with spending on libraries, calculated per capita (rs= -0.50); and Public Policies and Spending: Libraries ÷ pop. <100% FPL (-0.63), Libraries ÷ pop. <200% FPL (-0.59), Social services ÷ pop. <100% FPL (-0.53).


x

x

xx

xx

13

FIGURE 12

WHAT CORRELATES WITH THE PREVALENCE OF ANGINA/CORONARY HEART DISEASE?THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS


Soda intake (youth) 0.64 Sexual abstinence before age 18 -0.52

Current smokers 0.63


Commuting by motor vehicle 0.72 Neighborhood

resources for children -0.68

Distance to parks 0.64 Smoke-free homes -0.66

Residents in walkable neighborhoods -0.53




Employment -0.51

HEALTH SYSTEM

Avoidable hospitalization 0.75



Unemployment benefits ÷ pop. <100% FPL -0.52

*Correlation coefficients range from zero to 1.0 and measure how strongly one variable correlates with another. Factors on the right (negative coefficients) are inversely related (e.g., one goes up when the other goes down.

High correlations were also noted for other measures of Health Behaviors: Ever smokers (rs= 0.61); Physical and Social Environment: Smokers in household (child present) (0.65), Indoor smoking (child present) (0.62), Commuting by walking/cycling (-0.57), Indoor smoking (nonsmokers present) (0.54), Commuting by public transit (-0.54); and Public Policies and Spending: State income support ÷ pop. <200% FPL (-0.51).


x

x

x

x

xx

FIGURE 11

WHAT CORRELATES WITH DIABETES MORTALITY? THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS

Physical inactivity (adult) 0.54


Commuting by motor vehicle 0.63 Neighborhood

resources for children -0.62

Childhood trauma 0.60 Residents in walkable neighborhoods -0.60

Smokers in household (child present) 0.51



Residents in concentrated (>20%) poverty 0.62 Bachelor’s degree/higher -0.73

Severe housing disrepair 0.59 Employment -0.60

Food insecurity (households) 0.51 Higher educated

household head -0.56

Proficient in reading (grade 4) -0.51

HEALTH SYSTEM

Primary care shortage 0.68 Annual dental visit (adult) -0.58

Could not afford doctor 0.62 Private insurance -0.54


Unemployment benefits ÷ pop. <100% -0.62


Public welfare workers ÷ pop. <100% FPL -0.55


High correlations were also noted for other measures of Physical and Social Environment: Neighborhoods that are walkable (rs= -0.58), Commuting by public transit (-0.56); Social and Economic Factors: Poverty (children) (0.59), Residents in very concentrated (>40%) poverty (0.52); and Public Policies and Spending: State/Federal income support ÷ pop. <100% FPL (-0.57); Unemployment benefits ÷ pop. <200% FPL (-0.55), State income support ÷ pop. <200% FPL (-0.54); Public welfare workers ÷ pop. <200% FPL (-0.53).


x

x

x

xxx

14

adults who were current smokers was

21.7 percent in Bottom 10 states for high

rates of angina/coronary heart disease,

compared with 14.9 percent in Top 10

states with low heart disease rates.

But states with higher disease rates

were also places where other unhealthy

behaviors were more common. For

example, in these states, women were

less likely to breastfeed, and children

and teens had unhealthier diets (e.g.,

less fruit, more soda), were less likely

to be physically active, and became

sexually active at an earlier age. These

associations do not necessarily reflect

causal relationships but rather a pattern

of co-occurrence, where conditions “go

together” at the state level. States where

people often engage in a behavior that

causes one disease may also rank highly

on behaviors that cause other diseases

or injuries.

States where unhealthy behaviors

were more prevalent were also more

likely to have unhealthier physical

environments, which also correlated

highly with obesity, diabetes, and

cardiovascular diseases.3 For example,

as seen in Figures 9–15, states where

more residents commuted to work by

motor vehicle (rather than by walking,

cycling, or public transportation) had a

higher prevalence of overweight/obesity,

diabetes, angina/coronary heart disease,

and strokes, as well as higher diabetes,

cardiovascular, and cerebrovascular

mortality. Conversely, these conditions

FIGURE 13

WHAT CORRELATES WITH CARDIOVASCULAR MORTALITY?THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS


Current smokers 0.69 Bicycle helmet use (youth) -0.66

Soda intake (youth) 0.58 Fruit intake (youth) -0.60

Sexual abstinence before age 18 -0.54


Indoor smoking (child present) 0.77 Neighborhood resources for children -0.52


Air pollution 0.50


Poverty (adults) 0.64 Proficient in math (grade 8) -0.55

Residents in concentrated (>20%) poverty 0.62 Median household income -0.55

Poor living in concentrated (>20%) poverty 0.58 Bachelor’s degree/higher -0.55

Single-parent households 0.51 Higher educated household head -0.55

Severe housing disrepair 0.50 Employment -0.50

HEALTH SYSTEM

Avoidable hospitalization 0.75 Can afford doctor -0.52

Primary care shortage 0.59 Electronic health record system -0.51

Rehospitalization (heart failure) 0.59


High correlations were also noted for other measures of Health Behaviors: Exclusive breastfeeding (rs= -0.69); Physical and Social Environment: Indoor smoking (nonsmokers present) (0.63), Smokers in household (child present) (0.62), Commuting by walking/cycling (-0.60); Social and Economic Factors: Poverty (children) (0.63), Residents in very concentrated (>40%) poverty (0.59), Proficient in math (grade 4) (-0.52); and Health Systems: Rehospitalization (pneumonia) (0.54), Rehospitalization (0.52).


x

x

x

15

FIGURE 14

WHAT CORRELATES WITH THE PREVALENCE OF STROKES?THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS

Physical inactivity (adult) 0.71 Exclusive breastfeeding -0.67

Sexual activity before age 18 0.69 Bicycle helmet use (youth) -0.67

Current smokers 0.65 Fruit intake (youth) -0.62

Soda intake (youth) 0.58 Physical activity (children) -0.56

Birth control (youth) -0.50



Smokers in household (child present) 0.60 Neighborhood resources

for children -0.64

Childhood trauma 0.60 Residents in walkable neighborhoods -0.60



Poverty (children) 0.76 Employment -0.72

Poverty (adults) 0.74 Median household income -0.69Residents in concentrated (>20%) poverty 0.69 Higher educated


Single-parent households 0.59 Proficient in math (grade8) -0.63Poor living in concentrated (>20%) poverty 0.59 Bachelor’s degree/higher -0.57

Food insecurity (households) 0.58

Adults in prison 0.51

HEALTH SYSTEM

Avoidable hospitalization 0.60 Private insurance -0.66

Could not afford doctor 0.59 Annual dental visit (adult) -0.64

PUBLIC POLICIES AND SPENDINGState income support ÷ pop. <100% FPL -0.61Federal public assistance ÷ pop. <100% FPL -0.53Public welfare workers ÷ pop. <100% FPL -0.53


High correlations were also noted for other measures of Health Behaviors: Any breastfeeding (rs= -0.64); Physical and Social Environment: Commuting by walking/cycling (-0.64), Indoor smoking (child present) (0.57), Neighborhoods that are walkable (-0.57), Smoke-free homes (-0.56), Indoor smoking (nonsmokers present) (0.53); Social and Economic Factors: Proficient in reading (grade 8) (-0.59), Proficient in math (grade 4) (-0.56), Children with employed parents (-0.55); Health Systems: Public insurance (0.53); and Public Policies and Spending: State income support ÷ pop. <200% FPL (-0.57); State/Federal income support ÷ pop. <100% FPL (-0.52); Federal public assistance ÷ pop. <200% FPL (-0.51). Prevalence correlated with spending on libraries, calculated per capita (-0.48).

x

x

xx

xxx

FIGURE 15

WHAT CORRELATES WITH CEREBROVASCULAR MORTALITY?THE CORRELATION COEFFICIENTS (rs)*

HEALTH BEHAVIORS

Current smokers 0.67 Bicycle helmet use (youth) -0.56


Soda intake (youth) 0.61

Sexual activity before age 18 0.60


Commuting by motor vehicle 0.65 Neighborhoods that

are walkable -0.67

Smokers in household (child present) 0.63 Neighborhood resources

for children -0.66



Adults in prison 0.56 Median household income -0.60

Food insecurity (households) 0.51 Higher educated


Poverty (adults) 0.50

HEALTH SYSTEM

Primary care shortage 0.74 Annual dental visit (adult) -0.61

Avoidable hospitalization 0.52 Could afford doctor -0.60


Tobacco taxes -0.64

Medicaid eligibility limits -0.59


Unemployment benefits ÷ pop. <100% -0.50


High correlations were also noted for other measures of Physical and Social Environment: Residents in walkable neighborhoods (rs= -0.68), Commuting by walking/cycling (-0.58), Indoor smoking (child present) (0.53), Commuting by public transit (-0.50); and Public Policies and Spending: Medicaid eligibility (other) (-0.58), State/Federal income support ÷ pop. <100% FPL (-0.50).


xx

x

xxxx

16

In Bottom 10 states (with high stroke rates),

17.2 percent of the population could not

afford their doctor, compared with 10.2

percent in Top 10 states with the lowest

stroke rates. States with high rates of

avoidable hospitalizations — suggesting

inadequate primary care — ranked higher

on overweight/obesity, diabetes, angina/

coronary heart disease, cardiovascular

mortality, strokes, and cerebrovascular

mortality (see Figure 17). Rates for hospital

readmissions within 30 days — also

suggesting inadequate outpatient disease

management — also correlated with

diabetes prevalence and cardiovascular

mortality. There were fewer annual dental

visits in these states, another marker

for inadequate access to health care.

Diabetes and strokes were more common

in states where residents lacked private

health insurance and where more patients

reported being unable to afford their

doctor (Figures 10 and 13).

Socioeconomic conditions are

a powerful explanatory factor for these

correlations.3 State rankings for obesity,

diabetes, and cardiovascular conditions

correlated very highly with a variety

of measures of employment, income, and

education (Figures 9–15). For example,

in Top 10 states for low diabetes mortality,

more than one out of four adults (26.0

percent) had a Bachelor’s degree or higher,

compared with 16.6 percent in Bottom

10 states. In states where the prevalence

were less common in states where residents

had less exposure to secondhand smoke

at home, a healthier built environment, and

more walkable neighborhoods.

For example, in Top 10 states (with

low rates of adult overweight/obesity),

walkable neighborhoods were more than

five times more prevalent than in Bottom

10 states, commuting by public transpor-

tation was almost 10 times more common,

and access to parks was more than twice as

great (Figure 16). As reported elsewhere,4,5

air pollution may also matter; state rank-

ings for fine particulate matter correlated

with cardiovascular mortality rates.

The indicators available in our data

suggest that the social environment

may also be unhealthier in states where

cardiovascular diseases were more common.

School safety as perceived by parents

was poorer in states with higher rates

of diabetes (Figure 10), cardiovascular

mortality (Figure 13), and strokes (Figure 14).

In states with high rates of diabetes,

teens were more likely to report intimate

partner violence. States with high rates of

stroke had more children exposed to adverse

childhood events. Potential causal pathways

are likely complex, including unobserved

factors and bidirectional relationships.

Access to health care was also poorer

in states with higher rates of obesity,

diabetes, and cardiovascular conditions.

Primary care shortages were more

common, and care was less affordable.

A W

ORD

ABO

UT M

ETHO

DS We examined how strongly

health outcomes correlated

with state statistics in five

domains that shape health:

health behaviors, the physical

and social environment, social

and economic factors, health

care, and public policies and

spending. The results, presented

in Figures 9 to 15, are based

on Spearman rank-order

correlation coefficients (rs),

which measure the degree to

which the state ranking for the

indicator (e.g., poverty) matches

the state ranking for the health

outcome (e.g., infant mortality).

Zero represents no association

between the two rankings, and

1.0 represents an exact match.

A positive correlation means

that a high rank on the indicator

is linked to a high rank on the

health outcome, or vice versa;

a negative correlation means

that a high rank on the indicator

is linked to a low rank on the

health outcome, or vice versa.

See Supplement 1: The Health of

the States: Spotlight on methods2

for more details on data sources

and methods and the rationale

for omitting certain results from

this report.

17

0

5

10

15

20

25

3.3%

11.2%

Stroke prevalence

3.1%

19.6%

Cerebrovascular mortality

4.2%

19.9%

Diabetes mortality

5.7%

9.6%

Diabetes prevalence

3%

16.7%

Adult overweight and obesity

FIGURE 16BUILT ENVIRONMENT IN TOP 10 AND BOTTOM 10 STATES FOR WALKABLE NEIGHBORHOODS (%)

Top 10 states (lowest disease rates)

Bottom 10 states (highest disease rates)

0

4

2

6

8

10

12

0.1%

8.9%


0.9%

7%

Angina or CHD* prevalence

0.1%

9.9%

Diabetes mortality

0.8%

7.4%


FIGURE 16.2BUILT ENVIRONMENT IN TOP 10 AND BOTTOM 10 STATES FOR COMMUTING BY PUBLIC TRANSIT (%)



0

20

10

30

40

50

60

19.8%

39.1%


*CHD = coronary heart disease

21.1%

50.1%

Angina or CHD* prevalence

22.7%

43.2%

Diabetes prevalence

20.3%

49.4%


FIGURE 16.3BUILT ENVIRONMENT IN TOP 10 AND BOTTOM 10 STATES FOR PROXIMITY TO PARKS (% WITHIN HALF MILE)



18

was 17.0 percent, compared with 10.8

percent in Top 10 states.

The convergence of household poverty

and area poverty was a particularly strong

predictor of these diseases. For example,

in Bottom 10 states with the highest

prevalence of strokes, 32.3 percent of the

and mortality rates from these diseases

were high, there were also very high

rates of household poverty, concentrated

neighborhood poverty, single-parent

households, and poor housing conditions.

For example, in Bottom 10 states with the

highest rates of strokes, the poverty rate

FIGURE 17AVOIDABLE HOSPITALIZATIONS IN TOP 10 AND BOTTOM 10 STATES (DISCHARGES PER 1,000) Bottom 10 states (highest disease rates)


0

20

40

60

80

50.3%

83.3%

Cardiovascular mortality

48.7%

81.2%

Heart attack prevalence

51.5%

80.2%

Diabetes prevalence

50.2%

82.0%

Adult overweight/obesity prevalence

$0

1K

2K

3K

$943

$2,255

Stroke prevalence

$920

$2,120


$1,083

$2,162

Heart attack prevalence

$1,148

$2,253

Diabetes mortality

$1,018

$2,206


FIGURE 18INCOME SUPPORT PER CAPITA FOR PERSONS IN/NEAR POVERTY (INCOME LESS THAN 200% FPL) IN TOP 10 AND BOTTOM 10 STATES



19

tax rates for tobacco and broader Medicaid

eligibilitye (Figure 15). The tobacco tax

was $2.68 per pack in Top 10 states with

the lowest cerebrovascular mortality

rates, more than four times the tax rate

in Bottom 10 states ($0.63 per pack);

Medicaid eligibility was 142.3 percent

and 65.9 percent of the Federal poverty

level, respectively. As seen in Figures

9–15, disease rates were often highest

in states that spent less (per poor person)

on services such as unemployment

benefits, income support, public assistance,

and social service workers. The Top 10

states spent twice that of Bottom 10 states

per capita on income support relative

to the size of the population in/near

poverty (earning less than 200 percent

of the poverty level) (Figure 18).

e. Refers to states’ Med

icaid income eligibility

limits for adultsparents

of dependent children

and other nondisabled

adults as a percent of

the Federal poverty

level, as of August 2014.

population lived in areas of concentrated

poverty,d more than twice that of Top 10

states (12.6 percent); the corresponding

percentages for poor residents living in

concentrated poverty were 55.0 percent

and 33.6 percent, respectively. Food

insecurity was more common in states

with higher rates of diabetes prevalence

and mortality (Figures 10–11), strokes

(Figure 14), and cerebrovascular mortality

(Figure 15). Adult incarceration was

also higher in states with higher rates of

strokes and cerebrovascular mortality.

States’ policies also correlated with

these conditions. For example, states

with lower rates of overweight and

obesity spent more per capita on mass

transit (Figure 9), and states with lower

cerebrovascular mortality had higher

d. Concentrated poverty is

defined as 20 percent or

more of the area popula

tion living with incomes

below the Federal

poverty level.

What The Data Affirm: The Takeaway

Obesity, diabetes, and cardiovascular disease — which together account

for enormous health burden and cost in the United States — are influenced

heavily by individual behaviors, such as lack of exercise and smoking.

But these conditions occur more commonly in places where residents live

in an unhealthy and unsafe environment, struggle with socioeconomic

challenges, and lack health insurance and access to affordable primary care.

The bottom line? The epidemics of obesity, diabetes, and heart disease

are not the result of unhealthy lifestyles alone; they are less common in

states and communities that offer better economic conditions for families,

better educational outcomes for children, widespread access to health care,

and communities and neighborhoods designed to encourage — and remove

barriers to — healthy living.

20

.

1. Woolf SH, Aron L, Chapman DA, et al. The

Health of the States: How U.S. States Compare

in Health Status and the Factors that Shape

Health—Summary Report. Richmond, VA: Center

on Society and Health, Virginia Commonwealth

University, 2016.

2. Woolf SH, Aron L, Chapman DA, et al. The Health

of the States: How U.S. States Compare in Health

Status and the Factors that Shape Health—

Spotlight on Methods. Richmond, VA: Center

on Society and Health, Virginia Commonwealth

University, 2016.

3. Krueger PM, Tran MK, Hummer RA, Chang VW.

Mortality attributable to low levels of education in

the United States. PLoS One. 2015;10:e0131809.

4. Brook RD, Rajagopalan S, Pope CA III., et al.

Particulate matter air pollution and cardiovascular

disease: an update to the scientific statement

from the American Heart Association. Circulation

2010;121:23312378.

5. Kaufman JD, Adar SD, Allen RW, et al.

Prospective study of particulate air pollution

exposures, subclinical atherosclerosis, and clinical

cardiovascular disease: The MultiEthnic Study of

Atherosclerosis and Air Pollution (MESA Air). Am J

Epidemiol. 2012;176:82537.

References

21

Will Monson, Rolf Pendall, Bryce Peterson,

Kathryn Pettit, Molly Scott, and Janine Zweig.

We also thank Stephanie Zaza, Centers

for Disease Control and Prevention, for

assistance in accessing data from the Youth

Risk Behavior Surveillance System (YRBSS)

and Robert Johnson, Vanderbilt University,

for biostatistical consulting. Other col-

leagues who gave us advice included Oscar

Arevalo, Nicklaus Children’s Hospital;

Elizabeth Bradley, Yale University; Ichiro

Kawachi, Harvard School of Public Health;

Matthew Penn, Public Health Law Program,

Centers for Disease Control and Prevention;

Robert Phillips, Jr., American Board of

Family Medicine; Christopher B. Swanson,

Editorial Projects in Education; Daniel

Taber, University of Texas Health Science

Center at Houston, School of Public Health;

Alan Ellis, Joseph Morrissey, and Kathleen

Thomas, University of North Carolina

Cecil G. Sheps Center for Health Services

Research; and Angela Kimball, National

Alliance on Mental Illness.

FUNDING

This project was funded by grant

number 71508 from the Robert Wood

Johnson Foundation.

Although any errors or omissions are

those of the authors only, we would like to

thank our Expert Advisory Panel, which

included Nancy Adler, Paula Braveman,

Debbie Chang, Ana Diez Roux, Neal

Halfon, David Kindig, Anna Schenck, and

Jonathan Showstack. We also appreciate

the advice we received from the staff of

the Robert Wood Johnson Foundation,

notably Matthew Trujillo, who served as

our program officer, and his predecessor,

Herminia Palacio.

We thank our colleagues at Virginia

Commonwealth University for their roles

in this study, including Sarah Blackburn

and Cassandra Ellison for graphic design,

layout, and dissemination of this report,

Lauren Waaland-Kreutzer for data verifi-

cation, and Jill Hellman, for administrative

support. We also thank Allison Phillips for

managing the first phases of this project

and Steven Cohen for providing advice on

demographic research methods.

We thank our colleagues at the Urban

Institute, especially Julia Isaacs for guiding

our analysis of spending data, but also

William Adams, Nan Astone, Richard

Auxier, Maeve Gearing, Linda Giannarelli,

Chris Hayes, Olivia Healy, Carl Hedman,

Carrie Heller, Ryan King, Carlos Martin,

Acknowledgments

This report is one of a series produced, in partnership with the Urban Institute, as part

of the Health of the States project — an initiative funded by the Robert Wood

Johnson Foundation (grant number 71508). For more information on the project, and

to view other reports in the series, visit societyhealth.vcu.edu.

Virginia Commonwealth University

VCU Center on Society and Health

[email protected]

830 East Main Street, Suite 5035

P.O. Box 980212

Richmond, Virginia 23298-0212

(804) 6282462

© Virginia Commonwealth University

Center on Society and Health, 2017

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