Chronic diseases long-lasting illnesses, such as asthma, cancer, diabetes, diabetes. Cancer and diabetes were the next most prevalent with 8 …

The Burden of Chronic Disease in Fresno
Final Report
May 31, 2006

WP06-2 Primary Authors: P Hughes-Cromwick H Mull M Shaheen

The Burden of Chronic Disease in Fresno
Final Report
May 31, 2006

Prepared for Americas Pharmaceutical Companies

Altarum 3520 Green Court, Suite 300 Ann Arbor, Michigan 48105 734 302-4600
Corporate Headquarters 734 302 4600 Alexandria, VA 703 575 1200 San Antonio, TX 210 832 3000

Table of Contents
10 Executive Summary 1

Introduction 4

Chronic Disease in Fresno, CA 5 31 32 33 Key Findings on Prevalence and the Burden of Chronic Disease 5 Prevalence in Fresno Compared to the US 7 Prevalence by Disease 9 331 332 333 334 335 34 341 342 343 344 345 Cardiovascular Disease 9 Cancer 11 Diabetes 13 Asthma 13 Mental Illness 14 Cardiovascular Disease 15 Diabetes 15 Asthma 18 Cancer 19 Mental Illness 20

Chronic Disease Burden by Disease 15

Looking to the Future: Changing Behaviors to Improve Health 22 41 42 43 44 Obesity 23 Exercise 24 Smoking 24 Use of Preventive Health Care 25

Conclusions 27

References 28

Appendix: Data Sources and Methodology 35 71 Behavioral Risk Factor Surveillance System 35

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Chronic Disease in Fresno

72 73 74 75 76 77 78 79

California Center for Health Statistics Vital Statistics Query System 36 California Department of Health Services 36 California Health Interview Survey CHIS 36 Medical Expenditure Panel Survey MEPS 38 National Center for Chronic Disease Prevention and Health Promotion: Cardiovascular Health CVH 38 National Health Interview Survey 38 United States Census Data 39 Prevalence Rates Cost Estimates 39

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List of Figures
Figure 3-1: Prevalence of Chronic Disease in Fresno County CHIS, 2003 5 Figure 3-2: Deaths from Chronic Disease in Fresno County CA VS, 2005 6 Figure 3-3: Total Cost of Chronic Disease in Fresno County 7 Figure 3-4: Prevalence of Chronic Disease in the United States AHA, 2006; NCHS, 2006; ADA, 2006; NCHS, 2003; NIMH, 2006 8 Figure 3-5: Comparison of Chronic Disease Prevalence in Fresno, CA and the US AHA, NCHS, ADA, NIH, NIMH, CHIS 8 Figure 3-6: Census Information on Fresno City, Fresno County, CA and the US Census 9 Figure 3-7: National Prevalence of Heart Attack Among Americans Over Age 20 by Select Characteristics HealthyPeople, Heart Disease 10 Figure 3-8:
Prevalence of High Blood Pressure in Fresno County and CA by Race/Ethnicity CHIS, 2003 10 Figure 3-9: National Prevalence of Cancer by Select Characteristics CDC NHIS 12 Figure 3-10: Self-Reported Prevalence of Fresno Residents Who Do Not Use Cancer Screens CHIS 2003 12 Figure 3-11: National Prevalence of Diabetes by Select Characteristics CDC BRFSS 13 Figure 3-12: Prevalence of Asthma in Fresno, CA by Select Characteristics CHIS, 2003 14 Figure 3-13: National Direct Costs for Diabetes by Health Service Used ADA 2003 16 Figure 3-14: National Rates of Functional Disability Among Depressed and/or Patients with Diabetes Egede, 2004 17 Figure 3-15: Feelings of Parents Whose Children Have or Had Cancer Boman, 2003 19 Figure 4-1: Self-Reported Prevalence of Unhealthy Behavior in Fresno County CHIS, 2003 23 Figure 4-2: Prevalence of Overweight and Obesity in Fresno County by Age CHIS, 2003 23 Figure 4-3: Self-Reported Prevalence of Fresno Residents Who Do Not Use Cancer Screens CHIS, 2003 25

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10 Executive Summary
Chronic diseases long-lasting illnesses, such as asthma, cancer, diabetes, cardiovascular disease, and depression
impose a great burden on the Fresno community Together they comprise Fresnos number one health threat and the single greatest cause of death and disability Yet, many chronic diseases are preventable through changes in behavior This report, The Burden of Chronic Disease in Fresno, outlines the impact of chronic diseases in Fresno and how unhealthy behaviors are contributing to the crisisa Here are some of the highlights from the report: Chronic diseases directly affect one of three Fresno County residents Chronic illnesses affect a significant portion of people living in Fresno County Approximately 301,000 people or about one of three Fresnans 35 have been diagnosed with at least one chronic disease Cardiovascular diseases CVD are among the most prevalent chronic diseases in Fresno: More than one-quarter 27 of Fresnans or 160,000 people have a diagnosed cardiovascular disease or condition Asthma is the next most commonly diagnosed chronic condition, with about 15 or 126,000 residents affected Cancer affects 8 of Fresnans or 47,000 people About 7 of Fresnans or 44,000 residents have been diagnosed with diabetes

Chronic diseases affect many more Fresno area residents
indirectly The number of people burdened by chronic disease extends beyond those who actually have a diagnosed disease or condition themselves In reality, entire families are affected when one member has a chronic disease In the Fresno area, four out of five families 79 have at least one family member with a chronic disease

The total prevalence of chronic illness is likely much more than 301,000 people because many people with chronic diseases are unaware they have them The true prevalence of chronic disease in the Fresno area is difficult to estimate because it includes not only people who have been diagnosed with a disease ie, 301,000 people but also those people who are undiagnosed or are unaware they have a chronic disease

The Burden of Chronic Disease in Fresno was prepared for Americas Pharmaceutical Companies For a copy of the full report, visit wwwHealthyFresnoorg

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A US government survey, which looks at national data, estimates that nearly one-third 31 of people with diabetes do not know they have it If the rate of undiagnosed diabetes in Fresno is similar to the rest of the US, as many as 9,800 people in the
Fresno area may be living with undiagnosed diabetes

Each of the five chronic conditions examined in this report are believed by experts to be under-diagnosed and under-treated, according to multiple health studies and health experts Fresno has higher rates of asthma and cancer than the rest of the US Rates of diagnosed diabetes are about the same as elsewhere in the US, while rates of CVD and mental health problems are lower It should be noted, however, that undiagnosed conditions may be present, and originate from lack of access to health providers who can diagnose conditions and low health literacy Additionally, mental illnesses are often under-diagnosed by health providers Chronic diseases kill about 3,500 people per year in Fresno Chronic diseases pose a greater threat to the lives of Fresnans than any other health problem or safety issue Of all chronic diseases, cardiovascular diseases CVD cause the most deaths: Every year about 2,200 Fresnans die from heart attacks or strokes Cancer is the second leading cause of death in Fresno, killing about 1,100 per year Diabetes kills more than 190 Fresnans every year

Chronic diseases affect the quality of life of many more Chronic
diseases have a great impact on a persons ability to lead a normal life and perform in work or school For example: Asthma is the number one cause of missed school days among children in the US Diabetes is the leading cause of non-injury blindness and is responsible for 150 amputations per day in the US The burden of living with CVD is so great that close to half of patients are willing to sacrifice years of life to obtain a higher quality of life Major depression is the leading cause of disability among adults in developed nations; it is a leading cause of absenteeism and diminished productivity in the workplace

Chronic diseases cost the Fresno community 2 billion dollars every year Chronic diseases place an enormous burden on patients and their families, both emotionally and economically But the impact of chronic diseases does not stop

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there; it reaches the wider community and economy in many ways, primarily the health care and employment systems Chronic disease imposes a steep cost on the Fresno community: Every year, approximately 2 billion dollars is spent on chronic disease These costs include direct expenditures,
such as the amount of money spent on health care bills associated with chronic diseases They also include indirect costs, such as the amount of lost productivity and economic activity associated with loss of life and disability related to chronic disease

If Fresnans improved their health behaviors, they could reduce the burden of chronic disease in their community Right now, too many Fresnans are not taking advantage of all the ways they can protect and promote their health Fresno County residents self report many poor health behaviors that put them at risk for chronic disease: Almost one-fifth 17 of the population smokes; About three in ten 31 get no exercise; More than one out of three 37 is obese; and Many Fresnans also fail to get adequate preventive health care

Though the burden of chronic disease in Fresno is high, there is hope and opportunity If more people practiced healthy behaviors and increased their awareness of chronic disease symptoms and treatment, the burden of disease could be significantly lowered In Fresno County, if all residents practiced healthy behaviors, more than 188,000 people currently suffering from chronic disease could be living healthier
lives About 2,800 deaths could be prevented every year

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20 Introduction
Chronic diseases long-lasting illnesses, such as asthma, cancer, diabetes, heart disease and depression are the leading causes of death and disability in the United States Chronic diseases affect the quality of life of 90 million Americans and are responsible for seven out of every ten deaths in the US killing more than 17 million Americans every year24 Chronic illnesses place an enormous burden on patients and their families, both emotionally and economically They influence a persons ability to lead a normal lifestyle, and are associated with lower quality of life, and reduced civic participation and educational attainment, among other things But the impact of chronic diseases does not stop there; it reaches the wider community and economy in many ways, primarily through the health care and employment systems Chronic diseases are one of the main drivers behind the use of health care services in the US As the Centers for Disease Control CDC has warned, The United States cannot effectively address escalating health care costs without addressing the
problem of chronic diseases Of every dollar the nation spends on health care, more than 75 cents is spent on medical care for people with chronic illness Chronic diseases are also the number one cause of lost productivity in the workplace and missed workdays In the US, the direct and indirect costs of chronic disease are estimated to total more than 800 billion each yearb In the Fresno, California area the community evaluated in this report the burden of chronic disease is especially profound These conditions are widely prevalent and extremely costly Although current health status in Fresno is poor, especially for those with chronic conditions, much can be done both at the individual and community level to reduce the burden of chronic disease Health behaviors and low health literacy, two of the major contributors to these illnesses, are factors that can be modified But change will not occur unless residents have the resources and support to make the right decisions for their health, and unless community institutions, such as local government and businesses, schools and employers, step forward to support residents as they strive to lead healthier lives With the right
information, resources, and support, residents in Fresno can start to make better decisions for their health, reduce the burden of chronic disease in their community, and dramatically improve their overall health and well-being

Please see Appendix for information regarding cost and prevalence estimates, and data sources

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30 Chronic Disease in Fresno, CA
31 Key Findings on Prevalence and the Burden of Chronic Disease
Approximately 301,000 individuals living in Fresno County, or about one out of every three residents 347, have been diagnosed with at least one major chronic disease25, 75 But it isnt only people with the disease who are affected Chronic diseases affect the lives of the approximately four out of five families 785 in the Fresno area who have at least one family member suffering from a chronic diseasec Cardiovascular diseases such as heart disease and stroke, diabetes, and cancer, are among the most prevalent, costly, and preventable of all health problems, according to the CDC Asthma and mental health problems such as depression, also pose major problems to many Americans, but can often be managed with appropriate
treatment Among these five major chronic diseases, which are the focus of the discussion in this report, cardiovascular disease CVD is, by far, the most prevalent diagnosed chronic condition in Fresnod Almost one-third of adults 27 or about 160,000 people experience some form of the disease see Figure 3-1 Asthma is the next most common diagnosed condition, with about 15 or 126,000 residents including children being affected Cancer and diabetes were the next most prevalent with 8 and 75 of adults diagnosed respectively Mental illness was the least diagnosed of the conditions studied, with approximately 31,000 people seeing a mental health professional
Figure 3-1: Prevalence of Chronic Disease in Fresno County75
Fresno Co, CA Chronic Disease Prevalence
180,000 150,000 120,000 90,000 60,000 30,000 CVD Cancer Diabetes Asthma Mental Illness 47,000 44,000 31,000 159,905 126,000

c d

Based on national estimates, scaled by local data Please see appendix for methods Cardiovascular disease includes heart disease, hypertension and stroke unless otherwise noted

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The total prevalence of chronic disease in Fresno is likely to be much
higher than this because many people with chronic diseases are unaware they have them Total prevalence of chronic disease is difficult to estimate because it includes not only people who have been diagnosed with the condition the numbers referenced above, but also undiagnosed people those who have a chronic disease but do not know they have it It is very difficult to know how many residents have conditions or diseases but have not been diagnosed A US government survey, which looks at national data, estimates that nearly one third 31 of people with diabetes do not know they have it31 If the rate of undiagnosed diabetes in Fresno is similar to the rest of the US, as many as 9,800 people in the Fresno area may be living with undiagnosed diabetes The chronic conditions examined in this report are believed by experts to be underdiagnosed and under-treated, according to multiple health studies31, 57, 83 Two primary reasons account for undiagnosed chronic disease lack of access to a health care provider who would make the diagnosis, and poor health literacy that hinders the decision to seek health care for disease symptoms or to get screened to detect disease at an appropriately early
stage It is quite plausible that both factors are present in Fresno Nearly one in five 184 of Fresno-area adults do not have health care coverage, and may have very limited access to care75 Prevalence numbers in this report, therefore, can be considered lower bounds Chronic diseases kill about 3,500 people per year in Fresno, and CVD is the most deadly In 2005, 2,202 residents of Fresno County died of heart disease or stroke, the leading causes of death for CVD See Figure 3-2 Cancer, the second-leading killer with 1,096 deaths, and CVD accounted for more than two-thirds of the deaths from chronic disease Diabetes accounted for 194 known deaths, although deaths from diabetes are frequently attributed to cardiovascular disease21 Although asthma does not carry a great risk of death, it imposes a substantial burden on the quality of life
Figure 3-2: Deaths from Chronic Disease in Fresno County21
Fresno Co, CA Chronic Disease Deaths
2,500 2,000 1,500 1,000 500 Heart Cancer Disease/Stroke Diabetes Asthma 194 9 1,096 2,202

Chronic diseases limit the ability of Fresnans to lead normal lives, be productive in the school and workplace, and engage in the community In Fresno County, 38
of

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children have a health condition that limits their activities and 74 of adults have a physical or mental health problem that impairs their ability to work75 Fresno could reap substantial benefits from reducing the incidence of chronic disease, chronic disease disabilities, and deaths The benefits to Fresno residents in terms of their health and quality of life would be enormous; the wider community would benefit, as well Using national data to estimate disease cost, Fresno incurs approximately 2 billion in direct and indirect costs due to chronic disease see Figure 3-3e Reducing the burden of chronic disease would free resources that can better serve the health and other needs of the Fresno community While changing behaviors and improving health literacy is not free, the Centers for Disease Control has outlined the cost-effectiveness of a range of different prevention efforts including smoking cessation and arthritis self-help programs, providing Pap smears for lowincome women and greater use of mammograms among older women, among others, which yield savings in terms of improved longevity and quality of life, as well as
reduced health expenditures
Figure 3-3: Total Cost of Chronic Disease in Fresno County
Total Cost of Chronic Disease Burden in Fresno Co, CA in Millions
1,200 1,000 800 600 400 200 CVD Cancer Diabetes Asthma Depression 496 307 203 151

994

Prevalence in Fresno Compared to the US
National sources indicate that CVD is both the most prevalent chronic disease and the leading cause of death in the country CVD affects about 71 million Americans and kills about 240,000 per year9 Cancer, diabetes, and depression each affect about 20 million Americans and asthma about 11 million see Figure 3-4 Cancer remains the second leading cause of death, killing about 200,000 Americans every year; diabetes, depression and asthma have lower rates of mortality, killing about 186,000, 30,000 and 4,000 people respectively each year7, 78 Diabetes is growing more prevalent over time; the percentage of people with diagnosed diabetes is expected to more than double by the year 205018

Please see the appendix for information on the methods used to estimate Fresno area costs and prevalence

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Figure 3-4: Prevalence of Chronic Disease in the United
States6, 9, 24, 68
US Population with Disease in Millions
80 70 60 50 40 30 20 10 CVD Cancer Diabetes Asthma Depression 20 21 11 19 71

In Fresno, diagnosed asthma is considerably higher than the rest of the US Rates of cancer and diabetes are also slightly higher in Fresno than in the US Rates of CVD and diagnosed mental illness are lower in Fresno than in the US see Figure 3-5
Figure 3-5: Comparison of Chronic Disease Prevalence in Fresno, CA and the US6, 9, 24, 68, 75
Comparison of Chronic Disease Prevalence in Fresno Co and the US
350 300 250 200 150 100 50 00 CVD Cancer Diabetes Asthma Mental Illness Fresno Disease Rates National Disease Rates

The differences in disease prevalence in Fresno and the US could be explained in many ways National data may use different survey questions compared to local data or rely on self-reported rates of disease as compared to physician diagnosis Undiagnosed disease is certainly present in Fresno, CA, and this compounds the differences in diagnosed disease prevalence Fresnans without access to care will most certainly have a lower chance of diagnosis for chronic, often initially asymptomatic, conditions Similarly, a variety of factors lead to
under-diagnosis of mental illnesses, including lack of access to care and the negative stigma associated with some mental illnesses

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When mental illness occurs in conjunction with physical illness, it is often overshadowed and untreated It is likely that many people in Fresno are living with mental illness who have never been diagnosed by a health professional Numerous health services research studies have shown that certain characteristics, such as being a member of a traditionally underserved racial or ethnic minority group, are associated with greater levels of heart disease, diabetes, and asthma These relative differences in disease burden are called health disparities Fresno is a largely Hispanic community Nationally, 125 of the population is Hispanic, in Fresno that number is 399, more than triple Fresno also has a larger Asian population 112 versus 36 nationally See Figure 3-678 Health disparities concern not only racial groups Poverty status and disability are associated with greater rates of CVD, and they are two characteristics more common in Fresno than in the rest of the country Compared to the rest of the US, many
more people in Fresno County live below the poverty line 229 versus 12 nationally, and are disabled 21 versus 19 nationally see Figure 3-678 Poverty and disability are both linked to higher disease prevalence
Figure 3-6: Census Information on Fresno City, Fresno County, CA and the US78

Fresno City White Black Asian Hispanic Median Household Income 1999 Below Poverty Line Over Age 16 Employed 2004 Disabled 502 84 112 399 32,236 262 672 249

Fresno County 543 53 81 440 34,725 229 661 213

California 595 67 109 324 47,493 142 652 20

United States 751 123 36 125 41,994 124 659 192

Prevalence by Disease

331 Cardiovascular Disease
Heart disease is both the most prevalent chronic disease and the leading cause of death in the US9 Among Americans age 35 and older, heart disease killed 509 people per 100,00028 Although the death rate has been declining, nationally, evidence suggests that in recent years this trend is tapering off Increasing rates of poor health behaviors like obesity and smoking have been labeled as the causes of early heart disease death49 An estimated 27 of adults in Fresno County have diagnosed CVD,25 CVD is the number one killer of Fresno residents, and
was the cause of 2,202 deaths in 2005 CA VSQS, 2006 Compared to the rest of California, Fresno has a higher rate of heart

Within five years, half of heart attack victims die

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disease, a type of CVD: 74 of Fresnans have heart disease compared to 69 of Californians75 Prevalence of CVD, including heart attacks, varies by socioeconomic and demographic factors see Figures 3-7 and 3-828 Overall, males are more likely than females to experience a heart attack, with white males most likely to experience a heart attack28 Risk of heart attacks is 65 higher in African-American females than in white females

Figure 3-7: National Prevalence of Heart Attack Among Americans Over Age 20 by Select Characteristics28
Prevalence of Heart Attacks Among Americans Age 20
60 50 40 30 20 10 00
White Males White Female Black Male Black Hispanic Hispanic Female Male Female

52 43 33 20 19 41

Figure 3-8: Prevalence of High Blood Pressure in Fresno County and CA by Race/Ethnicity75
Prevalence of Hypertension by Race in Fresno and CA
500 400 300 200 100 00 Total Black Adult White Latino Asian Mixed Race Fresno Co CA

Results for Blacks, Asians and Mixed
Races in Fresno County are statistically unstable

Heart attack and stroke, the leading causes of death for patients with cardiovascular disease, can be largely predicted by health behaviors like smoking and exercise

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These health behaviors are similarly related to low income, low education, and disability32 More than one in four people in Fresno live below the poverty line, suggesting that CVD risk factors may be highly prevalent in this region

332 Cancer
Cancer is the second leading cause of death in America24 Contrary to popular belief, cancer does not only affect older people: It is the second most common cause of death in children, and half of the new cases of cancer occur in people under age 6526,
54

Cancer is the second leading cause of death among children

In Fresno County, about 82 of the adult population, or 47,000 residents, have ever been diagnosed with a malignancy75 In 2005, 1,096 Fresno County residents died from cancer21 Cancer ranked just behind heart disease as the most common cause of death, and the second most common cause of death in children The age-adjusted death rate per 100,000 in Fresno is 17020, 54
Cancers occur at different rates in different racial and ethnic populations, with African-Americans bearing the greatest burden African-Americans are 34 more likely to die of cancer than whites and more than two times as likely to die of cancer than Asian or Pacific Islanders, American Indians, and Hispanics see Figure 3-926 Five-year relative survival is also lower among African-Americans than among whites at each stage of diagnosis for nearly every cancer site54 African-American women: Are more likely to die of breast and colon cancers than are women of any other racial and ethnic group;26 and Have a lower incidence rate but nearly 20 higher death rate than whites for all cancer sites combined54

Similarly, African-American men: Have the highest death rates of colon and rectum, lung, and prostate cancers;26 Have lung cancer death rates that are approximately 40 higher than white males;26 and Have a 24 higher incidence rate and 40 higher death rate than whites for all cancer sites combined54

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Figure 3-9: National Prevalence of Cancer by Select Characteristics25
Prevalence of Cancer by Demographic Characteristics
250 200
150 100 50 00 Total Age 65 Black Adult White Hispanic Asian 70 42 79 36 28 217

This disparity is most likely not entirely genetic When African-Americans receive similar cancer treatment and medical care as white Americans, they tend to have similar outcomes, suggesting that barriers to timely and quality health care likely explain higher death rates among African-Americans54 In four major sites prostate, female breast, lung and bronchus, and colon and rectum, minority populations are more likely to be diagnosed at a later stage of their disease compared to non-Hispanic whites, leading to poorer treatment outcomes54 Cancer screenings, which provide early detection opportunities for colon, prostate, cervical, and breast cancers, are largely underused in Fresno see Figure 3-10 Breast and cervical cancer screening are more common; however, a considerable number of residents do not get screened for these highly prevalent cancers Research has demonstrated that early cancer detection leads to rapid treatment that dramatically reduces fatality24

Figure 3-10: Self-Reported Prevalence of Fresno Residents Who Do Not Use Cancer Screens75
Failure to Use Cancer Screening in Fresno Co
Age 40,
Never Had Colon Cancer Screen Male, Age 40, No PSA Test Female, Age 18 , No Pap Test Female, Age 30, No Mammogram 00 200 70 242 400 600 800 450 649

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333 Diabetes
More than 20 million Americans have diabetes6 In the past 15 years, the number of people with diabetes has increased by more than 50 The increases have been greatest among children 6 Most of the increase has come in the form of type 2 diabetes, with rates among children and teenagers increasing rapidly43 One in three children born in the US in the 2000 will develop diabetes over the course of their lifetime, according to the American Diabetes Association Children of this generation could have a lower life expectancy than their parents, an unprecedented event 6 Diabetes affects 75 of residents of Fresno County, or about 44,000 people75 An additional 14 of people in Fresno have been diagnosed as pre-diabetic and 3 are estimated to have undiagnosed diabetes24, 75 In 2005, diabetes claimed the lives of 194 Fresno County residents20, 21 Sixty-five percent of people with diabetes will die of either heart disease or stroke 6 Diabetes ranks as the sixth most common cause of
death in Fresno20 Diabetes disproportionately affects certain groups in the population see Figure 31125 The relative number of people with diabetes in African-American, Hispanic, and American Indian communities is one to five times greater than in white communities27
Figure 3-11: National Prevalence of Diabetes by Select Characteristics22
Adults Diagnosed with Diabetes in MS
1200 1000 800 600 400 200 000 Adults White Black Hispanic Other 111 960 87 61 117

1 in 3 children born in 2000 will develop diabetes in their lifetime

334 Asthma
Almost 15 million Americans, adults and children, have asthma30 Asthma is the most common chronic condition among children Asthma prevalence rates are lower among the elderly than for young adults because many children with asthma recover from most of the symptoms by adulthood Asthma also disproportionately affects certain populations Asthma is more common among African-Americans and whites than among Hispanics and Asians25 Hispanics generally report the highest average number of physically unhealthy days, days with activity limitations, and physically or mentally unhealthy days due to asthma42 African-Americans and Hispanics are two

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African-Americans and Hispanics are two to six times more likely to die from asthma

to six times more likely to die from asthma than are whites 30 The rates of asthma are higher for women 67 than men 52 , and higher for African-Americans 67 than whites 56 See Figure 3-12 30 Among adults, women of all races have higher rates of illness and death from asthma than men 30 Asthma rates in Fresno, CA are among the highest in the United States About one in six 15 of Fresno County residents, or 126,000 adults and children report having an asthma diagnosis in their lives75 About one in five 202 of children with asthma in Fresno visited an emergency room or urgent care due to asthma in 200275 In 2005, asthma claimed nine lives in Fresno County21

Figure 3-12: Prevalence of Asthma in Fresno, CA by Select Characteristics75
Adults Diagnosed with Asthma in Fresno
250 2180 200 145 1580 1640 1540

150

100

50 210 00 Tot al Adult Black Whit e Lat ino Asian M ixed Race

Results for Blacks, Asians and Mixed Races in Fresno County are statistically unstable

335 Mental Illness
Mental illness is estimated to directly affect 95 of the US population, while
numbers of diagnosed residents in Fresno County are closer to 66, or 37,80025, 68 Lifetime rates of depression are nearly 30 for the national population, though only 18 will receive an actual diagnosis57 Underreported and undiagnosed mental illnesses in Fresno are highly likely Depression is highest among the elderly and patients with chronic disease29 Women who are poor, have little formal education, and are on welfare or are unemployed are more likely to experience depression than women in the general population29 People with lower annual salaries have a higher prevalence of depression73 With the high rates of poverty and chronic disease in Fresno, it is likely that depression is quite common Depression is increasing in prevalence and impact: By 2020, depression will be second only to heart disease as the worlds greatest disease burden68 When not treated properly, the effects of depression can be extremely serious and even life threatening The vast majority 90 of suicides occur among people with a diagnosable mental illness68
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Chronic Disease Burden by Disease
Chronic diseases impose a severe burden on patients and their
families, as well as the wider community This section discusses the social and economic burden of chronic illness by disease and presents estimates of the effects of these diseases on the Fresno community in terms of both direct and indirect costs Using national data adjusted for local wages, Fresno has approximately 2 billion in direct and indirect costs annually due to chronic disease prevalence Reducing the burden of chronic disease through prevention has the potential to free substantial resources that could better the community, especially its health-related quality of life

341 Cardiovascular Disease
People with CVD experience significant problems with performing everyday activities Heart failure causes more severe impairment of physical functioning role limitation because of physical problems and lack of energy than chronic lung disease or arthritis51 Those with more severe heart failure have more severe limitation of social functioning and suffer impaired mental health compared to those with mild heart failure 51 In fact, the burden of heart failure is so great that close to half of patients are willing to sacrifice years of life to obtain a higher quality of life 51
Patients with CVD rank as low as patients on kidney dialysis on all quality of life measures far below the healthy population in self-reported general health55 CVD patients, especially those with advanced cases, experience high rates of depression55 Declines in physical well-being may have significant social, emotional, and economic repercussions; these declines correlate with job loss, high healthcare utilization, and increased mortality12 According to national data, coronary heart disease costs 1421 billion in direct medical costs and lost productivity from disability and early death9 When stroke and other cardiovascular diseases are included, the total cost reaches 4031 billion Using national cost estimates, CVD costs Fresno County an estimated 994 million per year This number is likely an underestimate of the true burden of heart disease, given undiagnosed heart attacks and increasing prevalence of CVD risk factors of high blood pressure and obesity

342 Diabetes
While diabetes is not as fatal as heart disease or cancer, the burden of complications it imposes is severe Diabetes, both type 1 and type 2, can cause heart disease, stroke, pregnancy complications, and deaths
related to flu and pneumonia If uncontrolled, complications from diabetes can lead to amputations, renal failure, and blindness27 Diabetes is a highly expensive chronic disease, accounting for a major portion of national health care expenditures Although inpatient care is the most expensive service used by diabetics, many different types of health services are required to appropriately treat the disease see Figure 3-13

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Figure 3-13: National Direct Costs for Diabetes by Health Service Used7
Diabetes Costs by Service in Billions
175 120 200

Outpatient Care Inpatient Care Nursing Home Care Physician Visit

100 403 139

Oral Agent/Insulin Medication

Diabetes is a major cause of functional disability It is the leading cause of non-injury blindness and is responsible for 150 amputations per day in the US Diabetes is associated with functional dependence, increased use of health services, increased health care costs, and increased risk of death40 The physical disability caused by diabetes can lead to future declines in health status, a greater likelihood of institutionalization and health service use, and serious reductions in
quality of life46 While the physical repercussions are daunting, diabetes also takes a significant emotional toll Nearly one-fourth 236 of people with diabetes have a depressive syndrome, compared with 171 of the non-diabetes population Compared with adolescents without diabetes or with other chronic conditions, adolescents with diabetes have a threefold increased risk of psychiatric disorders, with rates as high as 3372 Depression among people with diabetes causes a high economic burden to society in terms of both direct and indirect costs45

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Figure 3-14: National Rates of Functional Disability Among Depressed and/or Patients with Diabetes40
Functional Disability Among Diabetics
Neither diabetes no r depressio n Depression

25 51 58 78 20 40 60 80 100

Diabetes Diabetes and Depressio n

Diabetes can create many problems for workers 25 of people with diabetes experience significant work disability Studies show that disability claims and missed workdays are much higher for employees with diabetes than for those without71 Diabetes is estimated to cause a one-third reduction in earnings because of reduced workforce
participation, with annual costs ranging from 3,700 to 8,700 in 200271 The incremental cost to employers from medical and productivity losses for beneficiaries with diabetes was 4,410 more than people without diabetes71 Diabetes impacts a childs health and overall well-being Children with early-onset diabetes sometimes perform lower on intelligence measures than healthy children and children with other chronic diseases62 Children with poorly managed diabetes perform even worse in school61 A 2002 study found that children with diabetes had a mean absence rate of 73 days per year, compared to a rate of 53 days for their siblings62 This increase in absences may be the cause of lower school performance61 Eighteen percent of parents with diabetic children believed diabetes caused learning problems; 18 believed diabetes caused behavior problems; and 32 believed diabetes caused mood problems61 Parents, family members, and teachers each bear a significant burden due to diabetic children Because diabetes, especially type 1, depends on daily attention and consistent monitoring and care to maintain a healthy status, parents can experience considerable stress worrying about whether they are
providing appropriate care for their child72 Schools and daycare settings must also provide appropriate attention and supplies for children with diabetes72 When a child with diabetes has other health problems eg, asthma, eating disorders, poor school attendance, learning disabilities, and/or emotional and behavioral disorders, it is highly likely that management of the childs diabetes will be that much more difficult 72 Altogether, diabetes exacts an enormous penalty on a community The national total cost of diabetes is estimated at 132 billion7 Direct care costs for health services are considerable one dollar out of every five dollars spent on healthcare is spent on diabetes7 Applying national diabetes cost estimates suggests that the cost of diabetes in Fresno County is about 307 million

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343 Asthma
Although asthma kills few people, it is still a very frightening disease that imposes a substantial burden on patients, their families and friends Asthma is responsible for about 500,000 hospitalizations and 134 million days of restricted activity a year30 In 1996, asthma was the tenth most common principal diagnosis in emergency
department ED visits 30 Asthma attacks can be very scary and can leave an emotional scar on people with asthma The disease is highly correlated with depressive disorders: Up to 56 of patients with severe asthma experience anxiety and 19 have depression1 A decreased sense of personal control over health leading to decreased confidence and a diminished desire to manage their treatment is associated with a lower quality of life among people with asthma1 The age-adjusted likelihood for adults who have asthma to exhibit such behaviors as smoking, being obese, and being physical inactive is greater among adult with asthma who suffer frequent mental distress than among adults with asthma who do not74 Adults with asthma experience, on average, 10 days each month of impaired physical or mental health almost double that of those who have never have had asthma42 Asthma can be a debilitating condition for children Asthma is one of the most common causes of pediatric hospitalization60 Children with asthma are more likely to have learning disabilities due to difficulties in concentration, fatigue, and absenteeism17 In fact, asthma is the number one cause of missed school days with 101 missed
school days per year, on average, for children with asthma60 Parents of children with asthma also experience a significant burden Parents must be ever attentive to their childs situations at school, play, work, and home Parents report that they are constantly on guard concerning the health of the child with asthma Most describe their experience with asthma as exhausting, stressful, anxiety provoking, and frightening60, 81 Anxieties about the need to be available to support and care for their childs asthma condition serve to limit employment opportunities for parents Parents and children struggle with medical and insurance professionals to obtain needed care and treatment; with schools to assure access to health personnel knowledgeable about asthma; with employers to obtain job flexibility; and with the community to find support for clean air and a safe, smoke-free environment81 Adults with asthma suffer in their professional careers Asthma-related work disability, including job duty changes, is estimated to be significant with 23 to 40 of people experiencing at least one adverse work event related to asthma over a five year period15 Seven percent of adults with asthma ceased
working because of the severity of their conditions 15 Employer costs for asthma are estimated at approximately 25 times those for people who do not have asthma 5,385 vs 2,121, respectively per year14 Nationally, asthma costs 16 billion in direct medical costs and lost productivity67 For Fresno County, this translates into an estimated cost burden of 203 million annually

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344 Cancer
Cancer is a physically and emotionally devastating disease that exacts a high cost on patients, their families, and the community The effects of cancer can be long-lasting, extending beyond the time a person is physically ill with the disease Patients themselves experience substantial physical effects from the disease and treatment, and these effects can last for years Fatigue has been identified as the most disabling symptom experienced by cancer patients during treatment: 70 to 100 of cancer patients were affected by fatigue in 200436 A substantial number of longterm breast cancer survivors experience chronic pain that interferes with physical functioning, mood, work, relationships, sleep, and the enjoyment of life19 From the moment of diagnosis,
the lives of children with cancer are irrevocably changed For many, hospitalizations and medical procedures replace slumber parties, camping trips, and other childhood adventures13 Children with cancer have been found to be at risk for school adjustment difficulties for a number of reasons, including increased absenteeism13 Only 30 of children with cancer report that their teachers were sensitive to their individual needs, monitored their progress, and were responsible for their positive progress in school 13 Among parents of children with cancer, certain types of anxiety appear to persist for decades after the initial diagnosis16 Forty-five percent of parents feel fairly or very afraid, worried, and/or brooding about unpleasant things; 46 of parents report they suffered from difficulty in sleeping, early wakening, and/or during sleep, reexperiencing situations associated with the childs illness; 26 to 37 of parents report experiencing loss of control problems; and 70 of the parents expressed intermediate or high levels of anxiety see Figure 3-15 16
Figure 3-15: Feelings of Parents Whose Children Have or Had Cancer16
Feelings of Parents Whose Children Have/Had Cancer
Felt anxiety
Felt loss of control Suffered sleep problems Fairly or very afraid 0 20 40 37 46 45 60 80 70

Cancer puts a significant burden on caregivers The distress resulting from assuming the role of caregiver can be manifested as anxiety, depression, helplessness, burden, and fear, and it is often related to providing direct care, performing complex medical procedures, coping with disruptions in daily routine, and negotiating the need to provide emotional support to the patient and to other family members44 Depression is a common side effect of assuming caregiver responsibilities for cancer patients

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More than 30 of caregivers feel anxiety, sadness, and frustration while providing care, and 60 of caregivers under the age of 65 suffer from depression44, 58 Five percent of caregivers quit their job or decline advancement, and a large percentage of caregivers lose work hours or use special leave or holidays to fulfill their care giving responsibilities47 The total cost of family care giving time ranges from an average of 2,435 to 3,772 over a 3-month period48 Employment among cancer patients and survivors can be highly challenging Annual
employer healthcare costs were 16,246 for cancer patients versus 3,264 for others in a 2000 study11 Nationally, the cost of cancer is 189 billion per year Per capita it is the most costly chronic condition26 Given the prevalence of cancer and the national per capita cost of cancer, cancer is estimated to cost Fresno County approximately 496 million per year

345 Mental Illness
The World Health Organization found major depression to be the leading cause of disability among adults in developed nations29 With increased severity, people with depression experience a decline in their quality of life and physical and mental functioning as well as increased disability Evidence suggests that depression is under-diagnosed and under-treated, both because of the health system placing priority on physical health problems and because people with mental illnesses may themselves be reluctant to seek out help for a number of reasons Mental illnesses often do not receive the same attention in the healthcare system as other chronic diseases People may avoid seeking treatment for a variety of reasons the unaffordable cost of treatment, fear of the stigma of mental disease, or simply not even
recognizing they need mental health treatment as the effects of some mental illnesses often manifest themselves as physical symptoms Depression that is comorbid with other physical illnesses is often unnoticed while doctors focus on the more tangible disease People may avoid seeking treatment for depression for a variety of reasons These include the unaffordable cost of treatment, fear of the stigma of mental disease, or simply not even recognizing they need mental health treatment because the effects of some mental illnesses often manifest themselves as physical symptoms Only 25 of people with a mental disorder obtain professional help for their illness In comparison, 60 to 80 of people with heart disease seek and receive care 29 Forty percent of all people who have a severe mental illness do not seek treatment from either general medical or specialty mental health providers 29 Of those aged 18 years and older who get help, about 15 receive it from mental health specialists 29 Of young people aged 9 to 17 years who have a mental disorder, 27 receive professional treatment An additional 20 of children and adolescents with mental disorders use mental health services only in their
schools 29 Although only a minority seek professional help to relieve a mood disorder, people with depression are significantly more likely than others to visit a physician for some other reason 29 Depression is a leading cause of absenteeism and diminished productivity in the workplace 29 Individuals who filed at least one claim for depressive illness took a

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mean of 99 annual sick days38 Workers with depression reported significantly more total health-related lost productivity time than those without depression 56 hours per week versus 15 hours per week73 Major depression is costly to patients and employers It is estimated to cost 6,000 in health-related and work-related costs per depressed worker, and employers bear 4,200 of this amount38 Patients submitting claims for depressive illness incurred a mean annual total of 5,415 in health and disability payments38 Employees with depressive illness incur on average 4,373 in annual healthcare costs, significantly higher than the annual costs of 949 for employees without any other conditions38 The average mental health cost per enrollee associated with depression is 1,34138 The
national cost of mental illness in direct and indirect costs is 83 billion for diagnosed patients per year Applying national cost estimates to the diagnosed population in Fresno County yields a cost burden for depression of more than 150 million Rates of mental illness likely exceed rates of depression alone, suggesting that the true cost of mental illness is significantly higher

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40 Looking to the Future: Changing Behaviors to Improve Health
Though the burden of chronic disease in Fresno is high, there is hope and opportunity If more people practiced healthy behaviors and increased their awareness of chronic disease symptoms and treatment, the burden of disease could be lowered For example, research shows that: Improving ones diet and getting more exercise can also help to reduce likelihood a person will develop CVD or diabetes; About one-third of all cancer deaths are related to dietary factors and lack of physical activity in adulthood; and5 More than one million skin cancers diagnosed in 2003 could have been prevented by protection from the suns rays5

In fact, an estimated 70 to 90 of all chronic disease deaths can be
prevented through behavior and lifestyle changes, according to a January 2006 article published in Preventing Chronic Disease a CDC publication reviewing the research in this area4 Applying these estimates to Fresno County, approximately 2,800 deaths of the 3,500 deaths from chronic disease occurring every year could be prevented if residents practiced healthy behaviors In addition, the more than 188,000 people currently suffering from chronic disease in Fresno could potentially be living healthier lives4 Unfortunately, right now, too many Fresno residents have poor health behaviors that put them at risk for chronic disease see Figure 4-1 For example: Almost one-fifth 17 of the population smokes; About three in ten 31 get no exercise; More than one out of every three 37 adults is obese; and Many Fresnans are not getting adequate preventive health care

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Figure 4-1: Self-Reported Prevalence of Unhealthy Behavior in Fresno County75
Poor Health Behaviors in Fresno Co
170 309 368 562 200 400 600 800

Tobacco Use No Exercise Overw eight or Obese Adults Eat 5 servings fruit/vegetables daily 00

Obesity
Obesity is a major
epidemic in the US From 1960 to 2002, the number of obese adults between the ages of 20 and 74 has jumped from 134 to 30941 This spells trouble for the patients health and the US health care system Obesity and inactivity are strongly linked to many chronic diseases, including heart disease, type 2 diabetes, depression, and cancer10 And not only can obesity lead to chronic disease, it can also worsen the burden of existing chronic disease10 This places an economic strain on the health care system Health care costs are about 10 and 36 greater for overweight or obese people than for healthy weight individuals10 Already, almost 10 cents out of every dollar of all health care expenditures in the US is attributable to overweight and obesity10

Figure 4-2: Prevalence of Overweight and Obesity in Fresno County by Age75
Rates of Overweight and Obesity in Fresno Co

600

482 365 291

Age 0-11 Age 12-17 Adult 261

400

200

6886

00 Overw eight Obese

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Obesity is more prevalent among certain populations, including groups that are highly represented in Fresno Broken out by racial groups, 305 of Latinos in Fresno are obese compared to 238
of whites75 If Fresno residents reduced their obesity rate, they would most likely lower the levels of chronic disease in their community Weight loss, provided it is maintained, is associated with a 30 to 46 reduction in diabetes among high-risk populations and significant improvements in depression rates37, 63, 69 While weight loss is something that requires individuals to change, a growing body of literature has shown that the environment in which one lives and the amount of support for healthy living within a community can impact the likelihood that a person will achieve success with weight loss This fact is important to keep in mind in any community-based campaign to decrease obesity; an effective campaign will aim to lower community barriers to success in weight loss

Exercise
Only one in four adults in the United States gets the recommended amount of weekly exercise One in four adults are also completely sedentary10 Those who are inactive have, on average, 24 higher health care costs than those who exercise regularly10 In Fresno, 309 of adults report getting no exercise, compared to 23 of Americans22 Inactivity is one of the leading causes of death and disease in the US
Inactivity is believed to account for 22 of all heart disease, 22 of colon cancer, 12 of diabetes and hypertension, and 5 of breast cancer85 Increasing levels of physical activity can reduce the risk and the burden of these chronic diseases Those who are active have reduced risk of heart disease, stroke, type 2 diabetes, colon cancers, breast cancers, lung cancers, and depression34, 85 Exercise reduces the risk for heart disease by decrease resting heart rate, and it reduces the risk of type 2 diabetes by improving body glucose tolerance and increasing insulin sensitivity4 Exercise also lowers the risk of diabetes, another factor in many chronic diseases Adopting an active lifestyle could prevent one-third of all new cases of obesity and 43 of all new cases of diabetes80 African-Americans especially benefit from increases in exercise Risk for type 2 diabetes is 50 lower among African Americans who are at all physically active and two-thirds lower among those who are at least moderately active80

Smoking
Smoking is a large factor in many types of chronic disease It causes and exacerbates multiple types of cancers, heart disease, stroke, and asthma84 Smoking causes more than
400,000 deaths each year and costs more than 50 billion dollars in direct medical expenditures alone84 Each year, more people die from smoking than do from AIDS, alcohol, illegal drugs, motor vehicle accidents, homicide, and suicide combined33

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17 of Fresno area residents currently smoke75 If Fresno residents committed to quitting smoking, they would likely see dramatic reductions in the burden of chronic disease in their community With fewer smokers, the burden of lung diseases, such as lung cancer, asthma, and chronic obstructive pulmonary disease, would likely be lower In patients already suffering from heart disease, smoking cessation can reduce the risk of another heart attack by half and may be more effective in reducing heart disease mortality than any other medical treatment35

Use of Preventive Health Care
One of the most important steps that a person could take to prevent and detect chronic disease is to get appropriate preventive medical care Preventive care guidelines, established by groups like the Agency for Health care Research and Quality and the US Preventive Services Task Force, suggest which patients
should get what preventive tests or screenings based on their age, gender, and other risk factors In Fresno, it appears that many residents are not getting adequate preventive care Cancer screenings, which provide early detection opportunities for colon, prostate, cervical, and breast cancers, are largely underused in Fresno County see Figure 4-3 The prostate-specific antigen PSA test to screen for prostate cancer is not used by 65 of those eligible in Fresno Colon cancer screens like the fecal occult blood FOB test and colonoscopies are unused by 45 Among women eligible for mammograms, 24 in Fresno have not been screened75 Research has demonstrated that early cancer detection leads to rapid treatment that dramatically reduces fatality26

Figure 4-3: Self-Reported Prevalence of Fresno Residents Who Do Not Use Cancer Screens75
Failure to Use Cancer Screening in Fresno Co
Age 40, Never Had Colon Cancer Screen Male, Age 40, No PSA Test Female, Age 18 , No Pap Test Female, Age 30, No Mammogram 00 200 70 242 400 600 800 450 649

A number of factors, such as high rates of uninsurance and underinsurance, difficulty accessing primary care for rural residents, and provider organization
skills in addressing racial and ethnic and cultural factors in use services, may provide an explanation
The Burden of Chronic Disease in Fresno Altarum 25

Helping residents establish a strong relationship with a regular source of healthcare has the potential to help them get the preventive care they need When a patient sees a doctor regularly for healthcare, their doctor is more likely to know the medical history and important details about the patients health including health behaviors and whether the patient should be screened for a disease based on known risk factors Barriers to developing such relationships are numerous and range from lack of insurance, to a paucity of primary care physicians and problems finding a trusted physician, to a lack of understanding of the importance of having a primary care physician

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50 Conclusions
Chronic diseases impose a great burden on the Fresno community They are a serious health threat and together are responsible for more death and disability in the community than any other factor Yet, many chronic diseases are preventable through changes in behavior and improvements in early
detection The ability of Fresno residents to make these lifestyle changes depends on access to health care, an understanding of chronic diseases, health behaviors and risk factors, and how to prevent disease health literacy, proper motivation, and appropriate community and medical support Any effort to reduce chronic disease in the Fresno community must consider the barriers to good health behaviors and aim to reduce these barriers Initiatives must engage all segments of the community, including community and business leaders, and community institutions, such as employers, schools and churches, and, of course, residents themselves By improving access to health care, and residents knowledge of disease prevention and support for improvements in health behaviors, Fresno can divert a portion of the approximately 2 billion it spends annually on chronic disease and begin to invest in its future, instead of paying the price of poor health

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American Fact Finder Available at http://factfindercensusgov/home/saff/mainhtml, accessed April 27, 2006 Xuan, J, Duong, PT, Russo, PA, Lacey, MJ, Wong, B, The Economic Burden of Congestive Heart Failure in a Managed Care Population, The American Journal of Managed Care, 2000 Vol 66, p 693 Yancey, AK, Kumanyika, SK, Ponce, NA, McCarthy, WJ, Fielding, JE, Leslie, JP, Akbar, J, Population-Based Interventions Engaging Communities of Color in Healthy Eating and Active Living: A Review, Preventing Chronic Disease [serial online] January 2004 Yawn, BP, The Impact of Childhood Asthma on Daily Life of the Family: A Qualitative Study Using Recurrent Thematic Analysis, Primary Care Respiratory Journal, 2003 Vol 123, p 82 Yawn, BP, Wollan, PC, Jacobsen, SJ, Fryer, GE, Roger, VL, Identification of Womens Coronary Heart Disease and Risk Factors Prior to First Myocardial Infarction, Journal of Womens Health, 2004 Vol 1310, p 1087-100 Yeatts, K, Shy, C, Sotir, M, Music, S, Herget, C, Health Consequences for Children with Undiagnosed Asthma-Like Symptoms, Archives of Pediatric and Adolescent Medicine, 2003 Vol 1576, p 540 Zaza, S, Briss, PA, Harris, KW, The Guide to Community Preventative
Services: What Works to Promote Health?, Chapter 1: Tobacco, Task Force on Community Preventative Services, 2005

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77 78 79

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Zaza, S, Briss, PA, Harris, KW, The Guide to Community Preventative Services: What Works to Promote Health?, Chapter 2: Physical Activity, Task Force on Community Preventative Services, 2005

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70 Appendix: Data Sources and Methodology
71 Behavioral Risk Factor Surveillance System
The BRFSS is a state-based system of health surveys that generate information about health risk behaviors, clinical preventive practices, and health care access and use primarily related to chronic diseases and injury Some questions vary by state and year, so the most complete data set relies on information from 2000-2004 wwwcdcgov/brfss Prevalence information is based on the following questions from the BRFSS 2004 CA and national datasets: Heart disease: Are you currently taking medicine for your high blood pressure? Have you ever had your blood cholesterol checked? About how long has it been since you last had your blood cholesterol
checked? for the adult population Cancer: Have you ever had a mammogram? How long has it been since you had your last mammogram? Have you ever had a clinical breast exam? How long has it been since your last breast exam? Have you ever had a Pap test? How long has it been since you had your last Pap test? Have you ever had a PSA test? How long has it been since you had your last PSA test? Have you ever had a digital rectal exam? Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems Have you ever had either of these exams? How long has it been since you had your last sigmoidoscopy or colonoscopy? for the adult population, based on the age at which regular screenings are recommended Diabetes: Are you now taking insulin? Are you now taking diabetes pills? About how often do you check your blood for glucose or sugar? About how often do you check your feet for any sores or irritations? About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? About how many times in the past 12 months has a doctor, nurse, or other health professional
checked you for A one C? About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? for the adult population selfreporting diabetes Asthma: During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms? During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma? During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring? During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it? for the adult population self-reporting asthma

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72 California Center for Health Statistics Vital Statistics Query System
This query system allows the user to search for cause of death events It Identifies the year of the event 1994-2001, allows the choice of an individual county or the entire state and can sort by age, race/ethnicity, gender http://wwwapplicationsdhscagov/vsq/

California Department of
Health Services
A 2002 report from the Department of Health and Human Services, highlights risk factors, hospitalization surveillance data by county, clinical treatment and disease management, and mortality surveillance data by county see Kamigaki, 2002 Also within the DHS is the Center for Health Statistics, Office of Health Information and Research This office contains information on Fresno County death rates and a 2005 Health Status Profile http://wwwdhscagov/hisp/chs/ohir/reports/healthstatusprofiles/2005/individualpro fileshtm

California Health Interview Survey CHIS
CHIS is a telephone survey of adults, adolescents, and children from all parts of the State of California The survey is conducted every two years The most recent data set is for 2003, although some questions were not asked in this year Health data is searchable by geographic area, health topic and population age, race, gender, poverty level The sample size for Fresno County in the 2003 data was 630 adults age 18 and older, 66 adolescents age 13-17, and 177 children 0-12 years old wwwchisuclaedu Prevalence information is based on the following questions from the CHIS 2003 dataset unless otherwise specified:
Heart disease: Has a doctor ever told you that you have high blood pressure? Are you now taking any medications to control your high blood pressure? Has a doctor ever told you that you have any kind of heart disease? Has a doctor ever told you that you have heart failure or congestive heart failure? Has a doctor ever told you that you had a stroke? for the adult population Diabetes: {Other than during pregnancy, has/Has} a doctor ever told you that you have diabetes or sugar diabetes? How old were you when a doctor first told you that you have diabetes? Were you told that you had Type 1 or Type 2 diabetes? Are you now taking insulin? Do you now take diabetic pills to lower your blood sugar? About how many times per day, per week, or per month do you or a family member or friend check your blood for glucose or sugar for the adult and teen populations These results include the prediabetes population Asthma: Has a doctor ever told you that you have asthma? Do you still have asthma? During the past 12 months, have you had an episode of asthma or an asthma attack? During the past 12 months, how often have you had asthma

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symptoms
such as coughing, wheezing, shortness of breath, chest tightness or phlegm? During the past 12 months, have you had to visit a hospital emergency room or urgent care clinic because of your asthma? Are you now taking a daily medication to control your asthma that was prescribed or given to you by a doctor? During the past 12 months, how many days of work did you miss due to asthma? Has a doctor or other health professional ever given you an asthma management plan? for the population over age 1 Cancer: Has a doctor ever told you that you had a cancer of any kind? What kind of cancer was it? for the adult population Mental illness: Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? About how often during the past 30 days did you feel nervous–Would you say all of the time, most of the time, some of the time, a little of the time, or none of the time? During the past 30 days, about how often did
you feel hopeless–all of the time, most of the time, some of the time, a little of the time, or none of the time? During the past 30 days, about how often did you feel restless or fidgety? Often did you feel so depressed that nothing could cheer you up? During the past 30 days, about how often did you feel that everything was an effort? During the past 30 days, about how often did you feel worthless? Not counting overnight stays, emergency room visits, or visits for drug or alcohol problems, in the past 12 months, have you seen a psychiatrist, psychologist, social worker, or counselor for emotional or mental health problems? During the past 12 months, did you think you needed help for emotional or mental health problems, such as feeling sad, anxious or nervous? During the past 12 months, did you take any prescription medications, such as an antidepressant or sedative, almost daily for two weeks or more, for an emotional or personal problem? for the adult population, CHIS 2001

Health Behaviors: High blood pressure: Ever diagnosed with high blood pressure for the adult population Colon cancer: Ever had colonoscopy or fecal occult blood test for adult population over age
40, CHIS 2001 Prostate cancer: Ever had PSA test for adult men over age 40 Skin cancer: Uses SPF 15 when outside for population over age 1, CHIS 2001 Cervical cancer: Most recent Pap test for all adult women Breast cancer: Most recent mammogram for adult women over age 30 Tobacco use: Current smoker for teens and adults Exercise: Level of exercise per week for adults, CHIS 2001 Overweight or Obese: Height and Weight for teens and adults processed to BMI BMI greater than 25 indicates overweight or obesity for adults For

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adolescents, Overweight or obese includes the respondents who have a BMI in the highest 95 percentile with respect to their age and gender

Medical Expenditure Panel Survey MEPS
The Medical Expenditure Panel Survey MEPS is a set of large-scale surveys of families and individuals that collects information on health care utilization and expenditures, health insurance, and health status, as well as a variety of demographic, social, and economic characteristics of a representative sample of Americans The most recent complete dataset is for 2003 wwwmepsahrqgov

76 National Center for Chronic Disease Prevention and
Health Promotion: Cardiovascular Health CVH
This system operates through a division of the Centers for Disease Control CDC and compiles cardiovascular mortality rates This website features interactive heart disease and stroke death rate maps by state and allows for statistics by county, gender and race/ethnicity http://appsnccdcdcgov/giscvh

National Health Interview Survey
The NHIS is a cross-sectional household interview survey that monitors the health status of the national non-institutionalized adult population Data is classified by sex, age, race and Hispanic origin, education, family income, poverty status, health insurance coverage, marital status, place of residence, and region of residence for chronic condition prevalence, health status, functional limitations, health care access and utilization, health behaviors, and human immunodeficiency virus testing In 2004, data were collected for 31,326 adults for the Sample Adult questionnaire The conditional response rate the number of completed interviews divided by the total number of eligible sample adults was 838, and the final response rate the conditional rate multiplied by the overall family response rate of 865, was
725 The health information for adults in this report was obtained from one randomly selected adult per family In very rare instances where the sample adult was not able to respond for him or herself, a proxy was allowed The most recent complete dataset is for 2004 wwwcdcgov/nchs/nhis Prevalence information is age-adjusted based on the following questions from the NHIS 2004 dataset: Heart disease: Have you EVER been told by a doctor or other health professional that you hadHypertension, also called high blood pressure?; Have you EVER been told by a doctor or other health professional that you had Coronary heart disease? Angina, also called angina pectoris? A heart attack also called myocardial infarction? Any kind of heart condition or heart disease other than the ones I just asked about? A stroke? for the adult population Diabetes: Have you EVER been told by a doctor or health professional that you have diabetes or sugar diabetes? Are you NOW taking insulin? Are you

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NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents For the adult population, excluding
pre-diabetes and pregnancy-related diabetes Asthma: Have you EVER been told by a doctor or other health professional that you had asthma? Do you still have asthma? During the PAST 12 MONTHS, have you had an episode of asthma or an asthma attack? During the PAST 12 MONTHS, have you had to visit an emergency room or urgent care center because of asthma? DURING THE PAST 12 MONTHS, HOW MANY DAYS were you UNABLE to work because of your asthma? An asthma management plan is a printed form that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room Has a doctor or other health professional EVER given you an asthma management plan? for the adult population Cancer: Have you EVER been told by a doctor or other health professional that you had Cancer or a malignancy of any kind? for adult population
1 Bladder 2 Blood 3 Bone 4 Brain 5 Breast 6 Cervix 7 Colon 8 Esophagus 9 Gallbladder 10 Kidney 11 Larynx-windpipe 12 Leukemia 13 Liver 14 Lung 15 Lymphoma 16 Melanoma 17 Mouth/tongue/lip 18 Ovary 19 Pancreas 20 Prostate 21 Rectum 22 Skin nonmelanoma 23 Skin Dont know what kind 24 Soft Tissue muscle or fat 25 Stomach 26 Testis
27 Throat pharynx 28 Thyroid 29 Uterus 30 Other 96 More than 3 kinds 97 Refused 99 Dont know

Mental illness-depression proxy: During the PAST 30 DAYS, how often did you feel So sad that nothing could cheer you up? Nervous? Restless or fidgety? Hopeless? That everything was an effort? Worthless? Altogether, how MUCH did these feelings interfere with your life or activities: a lot, some, a little, or not at all? During the PAST 12 MONTHS, that is since {12 month refdate}, have you seen or talked to any of the following health care providers about your own health? A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker? for the adult population

United States Census Data
Data from the US Census in 2000 and the American Community Survey in 2004 provided many of the local statistics used to calculate demographic rates in California, Fresno, and the nation wwwcensusgov

Prevalence Rates Cost Estimates
Estimates for the US

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As discussed in the body of this report, chronic diseases include diagnosed diabetes both type 1 and type 2, cardiovascular disease heart
disease, hypertension, and stroke, asthma, COPD, cancer, and mental health problems Combined direct and indirect annual cost estimates were obtained from national sources as follows: CVD American Heart Association 4031 billion Cancer National Cancer Institute 189 billion Diabetes American Diabetes Association 132 billion Asthma National Heart, Lung and Blood Institute 161 billion Mental illness depression National Institute for Mental Health 83 billion

These costs sum to 8232 billion Estimates for Fresno As discussed in the body of this report, chronic diseases include diagnosed diabetes both type 1 and type 2, cardiovascular disease heart disease, hypertension, and stroke, asthma, COPD, cancer, and mental health problems Numbers and percentages of individuals counted in the prevalence estimates are based on 2004 NHIS combined prevalence rates for the West region, broken out by age, gender, and race The West region includes the following states: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii These rates were applied by age, gender, and race to 2004 Census estimates for Fresno County, CA They were
further adjusted for known prevalence rates by disease that are specific to Fresno County, using data from CHIS The percent of families affected is based on an assumption that the 347 of individuals with at least one disease are randomly distributed among families, and that average family size is 366 individuals from US Census data Combined direct and indirect per capita cost estimates were obtained from national sources as follows: CVD American Heart Association 5,654 Cancer National Cancer Institute 9,594 Diabetes American Diabetes Association 6,346 Asthma National Heart, Lung and Blood Institute 1,464 Mental illness National Institute for Mental Health 4,415

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These estimates were also checked against direct costs as calculated using 2003 Medical Expenditure Panel Survey data To derive cost estimates for Fresno, these per capita costs were first multiplied by the prevalence numbers, and second, multiplied by the wage index for Fresno 110 as found in the Fiscal Year 2006 Medicare Prospective Payment System Federal Register, August 12, 2005 The cost estimate computations are: CVD 5,654 159,905 110 994,439,268
Cancer 9,594 47,000 110 496,005,076 Diabetes 6,346 44,000 110 307,153,846 Asthma 1,464 126,000 110 202,860,000 Mental illness 4,415 31,000 110 150,547,872

These costs sum to: 2,151,006, 063

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Source:health.wyo.gov

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