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<meta name="robots" content="NOINDEX,NOFOLLOW,NOARCHIVE,NOIMAGEINDEX" /><meta name="citation_inbook_title" content="Health, United States, 2004: With Chartbook on Trends in the Health of Americans" /><meta name="citation_title" content="Chartbook on Trends in the Health of Americans" /><meta name="citation_publisher" content="National Center for Health Statistics (US)" /><meta name="citation_date" content="2004/09" /><meta name="citation_author" content="National Center for Health Statistics (US)&#10;" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK20758/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Chartbook on Trends in the Health of Americans" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="National Center for Health Statistics (US)" /><meta name="DC.Contributor" content="National Center for Health Statistics (US)&#10;" /><meta name="DC.Date" content="2004/09" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK20758/" /><meta name="description" content="From 1950 to 2000 the total resident population of the United States increased from 150 million to 281 million, representing an average annual growth rate of 1 percent (figure 1). During the same period, the population 65 years of age and over grew almost twice as rapidly and increased from 12 to 35 million persons. The population 75 years of age and over grew almost three times as quickly as the total population, increasing from 4 to 17 million persons. Projections indicate that the rate of population growth during the next 50 years will be somewhat slower for all age groups and older age groups will continue to grow more than twice as rapidly as the total population.Figure 1Total population, population 65 years and over and 75 years and over: United States, 1950–2050 Click here for spreadsheet version Click here for PowerPoint NOTES: See Data Table for data points graphed and additional notes.SOURCE: U.S. Census Bureau, 1950–2000 decennial censuses and 2010–50 interim population projections." /><meta name="og:title" content="Chartbook on Trends in the Health of Americans" /><meta name="og:type" content="book" /><meta name="og:description" content="From 1950 to 2000 the total resident population of the United States increased from 150 million to 281 million, representing an average annual growth rate of 1 percent (figure 1). 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Projections indicate that the rate of population growth during the next 50 years will be somewhat slower for all age groups and older age groups will continue to grow more than twice as rapidly as the total population.Figure 1Total population, population 65 years and over and 75 years and over: United States, 1950–2050 Click here for spreadsheet version Click here for PowerPoint NOTES: See Data Table for data points graphed and additional notes.SOURCE: U.S. Census Bureau, 1950–2000 decennial censuses and 2010–50 interim population projections." /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK20758/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-healthus04-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/healthus04/chartbook/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK20758/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" media="print" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} .body-content h2, .body-content .h2 {border-bottom: 1px solid #97B0C8} .body-content h2.inline {border-bottom: none} a.page-toc-label , .jig-ncbismoothscroll a {text-decoration:none;border:0 !important} .temp-labeled-list .graphic {display:inline-block !important} .temp-labeled-list img{width:100%}</style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript" src="/corehtml/pmc/js/large-obj-scrollbars.min.js"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script><meta name="book-collection" content="healthuscollect" />
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>National Center for Health Statistics (US) . Health, United States, 2004: With Chartbook on Trends in the Health of Americans. Hyattsville (MD): National Center for Health Statistics (US); 2004 Sep. </p></div><div class="bk_msg_box bk_bttm_mrgn clearfix bk_noprnt"><div class="iconblock clearfix"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/healthus20_21/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-healthus20_21-lrg.png" alt="Cover" height="100px" width="80px" /></a><div class="icnblk_cntnt"><ul class="messages"><li class="info icon"><span class="icon"><a href="/books/n/healthus20_21/">A new version of this report is available.</a></span></li></ul></div></div></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/healthus04/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-healthus04-lrg.png" alt="Cover of Health, United States, 2004" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>Health, United States, 2004: With Chartbook on Trends in the Health of Americans.</h2><a data-jig="ncbitoggler" href="#__NBK20758_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK20758_dtls__"><div>National Center for Health Statistics (US)
.</div><div>Hyattsville (MD): <a href="http://www.cdc.gov/nchs/hus.htm" ref="pagearea=page-banner&amp;targetsite=external&amp;targetcat=link&amp;targettype=publisher">National Center for Health Statistics (US)</a>; 2004 Sep.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/healthus04/">Contents</a></li></ul></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/healthus04/highlights/" title="Previous page in this title">&lt; Prev</a><a class="active page_link next" href="/books/n/healthus04/trend-tables/" title="Next page in this title">Next &gt;</a></div></div></div></div></div>
<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK20758_"><span class="title" itemprop="name">Chartbook on Trends in the Health of Americans</span></h1></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="A46"><h2 id="_A46_">Population</h2><div id="A47"><h3>Age</h3><p>From 1950 to 2000 the total resident population of the United States increased from 150
million to 281 million, representing an average annual growth rate of 1 percent (<a class="figpopup" href="/books/NBK20758/figure/A48/?report=objectonly" target="object" rid-figpopup="figA48" rid-ob="figobA48">figure 1</a>). During the same period, the population 65 years of
age and over grew almost twice as rapidly and increased from 12 to 35 million persons. The
population 75 years of age and over grew almost three times as quickly as the total population,
increasing from 4 to 17 million persons. Projections indicate that the rate of population
growth during the next 50 years will be somewhat slower for all age groups and older age groups
will continue to grow more than twice as rapidly as the total population.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA48" co-legend-rid="figlgndA48"><a href="/books/NBK20758/figure/A48/?report=objectonly" target="object" title="Figure 1" class="img_link icnblk_img figpopup" rid-figpopup="figA48" rid-ob="figobA48"><img class="small-thumb" src="/books/NBK20758/bin/pages41-46f1.gif" src-large="/books/NBK20758/bin/pages41-46f1.jpg" alt="Figure 1. Total population, population 65 years and over and 75 years and over: United States, 1950&#x02013;2050." /></a><div class="icnblk_cntnt" id="figlgndA48"><h4 id="A48"><a href="/books/NBK20758/figure/A48/?report=objectonly" target="object" rid-ob="figobA48">Figure 1</a></h4><p class="float-caption no_bottom_margin">Total population, population 65 years and over and 75 years and over: United States,
1950&#x02013;2050.
Click here for spreadsheet version
Click here for
PowerPoint
NOTES: See Data Table for data points graphed and
additional notes.</p></div></div></p><p>During 1950 to 2000, the U.S. population grew older (<a class="figpopup" href="/books/NBK20758/figure/A49/?report=objectonly" target="object" rid-figpopup="figA49" rid-ob="figobA49">figure
2</a>). From 1950 to 2000 the percent of the population under 18 years of age fell from 31
percent to 26 percent while the percent 65&#x02013;74 years increased from 6 to 7 percent and
the percent 75 years and over increased from 3 to 6 percent.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA49" co-legend-rid="figlgndA49"><a href="/books/NBK20758/figure/A49/?report=objectonly" target="object" title="Figure 2" class="img_link icnblk_img figpopup" rid-figpopup="figA49" rid-ob="figobA49"><img class="small-thumb" src="/books/NBK20758/bin/pages41-46f2.gif" src-large="/books/NBK20758/bin/pages41-46f2.jpg" alt="Figure 2. Percent of population in 4 age groups: United States, 1950, 2000, and 2050." /></a><div class="icnblk_cntnt" id="figlgndA49"><h4 id="A49"><a href="/books/NBK20758/figure/A49/?report=objectonly" target="object" rid-ob="figobA49">Figure 2</a></h4><p class="float-caption no_bottom_margin">Percent of population in 4 age groups: United States, 1950, 2000, and 2050.
Click here for spreadsheet version
Click here for
PowerPoint
NOTES: See Data Table for data points graphed and
additional notes.</p></div></div></p><p>From 2000 to 2050 it is anticipated that the percent of the population 65 years and over will
increase substantially. Between 2000 and 2050 the percent of the population 65&#x02013;74
years of age will increase from 7 to 9 percent and the population 75 years and over will
increase from 6 to 12 percent. By 2040 the population 75 years and over will exceed the
population 65&#x02013;74 years of age.</p><p>The aging of the population has important consequences for the health care system (<a class="bk_pop" href="#A51">1</a>,<a class="bk_pop" href="#A52">2</a>). As the older
fraction of the population increases, more services will be required for the treatment and
management of chronic and acute health conditions. Providing health care services needed by
Americans of all ages will be a major challenge in the 21st century.</p><div id="A47.reflist0"><h4>References for figures 1 and 2</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A51">Wolf DA . Population change: Friend or foe of the chronic care system? <span><span class="ref-journal">Health Aff. </span>2001;<span class="ref-vol">20</span>(6):28–42.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11816669" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11816669</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A52">Goulding MR , Rogers ME , Smith SM . Health and aging: Trends in aging&#x02014;United States and
worldwide. <span><span class="ref-journal">MMWR. </span>2003;<span class="ref-vol">52</span>(06):101–6.</span></div></dd></dl></div></div><div id="A53"><h3>Race and Ethnicity</h3><p>Changes in the racial and ethnic composition of the population have important consequences
for the Nation&#x02019;s health because many measures of disease and disability differ
significantly by race and ethnicity (<i>Health, United States, 2004</i>, trend
tables). One of the overarching goals of U.S. public health policy is elimination of racial and
ethnic disparities in health.</p><p>Diversity has long been a characteristic of the U.S. population, but the racial and ethnic
composition of the Nation has changed over time. In recent decades the percent of the
population of Hispanic origin and Asian or Pacific Islander race has risen (<a class="figpopup" href="/books/NBK20758/figure/A54/?report=objectonly" target="object" rid-figpopup="figA54" rid-ob="figobA54">figure 3</a>). In 2000 over one-quarter of adults and more than
one-third of children identified themselves as Hispanic, as black, as Asian or Pacific
Islander, or as American Indian or Alaska Native.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA54" co-legend-rid="figlgndA54"><a href="/books/NBK20758/figure/A54/?report=objectonly" target="object" title="Figure 3" class="img_link icnblk_img figpopup" rid-figpopup="figA54" rid-ob="figobA54"><img class="small-thumb" src="/books/NBK20758/bin/pages41-46f3.gif" src-large="/books/NBK20758/bin/pages41-46f3.jpg" alt="Figure 3. Percent of population in selection race and Hispanic origin groups by age: United States, 1980&#x02013;2000." /></a><div class="icnblk_cntnt" id="figlgndA54"><h4 id="A54"><a href="/books/NBK20758/figure/A54/?report=objectonly" target="object" rid-ob="figobA54">Figure 3</a></h4><p class="float-caption no_bottom_margin">Percent of population in selection race and Hispanic origin groups by age: United
States, 1980&#x02013;2000.
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NOTES: Persons of Hispanic origin may be of any race. Race data for 2000 are not <a href="/books/NBK20758/figure/A54/?report=objectonly" target="object" rid-ob="figobA54">(more...)</a></p></div></div></p><p>In the 1980 and 1990 decennial censuses, Americans could choose only one racial category to
describe their race (<a class="bk_pop" href="#A56">1</a>). In the 2000 census the question
on race was modified to allow the choice of more than one racial category. Although overall a
small percent of persons of non-Hispanic origin selected two or more races in 2000, a higher
percent of children than adults were described as being of more than one race. The number of
American adults identifying themselves or their children as multiracial is expected to increase
in the future (<a class="bk_pop" href="#A57">2</a>).</p><p>In 2000 the percent of persons reporting two or more races also varied considerably among
racial groups. For example, the percent of all persons reporting a specified race who mentioned
that race in combination with one or more additional racial groups was 1.4 percent for white
persons and 37 percent for American Indians or Alaska Natives (<a class="bk_pop" href="#A58">3</a>).</p><div id="A53.reflist0"><h4>References for figure 3</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A56">Grieco EM, Cassidy RC. Overview of race and Hispanic origin.
Census 2000 Brief. United States Census 2000. March 2001.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A57">Waters MC . Immigration, intermarriage, and the challenges of measuring racial/ethnic
identities. <span><span class="ref-journal">Am J Public Health. </span>2000;<span class="ref-vol">90</span>(11):1735–7.</span> [<a href="/pmc/articles/PMC1446407/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC1446407</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/11076242" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11076242</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A58">U.S. Census Bureau: Census 2000 Modified Race Data Summary
File: 2000 Census of Population and Housing, September 2002.</div></dd></dl></div></div><div id="A59"><h3>Poverty</h3><p>Children and adults in families with incomes below or near the Federal poverty level have
worse health than those with higher incomes (see <a href="/books/n/healthus04/app2/">Appendix II,
Poverty level</a> for a definition of the Federal poverty level). Although, in some cases,
illness can lead to poverty, more often poverty causes poor health by its connection with
inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy
lifestyles, and decreased access to and use of health care services (<a class="bk_pop" href="#A63">1</a>).</p><p>In 2002 the overall percent of Americans living in poverty increased to 12.1 percent, up from
11.7 percent in 2001 and 11.3 percent in 2000, reflecting the recession that started in the
spring of 2000 and the economic fallout from the September 11, 2001, attacks. These were the
first increases in the poverty rate since 1993. Most of the increase in the poverty rate from
2000 to 2001 was accounted for by working-age adults who are less likely to receive income from
government programs than are children and persons 65 years of age and over. However in 2002 the
poverty rate increased for all ages (<a class="bk_pop" href="#A64">2</a>).</p><p>Starting in 1974 children were more likely than either working-age adults or older Americans
to be living in poverty (<a class="figpopup" href="/books/NBK20758/figure/A60/?report=objectonly" target="object" rid-figpopup="figA60" rid-ob="figobA60">figure 4</a>). In 1974 poverty among
children started increasing and remained at 20 percent or above from 1981 to 1997. Since then,
the children&#x02019;s poverty rate gradually declined to 16 percent but increased to 17
percent in 2002.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA60" co-legend-rid="figlgndA60"><a href="/books/NBK20758/figure/A60/?report=objectonly" target="object" title="Figure 4" class="img_link icnblk_img figpopup" rid-figpopup="figA60" rid-ob="figobA60"><img class="small-thumb" src="/books/NBK20758/bin/pages41-46f4.gif" src-large="/books/NBK20758/bin/pages41-46f4.jpg" alt="Figure 4. Poverty rates by age: United States, 1966&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA60"><h4 id="A60"><a href="/books/NBK20758/figure/A60/?report=objectonly" target="object" rid-ob="figobA60">Figure 4</a></h4><p class="float-caption no_bottom_margin">Poverty rates by age: United States, 1966&#x02013;2002.
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NOTES: Data shown are the percent of persons with family income below the poverty level.
See Data Table for table points graphed and
additional <a href="/books/NBK20758/figure/A60/?report=objectonly" target="object" rid-ob="figobA60">(more...)</a></p></div></div></p><p>Before 1974 persons 65 years of age and over were more likely to live in poverty than people
of other ages. With the availability of inflation-adjusted government social insurance programs
such as Social Security and Supplemental Security Income, the poverty rate of older Americans
declined rapidly until 1974 and continued to decline gradually until the end of the 1990s
(<a class="bk_pop" href="#A65">3</a>). From 2000 to 2002 the poverty rate among persons
65 years of age and over increased.</p><p>In 2002 the percent of persons living in poverty continued to differ significantly by age,
race, and ethnicity (<a class="figpopup" href="/books/NBK20758/figure/A61/?report=objectonly" target="object" rid-figpopup="figA61" rid-ob="figobA61">figure 5</a>). At all ages, a higher
percent of Hispanic and black persons than non-Hispanic white persons were poor. In 2002,
29&#x02013;32 percent of Hispanic and black children were poor compared with 10&#x02013;12
percent of Asian and white non-Hispanic children. Similarly, among persons 65 years of age or
over more than one-fifth of Hispanic and nearly one-quarter of black persons were poor,
compared with 8 percent of Asians and white non-Hispanic persons. In 2000&#x02013;2002 more
than 1 in 5 American Indians and Alaska Natives lived in poverty. Poverty estimates for
American Indians and Alaska Natives combine data for all age groups and several years in order
to produce an estimate (<a class="bk_pop" href="#A66">4</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA61" co-legend-rid="figlgndA61"><a href="/books/NBK20758/figure/A61/?report=objectonly" target="object" title="Figure 5" class="img_link icnblk_img figpopup" rid-figpopup="figA61" rid-ob="figobA61"><img class="small-thumb" src="/books/NBK20758/bin/pages41-46f5.gif" src-large="/books/NBK20758/bin/pages41-46f5.jpg" alt="Figure 5. Low income population by age, race, and Hispanic origin: United States, 2002." /></a><div class="icnblk_cntnt" id="figlgndA61"><h4 id="A61"><a href="/books/NBK20758/figure/A61/?report=objectonly" target="object" rid-ob="figobA61">Figure 5</a></h4><p class="float-caption no_bottom_margin">Low income population by age, race, and Hispanic origin: United States, 2002.
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NOTES: Poor is defined as family income less than 100 percent of the poverty level and
near poor as 100-199 percent <a href="/books/NBK20758/figure/A61/?report=objectonly" target="object" rid-ob="figobA61">(more...)</a></p></div></div></p><div id="A59.reflist0"><h4>References for figures 4 and 5</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A63">Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic
Status and Health Chartbook. Health, United States, 1998. Hyattsville, Maryland: National
Center for Health Statistics. 1998.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A64">Proctor B, Dalaker J. Poverty in the United States: 2002.
Current population reports, series P-60 no 222. Washington, DC: U.S. Government Printing
Office. 2003.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A65">Hungerford T, Rassette M, Iams H, Koenig M. Trends in the
economic status of the elderly. Social Security Bulletin 64(3).
2001&#x02013;2002. [<a href="https://pubmed.ncbi.nlm.nih.gov/12655738" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12655738</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A66">U.S. Census Bureau. Data available at: <a href="http://www.census.gov/hhes/poverty/poverty02/pov2_and_3-yr_avgs.html" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.census.gov/hhes/poverty<wbr style="display:inline-block"></wbr>​/poverty02/pov2_and_3-yr_avgs<wbr style="display:inline-block"></wbr>​.html</a>.</div></dd></dl></div></div></div><div id="A67"><h2 id="_A67_">Health Insurance</h2><div id="A68"><h3>Health Insurance</h3><p>Health insurance coverage is an important determinant of access to health care (<a class="bk_pop" href="#A72">1</a>). Uninsured children and adults under 65 years of age are
substantially less likely to have a usual source of health care or a recent health care visit
than their insured counterparts (<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A878/?report=objectonly" target="object">tables 71</a>, <a href="/books/n/healthus04/trend-tables/table/A881/?report=objectonly" target="object">74</a>,
<a href="/books/n/healthus04/trend-tables/table/A882/?report=objectonly" target="object">75</a>, and <a href="/books/n/healthus04/trend-tables/table/A884/?report=objectonly" target="object">77</a>).
Uninsured persons are more likely to forgo needed health care due to cost concerns (<a class="bk_pop" href="#A72">1</a>,<a class="bk_pop" href="#A73">2</a>). The major source
of coverage for persons under 65 years of age is private employer-sponsored group health
insurance. Private health insurance may also be purchased on an individual basis, but it
generally costs more and provides less adequate coverage than group insurance. Public programs
such as Medicaid and the State Children&#x02019;s Health Insurance Program provide coverage
for many low-income children and adults.</p><p>Between 1984 and 1994 private coverage declined among persons under 65 years of age while
Medicaid coverage and uninsurance increased. Since 1994 the age adjusted percent of the
nonelderly population with no health insurance coverage has been between 16&#x02013;17
percent, Medicaid between 9&#x02013;12 percent, and private coverage between 70&#x02013;73
percent (<a class="figpopup" href="/books/NBK20758/figure/A69/?report=objectonly" target="object" rid-figpopup="figA69" rid-ob="figobA69">figure 6</a>). In 2002 the percent with private
health insurance decreased. This decrease was offset by an increase in the percent with
Medicaid, resulting in little change in the percent uninsured.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA69" co-legend-rid="figlgndA69"><a href="/books/NBK20758/figure/A69/?report=objectonly" target="object" title="Figure 6" class="img_link icnblk_img figpopup" rid-figpopup="figA69" rid-ob="figobA69"><img class="small-thumb" src="/books/NBK20758/bin/pages47-48f6.gif" src-large="/books/NBK20758/bin/pages47-48f6.jpg" alt="Figure 6. Health insurance coverage among persons under 65 years of age: United States, 1984&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA69"><h4 id="A69"><a href="/books/NBK20758/figure/A69/?report=objectonly" target="object" rid-ob="figobA69">Figure 6</a></h4><p class="float-caption no_bottom_margin">Health insurance coverage among persons under 65 years of age: United States,
1984&#x02013;2002.
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NOTES: Percents are age adjusted. See Data Table
for data points graphed, standard errors, <a href="/books/NBK20758/figure/A69/?report=objectonly" target="object" rid-ob="figobA69">(more...)</a></p></div></div></p><p>In 2002, 17 percent of Americans under 65 years of age reported having no health insurance
coverage. The percent of adults under 65 years of age without health insurance coverage
decreases with age. In 2002 adults 18&#x02013;24 years of age were most likely to lack
coverage and those 55&#x02013;64 years of age were least likely (<a class="figpopup" href="/books/NBK20758/figure/A70/?report=objectonly" target="object" rid-figpopup="figA70" rid-ob="figobA70">figure 7</a>). Persons with incomes below or near the poverty level were at least
three times as likely to have no health insurance coverage as those with incomes twice the
poverty level or higher. Hispanic persons and non-Hispanic black persons were more likely to
lack health insurance than non-Hispanic white persons. Persons of Mexican origin were more
likely to be uninsured than non-Hispanic black persons or other Hispanics. Access to health
insurance coverage through employment is lowest for Hispanic persons (<i>Health, United
States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A410/?report=objectonly" target="object">table 129</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA70" co-legend-rid="figlgndA70"><a href="/books/NBK20758/figure/A70/?report=objectonly" target="object" title="Figure 7" class="img_link icnblk_img figpopup" rid-figpopup="figA70" rid-ob="figobA70"><img class="small-thumb" src="/books/NBK20758/bin/pages47-48f7.gif" src-large="/books/NBK20758/bin/pages47-48f7.jpg" alt="Figure 7. No health insurance coverage among persons under 65 years of age by selected characteristics: United States 2002." /></a><div class="icnblk_cntnt" id="figlgndA70"><h4 id="A70"><a href="/books/NBK20758/figure/A70/?report=objectonly" target="object" rid-ob="figobA70">Figure 7</a></h4><p class="float-caption no_bottom_margin">No health insurance coverage among persons under 65 years of age by selected
characteristics: United States 2002.
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NOTES: Percents by poverty level, Hispanic origin, and race are age adjusted. <a href="/books/NBK20758/figure/A70/?report=objectonly" target="object" rid-ob="figobA70">(more...)</a></p></div></div></p><div id="A68.reflist0"><h4>References for figures 6 and 7</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A72">Institute of Medicine. Committee on the Consequences of
Uninsurance. Series of reports: Coverage matters: Insurance and health care; Care without
coverage; Health insurance is a family matter; A shared destiny: Community effects of
uninsurance; Hidden costs, value lost: Uninsurance in America. Washington, DC: National
Academy Press. 2001&#x02013;2003.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A73">Ayanian JZ , Weissman JS , Schneider EC . et al. Unmet health needs of uninsured adults in the United States. <span><span class="ref-journal">JAMA. </span>2000;<span class="ref-vol">285</span>(4):2061–9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11042754" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11042754</span></a>]</div></dd></dl></div></div></div><div id="A74"><h2 id="_A74_">Preventive Health Care</h2><div id="A75"><h3>Prenatal Care</h3><p>Prenatal care that begins in the first trimester and continues throughout pregnancy reduces
the risk of maternal morbidity and poor birth outcomes. Appropriate prenatal care can enhance
pregnancy outcome and long-term maternal health by managing preexisting and pregnancy-related
medical conditions, providing health behavior advice, and assessing the risk of poor pregnancy
outcome (<a class="bk_pop" href="#A79">1</a>). Attitudes toward pregnancy, lifestyle
factors, and cultural beliefs have been suggested as reasons women delay recommended prenatal
care. Financial and health insurance problems are among the most important barriers to such
care (<a class="bk_pop" href="#A80">2</a>). Expansion of Medicaid coverage for
pregnancy-related services has increased availability and use of prenatal care by low income
women (<a class="bk_pop" href="#A81">3</a>).</p><p>During the last three decades, the percent of mothers reporting prenatal care beginning in
the first trimester rose from 68 percent in 1970 to almost 84 percent by 2002 (<i>Health,
United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A284/?report=objectonly" target="object">table 6</a>). This upward
trend reflects increases during the 1970s and the 1990s. Increases in use of prenatal care
beginning in the first trimester are observed among mothers in all major racial and ethnic
groups (<a class="figpopup" href="/books/NBK20758/figure/A76/?report=objectonly" target="object" rid-figpopup="figA76" rid-ob="figobA76">figure 8</a>). Increases in use of prenatal care in
the 1990s were greatest for those with the lowest rates of care: Hispanic, non-Hispanic black,
and American Indian or Alaska Native women.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA76" co-legend-rid="figlgndA76"><a href="/books/NBK20758/figure/A76/?report=objectonly" target="object" title="Figure 8" class="img_link icnblk_img figpopup" rid-figpopup="figA76" rid-ob="figobA76"><img class="small-thumb" src="/books/NBK20758/bin/pages49-53f8.gif" src-large="/books/NBK20758/bin/pages49-53f8.jpg" alt="Figure 8. Early prenatal care by race and Hispanic origin of mother: United States, 1980&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA76"><h4 id="A76"><a href="/books/NBK20758/figure/A76/?report=objectonly" target="object" rid-ob="figobA76">Figure 8</a></h4><p class="float-caption no_bottom_margin">Early prenatal care by race and Hispanic origin of mother: United States,
1980&#x02013;2002.
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NOTES: Early prenatal care begins during the first trimester of pregnancy. See Data Table for data <a href="/books/NBK20758/figure/A76/?report=objectonly" target="object" rid-ob="figobA76">(more...)</a></p></div></div></p><p>Important racial and ethnic differences in the percent of mothers reporting early prenatal
care persist (<a class="figpopup" href="/books/NBK20758/figure/A77/?report=objectonly" target="object" rid-figpopup="figA77" rid-ob="figobA77">figure 9</a>). In 2002 the percent receiving
early care was higher for non-Hispanic white women than for non-Hispanic black women, American
Indian or Alaska Native women, and most groups of Hispanic women.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA77" co-legend-rid="figlgndA77"><a href="/books/NBK20758/figure/A77/?report=objectonly" target="object" title="Figure 9" class="img_link icnblk_img figpopup" rid-figpopup="figA77" rid-ob="figobA77"><img class="small-thumb" src="/books/NBK20758/bin/pages49-53f9.gif" src-large="/books/NBK20758/bin/pages49-53f9.jpg" alt="Figure 9. Early prenatal care by detailed race and Hispanic origin of mother: United States, 2002." /></a><div class="icnblk_cntnt" id="figlgndA77"><h4 id="A77"><a href="/books/NBK20758/figure/A77/?report=objectonly" target="object" rid-ob="figobA77">Figure 9</a></h4><p class="float-caption no_bottom_margin">Early prenatal care by detailed race and Hispanic origin of mother: United States,
2002.
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NOTES: Early prenatal care begins during the first trimester of pregnancy. Persons of
Hispanic origin <a href="/books/NBK20758/figure/A77/?report=objectonly" target="object" rid-ob="figobA77">(more...)</a></p></div></div></p><p>In 2002 about 4 percent of women began care in the third trimester of pregnancy or received
no care at all, compared with 6 percent in 1990. The proportion of women receiving late or no
prenatal care was highest among American Indian or Alaska Native women, non-Hispanic black
women, and women of Mexican origin (6&#x02013;8 percent) (<i>Health, United States,
2004</i>, <a href="/books/n/healthus04/trend-tables/table/A284/?report=objectonly" target="object">table 6</a>).</p><div id="A75.reflist0"><h4>References for figures 8 and 9</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A79">Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,
Munson ML. Births: Final data for 2002. National vital statistics reports; vol 52 no 10.
Hyattsville, Maryland: National Center for Health Statistics. 2003. [<a href="https://pubmed.ncbi.nlm.nih.gov/14717305" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14717305</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A80">Lewis CT, Mathews TJ, Heuser RL. Prenatal care in the United
States, 1980&#x02013;94. Vital Health Stat 21(54). Hyattsville, Maryland: National Center
for Health Statistics. 1996. [<a href="https://pubmed.ncbi.nlm.nih.gov/8797372" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 8797372</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A81">Rowland D , Salganicoff A , Keenan PS . The key to the door: Medicaid&#x02019;s role in improving health care for
women and children. <span><span class="ref-journal">Annu Rev Public Health. </span>1999;<span class="ref-vol">20</span>:403–26.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10352864" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10352864</span></a>]</div></dd></dl></div></div><div id="A82"><h3>Vaccination: Adults 65 Years of Age and Over</h3><p>In the United States influenza resulted in the death of about 36,000 persons 65 years of age
and over each year during the 1990s (<a class="bk_pop" href="#A87">1</a>). Pneumococcal
disease accounts for more deaths than any other vaccine-preventable bacterial disease. Annual
influenza vaccination and one dose of pneumococcal polysaccharide vaccine can lessen the risk
of illness and subsequent complications among older persons 65 years of age and over.</p><p>In 2002, 66 percent of noninstitutionalized adults 65 years of age and over reported an
influenza vaccination during the past year, the same percent as in 1999. Between 1989 and 1999
the percent more than doubled to 66 percent and then decreased slightly in 2000 and 2001 (<a class="figpopup" href="/books/NBK20758/figure/A83/?report=objectonly" target="object" rid-figpopup="figA83" rid-ob="figobA83">figure 10</a>). Between 1989 and 2002 the percent of adults 65
years of age and over ever having received a pneumococcal vaccine increased sharply from 14
percent to 56 percent. Several factors have been suggested as contributing to these increases:
greater acceptance of preventive health care by consumers and practitioners, improved Medicare
coverage for these vaccines since 1993, and wider delivery of this care by health care
providers other than physicians (<a class="bk_pop" href="#A88">2</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA83" co-legend-rid="figlgndA83"><a href="/books/NBK20758/figure/A83/?report=objectonly" target="object" title="Figure 10" class="img_link icnblk_img figpopup" rid-figpopup="figA83" rid-ob="figobA83"><img class="small-thumb" src="/books/NBK20758/bin/pages49-53f10.gif" src-large="/books/NBK20758/bin/pages49-53f10.jpg" alt="Figure 10. Influenza and pneumococcal vaccination among adults 65 years of age over: United States 1989&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA83"><h4 id="A83"><a href="/books/NBK20758/figure/A83/?report=objectonly" target="object" rid-ob="figobA83">Figure 10</a></h4><p class="float-caption no_bottom_margin">Influenza and pneumococcal vaccination among adults 65 years of age over: United
States 1989&#x02013;2002.
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NOTES: Data are for the civilian noninstitutionalized population and are age adjusted. <a href="/books/NBK20758/figure/A83/?report=objectonly" target="object" rid-ob="figobA83">(more...)</a></p></div></div></p><p>Although influenza and pneumococcal vaccination rates have increased for non-Hispanic and
Hispanic population groups, substantial gaps persist by race and ethnicity (<a class="bk_pop" href="#A89">3</a>). In 2000&#x02013;2002 vaccinations against influenza
were received by two-thirds of non-Hispanic white adults, nearly three-fifths of Asian adults,
and approximately one-half of Hispanic and non-Hispanic black older adults. Vaccinations
against pneumococcal disease were received by nearly three-fifths of non-Hispanic white, and
approximately one-third of Asian, non-Hispanic black, and Hispanic older adults (<a class="figpopup" href="/books/NBK20758/figure/A84/?report=objectonly" target="object" rid-figpopup="figA84" rid-ob="figobA84">figure 11</a>). Continued monitoring of vaccination rates for all
racial and ethnic groups is needed to apprise efforts to improve rates overall and to reduce
disparities in vaccination levels (<a class="bk_pop" href="#A90">4</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA84" co-legend-rid="figlgndA84"><a href="/books/NBK20758/figure/A84/?report=objectonly" target="object" title="Figure 11" class="img_link icnblk_img figpopup" rid-figpopup="figA84" rid-ob="figobA84"><img class="small-thumb" src="/books/NBK20758/bin/pages49-53f11.gif" src-large="/books/NBK20758/bin/pages49-53f11.jpg" alt="Figure 11. Influenza and pneumococcal vaccination among adults 65 years of age and over by race and Hispanic origin: United States 2000&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA84"><h4 id="A84"><a href="/books/NBK20758/figure/A84/?report=objectonly" target="object" rid-ob="figobA84">Figure 11</a></h4><p class="float-caption no_bottom_margin">Influenza and pneumococcal vaccination among adults 65 years of age and over by race
and Hispanic origin: United States 2000&#x02013;2002.
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NOTES: Data are for the civilian noninstitutionalized <a href="/books/NBK20758/figure/A84/?report=objectonly" target="object" rid-ob="figobA84">(more...)</a></p></div></div></p><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA85" co-legend-rid="figlgndA85"><a href="/books/NBK20758/figure/A85/?report=objectonly" target="object" title="Figure 12" class="img_link icnblk_img figpopup" rid-figpopup="figA85" rid-ob="figobA85"><img class="small-thumb" src="/books/NBK20758/bin/pages49-53f12.gif" src-large="/books/NBK20758/bin/pages49-53f12.jpg" alt="Figure 12. Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965&#x02013;2003." /></a><div class="icnblk_cntnt" id="figlgndA85"><h4 id="A85"><a href="/books/NBK20758/figure/A85/?report=objectonly" target="object" rid-ob="figobA85">Figure 12</a></h4><p class="float-caption no_bottom_margin">Cigarette smoking among men, women, high school students, and mothers during pregnancy:
United States, 1965&#x02013;2003.
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NOTES: Percents for men and women are age adjusted. See Data Table <a href="/books/NBK20758/figure/A85/?report=objectonly" target="object" rid-ob="figobA85">(more...)</a></p></div></div><div id="A82.reflist0"><h4>References for figures 10 and 11</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A87">Thompson WW . et al. Mortality associated with influenza and respiratory syncytial virus in the
United States. <span><span class="ref-journal">JAMA. </span>2003;<span class="ref-vol">289</span>(2):179–86.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12517228" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12517228</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A88">Singleton JA . et al. Influenza, pneumococcal, and tetanus toxoid vaccination of
adults&#x02014;United States, 1993&#x02013;97. In: CDC Surveillance
Summaries. <span><span class="ref-journal">MMWR. </span>2000;<span class="ref-vol">49(SS-9)</span>:39–62.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11016877" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11016877</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A89">Centers for Disease Control and Prevention. Racial/ethnic disparities in influenza and pneumococcal vaccination levels
among persons aged 65 years and over&#x02014;United States,
1989&#x02013;2001. <span><span class="ref-journal">MMWR. </span>2003;<span class="ref-vol">52</span>(40):958–62.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14534511" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14534511</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A90">Fedson, DS Adult immunization: Summary of the National Vaccine Advisory Committee
report. <span><span class="ref-journal">JAMA. </span>1994;<span class="ref-vol">272</span>(14):1133–7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/7933327" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 7933327</span></a>]</div></dd></dl></div></div></div><div id="A91"><h2 id="_A91_">Health Risk Factors</h2><div id="A92"><h3>Smoking</h3><p>As the leading cause of preventable death and disease in the United States, smoking is
associated with significantly increased risk of heart disease, stroke, lung cancer, and chronic
lung diseases (<a class="bk_pop" href="#A95">1</a>). Smoking during pregnancy contributes
to elevated risk of miscarriage, premature delivery, and having a low-birthweight infant.
Preventing smoking among teenagers is critical since smoking usually begins in adolescence
(<a class="bk_pop" href="#A96">2</a>). Decreasing cigarette smoking among adolescents and
adults is a major public health objective for the Nation.</p><p>Cigarette smoking among adult men and women declined substantially following the first
Surgeon General&#x02019;s Report on smoking in 1964 (<a class="figpopup" href="/books/NBK20758/figure/A85/?report=objectonly" target="object" rid-figpopup="figA85" rid-ob="figobA85">figure
12</a>). Since 1990 the percent of adults who smoke has continued to decline but at a
slower rate than previously. In 2002, 25 percent of men and 20 percent of women were smokers.
Cigarette smoking by adults continues to be strongly associated with educational attainment.
Among adults, persons with less than a high school education were almost three times as likely
to smoke as those with a bachelor&#x02019;s degree or more education (<i>Health, United
States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A339/?report=objectonly" target="object">table 61</a>).</p><p>Among high school students, the percent reporting recent cigarette smoking decreased between
1997 and 2003 after increasing in the early 1990s. During the last decade, a similar percent of
male and female students reported smoking. Despite the declines in cigarette smoking rates
among high school students, 26 percent of high school students in grade 12 were current smokers
in 2003, and 13 percent smoked on 20 or more days in the past month (frequent smokers) (<a class="figpopup" href="/books/NBK20758/figure/A93/?report=objectonly" target="object" rid-figpopup="figA93" rid-ob="figobA93">figure 13</a>). Many high school students who were frequent
smokers have already become nicotine dependent (<a class="bk_pop" href="#A97">3</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA93" co-legend-rid="figlgndA93"><a href="/books/NBK20758/figure/A93/?report=objectonly" target="object" title="Figure 13" class="img_link icnblk_img figpopup" rid-figpopup="figA93" rid-ob="figobA93"><img class="small-thumb" src="/books/NBK20758/bin/pages54-58f13.gif" src-large="/books/NBK20758/bin/pages54-58f13.jpg" alt="Figure 13. Current cigarette smoking among high school students by sex, frequency, and grade level: United States, 2003." /></a><div class="icnblk_cntnt" id="figlgndA93"><h4 id="A93"><a href="/books/NBK20758/figure/A93/?report=objectonly" target="object" rid-ob="figobA93">Figure 13</a></h4><p class="float-caption no_bottom_margin">Current cigarette smoking among high school students by sex, frequency, and grade
level: United States, 2003.
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NOTES: Current cigarette smoking is defined as having smoked cigarettes on 1 or <a href="/books/NBK20758/figure/A93/?report=objectonly" target="object" rid-ob="figobA93">(more...)</a></p></div></div></p><p>Among mothers with a live birth, the percent reporting smoking cigarettes during pregnancy
declined between 1989 and 2002 (<a class="bk_pop" href="#A98">4</a>,<a class="bk_pop" href="#A99">5</a>). Eleven percent of mothers with a live birth in 2002 reported smoking
cigarettes during pregnancy. Maternal smoking has declined for all racial and ethnic groups,
but differences among these groups persist (<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A289/?report=objectonly" target="object">table 11</a>). In 2002 the percent of mothers reporting tobacco
use during pregnancy was highest for American Indian or Alaska Native mothers (20 percent),
non-Hispanic white mothers (15 percent), and Hawaiian mothers (14 percent).</p><div id="A92.reflist0"><h4>References for figures 12 and 13</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A95">Centers for Disease Control and Prevention. Tobacco use&#x02014;United States, 1900&#x02013;1999. <span><span class="ref-journal">MMWR. </span>1999;<span class="ref-vol">48</span>(43):986–93.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10577492" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10577492</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A96">U.S. Department of Health and Human Services. Preventing
tobacco use among young people: A report of the Surgeon General. Atlanta, Georgia: Centers
for Disease Control and Prevention. 1994.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A97">Centers for Disease Control and Prevention. Trends in cigarette smoking among high school students&#x02014;United
States, 1991&#x02013;2001. <span><span class="ref-journal">MMWR. </span>2002;<span class="ref-vol">51</span>(19):409–12.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12033476" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12033476</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A98">Mathews TJ. Smoking during pregnancy in the 1990s. National
vital statistics reports; vol 49 no 7. Hyattsville, Maryland: National Center for Health
Statistics. 2001. [<a href="https://pubmed.ncbi.nlm.nih.gov/11561426" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11561426</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A99">Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data
for 2002. National vital statistics reports; vol 52 no 10. Hyattsville, Maryland: National
Center for Health Statistics. 2003. [<a href="https://pubmed.ncbi.nlm.nih.gov/14717305" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14717305</span></a>]</div></dd></dl></div></div><div id="A100"><h3>Physical Activity</h3><p>Benefits of regular physical activity include a reduced risk of premature mortality and
reduced risks of coronary heart disease, diabetes, colon cancer, hypertension, and
osteoporosis. In addition physical activity can enhance physical functioning and aid in weight
control (<a class="bk_pop" href="#A104">1</a>). It also improves symptoms associated with
musculoskeletal conditions and mental health conditions such as depression and anxiety.
Although vigorous physical activity produces the greatest cardiovascular benefits, moderate
amounts of physical activity are associated with lower levels of mortality. Among older
persons, even small amounts of physical activity may improve cardiovascular functioning (<a class="bk_pop" href="#A105">2</a>).</p><p>In 2003, 40 percent of female high school students and 27 percent of male high school
students reported a level of physical activity that did not meet the criteria for the
recommended amount of either moderate or vigorous physical activity (<a class="figpopup" href="/books/NBK20758/figure/A101/?report=objectonly" target="object" rid-figpopup="figA101" rid-ob="figobA101">figure 14</a>, see data table for definition of physical activity levels). The
percent that reported not engaging in recommended amounts of moderate and vigorous physical
activity was higher among students in 11th and 12th grade than among students in 9th and 10th
grade. Between 2001 and 2003 the percent of high school students reporting an insufficient
amount of moderate and vigorous physical activity remained stable (<a class="bk_pop" href="#A106">3</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA101" co-legend-rid="figlgndA101"><a href="/books/NBK20758/figure/A101/?report=objectonly" target="object" title="Figure 14" class="img_link icnblk_img figpopup" rid-figpopup="figA101" rid-ob="figobA101"><img class="small-thumb" src="/books/NBK20758/bin/pages54-58f14.gif" src-large="/books/NBK20758/bin/pages54-58f14.jpg" alt="Figure 14. High school students not engaging in recommended amounts of physical activity (neither moderate nor vigorous) by grade and sex: United States, 2003." /></a><div class="icnblk_cntnt" id="figlgndA101"><h4 id="A101"><a href="/books/NBK20758/figure/A101/?report=objectonly" target="object" rid-ob="figobA101">Figure 14</a></h4><p class="float-caption no_bottom_margin">High school students not engaging in recommended amounts of physical activity (neither
moderate nor vigorous) by grade and sex: United States, 2003.
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SOURCE: Centers for Disease Control and <a href="/books/NBK20758/figure/A101/?report=objectonly" target="object" rid-ob="figobA101">(more...)</a></p></div></div></p><p>In 2002 nearly 40 percent of noninstitutionalized adults 18 years of age and over reported
that they did not engage in physical activity during leisure time. The trend in leisure-time
physical activity among adult men and women has remained stable in recent years (<a class="figpopup" href="/books/NBK20758/figure/A102/?report=objectonly" target="object" rid-figpopup="figA102" rid-ob="figobA102">figure 15</a>). Among men and women, the percent that are
physically inactive during leisure time increases with age. More than one-half of adults 65
years of age and over indicated being physically inactive during leisure time compared with
about one-third of adults 18&#x02013;44 years of age. Women were more physically inactive
during leisure time than men of the same age, consistent with the pattern found among male and
female high school students.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA102" co-legend-rid="figlgndA102"><a href="/books/NBK20758/figure/A102/?report=objectonly" target="object" title="Figure 15" class="img_link icnblk_img figpopup" rid-figpopup="figA102" rid-ob="figobA102"><img class="small-thumb" src="/books/NBK20758/bin/pages54-58f15.gif" src-large="/books/NBK20758/bin/pages54-58f15.jpg" alt="Figure 15. Adults not engaging in leisure-time physical activity by age and sex: United States, 1998&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA102"><h4 id="A102"><a href="/books/NBK20758/figure/A102/?report=objectonly" target="object" rid-ob="figobA102">Figure 15</a></h4><p class="float-caption no_bottom_margin">Adults not engaging in leisure-time physical activity by age and sex: United States,
1998&#x02013;2002.
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NOTE: See Data Table for data points graphed,
standard errors, and additional notes <a href="/books/NBK20758/figure/A102/?report=objectonly" target="object" rid-ob="figobA102">(more...)</a></p></div></div></p><p>Leisure-time physical activity is one component of an active, healthy lifestyle and is
reflective of overall activity. A 2000 study that looked at both usual daily activity and
leisure-time physical activity showed that, consistent with the pattern found in leisure-time
activity, women were more likely than men to never engage in any physical activity overall, and
men were more likely than women to engage in a high level of physical activity overall (<a class="bk_pop" href="#A107">4</a>).</p><div id="A100.reflist0"><h4>References for figures 14 and 15</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A104">U.S. Department of Health and Human Services. Physical
activity and health: A report of the Surgeon General. Atlanta, Georgia: Centers for Disease
Control and Prevention. 1996.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A105">Mensink GB , Ziese T , Kok FJ . Benefits of leisure-time physical activity on the cardiovascular risk profile
at older age. <span><span class="ref-journal">Int J Epidemiol. </span>1999;<span class="ref-vol">28</span>(4):659–66.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10480693" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10480693</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A106">Grunbaum JA, Kann L, Kinchen SA, et al. Youth Risk Behavior
Surveillance&#x02014;United States, 2001. In: CDC Surveillance Summaries. MMWR 51(No.
SS-4). 2002. [<a href="https://pubmed.ncbi.nlm.nih.gov/12102329" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12102329</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A107">Barnes PM, Schoenborn CA. Physical activity among adults:
United States, 2000. Advance data from vital and health statistics; no 333. Hyattsville,
Maryland: National Center for Health Statistics. 2003.</div></dd></dl></div></div><div id="A108"><h3>Overweight and Obesity</h3><p>Epidemiologic and actuarial studies have shown that increased body weight is associated with
excess morbidity and mortality (<a class="bk_pop" href="#A112">1</a>). Among adults,
overweight and obesity elevate the risk of heart disease, diabetes, and some types of cancer.
Overweight and obesity are also factors that increase the severity of disease associated with
hypertension, arthritis, and other musculoskeletal problems (<a class="bk_pop" href="#A113">2</a>). Among children and adolescents, obesity increases the risk of high cholesterol,
hypertension, and diabetes (<a class="bk_pop" href="#A114">3</a>). Diet, physical
activity, genetic factors, and health conditions all contribute to overweight in children and
adults. The potential health benefits from reduction in the prevalence of overweight and
obesity are of significant public health importance.</p><p>Results from a series of National Health and Nutrition Examination Surveys indicate that the
prevalence of overweight and obesity changed little between the early 1960s and
1976&#x02013;80 (<a class="figpopup" href="/books/NBK20758/figure/A109/?report=objectonly" target="object" rid-figpopup="figA109" rid-ob="figobA109">figure 16</a>). Findings from the
1988&#x02013;94 and 1999&#x02013;2002 surveys, however, showed substantial increases in
overweight and obesity among adults. The upward trend in overweight since 1980 reflects
primarily an increase in the percent of adults 20&#x02013;74 years of age who are obese. In
1999&#x02013;2002, 65 percent of adults were overweight with 31 percent obese.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA109" co-legend-rid="figlgndA109"><a href="/books/NBK20758/figure/A109/?report=objectonly" target="object" title="Figure 16" class="img_link icnblk_img figpopup" rid-figpopup="figA109" rid-ob="figobA109"><img class="small-thumb" src="/books/NBK20758/bin/pages54-58f16.gif" src-large="/books/NBK20758/bin/pages54-58f16.jpg" alt="Figure 16. Overweight and obesity by age: United States, 1960-2002." /></a><div class="icnblk_cntnt" id="figlgndA109"><h4 id="A109"><a href="/books/NBK20758/figure/A109/?report=objectonly" target="object" rid-ob="figobA109">Figure 16</a></h4><p class="float-caption no_bottom_margin">Overweight and obesity by age: United States, 1960-2002.
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NOTES: Percents for adults are age adjusted. For adults: &#x0201c;overweight including
obese&#x0201d; Is defined as a body mass Index <a href="/books/NBK20758/figure/A109/?report=objectonly" target="object" rid-ob="figobA109">(more...)</a></p></div></div></p><p>The percent of children (6&#x02013;11 years of age) and adolescents (12&#x02013;19 years
of age) who are overweight has also risen. Among children and adolescents, the percent
overweight increased since 1976&#x02013;80. In 1999&#x02013;2002 about 16 percent of
children and adolescents were overweight. The prevalence of overweight among adolescents varies
by race and ethnicity. In 1999&#x02013;2002, 14 percent of non-Hispanic white adolescents, 21
percent of non-Hispanic black adolescents, and 23 percent of Mexican-origin adolescents were
overweight.</p><p>The prevalence of obesity varies among adults by sex, race, and ethnicity (<a class="figpopup" href="/books/NBK20758/figure/A110/?report=objectonly" target="object" rid-figpopup="figA110" rid-ob="figobA110">figure 17</a>). In 1999&#x02013;2002, 28 percent of men and 34
percent of women 20&#x02013;74 years of age were obese. The prevalence of obesity among women
differed significantly by racial and ethnic group; non-Hispanic black women had a higher
prevalence of obesity than did non-Hispanic white women. In 1999&#x02013;2002 one-half of
non-Hispanic black women were obese.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA110" co-legend-rid="figlgndA110"><a href="/books/NBK20758/figure/A110/?report=objectonly" target="object" title="Figure 17" class="img_link icnblk_img figpopup" rid-figpopup="figA110" rid-ob="figobA110"><img class="small-thumb" src="/books/NBK20758/bin/pages54-58f17.gif" src-large="/books/NBK20758/bin/pages54-58f17.jpg" alt="Figure 17. Obesity among adults 20-74 years of age by sex, race and Hispanic origin: United States, 1999&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA110"><h4 id="A110"><a href="/books/NBK20758/figure/A110/?report=objectonly" target="object" rid-ob="figobA110">Figure 17</a></h4><p class="float-caption no_bottom_margin">Obesity among adults 20-74 years of age by sex, race and Hispanic origin: United
States, 1999&#x02013;2002.
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NOTES: Percents are age adjusted. Obese is defined as a body mass index (BMI) greater <a href="/books/NBK20758/figure/A110/?report=objectonly" target="object" rid-ob="figobA110">(more...)</a></p></div></div></p><div id="A108.reflist0"><h4>References for figures 16 and 17</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A112">National Institutes of Health. Clinical guidelines on the
identification, evaluation, and treatment of overweight and obesity in adults: The evidence
report. NIH Pub. No. 98&#x02013;4083. September 1998. [<a href="https://pubmed.ncbi.nlm.nih.gov/9813653" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9813653</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A113">U.S. Department of Health and Human Services. The Surgeon
General&#x02019;s call to action to prevent and decrease overweight and obesity. Rockville,
Maryland. 2001.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A114">Dietz WH . Health consequences of obesity in youth: Childhood predictors of adult
disease. <span><span class="ref-journal">Pediatrics. </span>1998;<span class="ref-vol">101(3 Pt 2)</span>:518–25.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12224658" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12224658</span></a>]</div></dd></dl></div></div></div><div id="A115"><h2 id="_A115_">Limitation of Activity</h2><div id="A116"><h3>Limitation of Activity: Children</h3><p>Limitation of activity due to chronic physical, mental, or emotional disorders or deficits is
a broad measure of health and functioning that gauges a child&#x02019;s ability to engage in
major age-appropriate activities. Play is the primary activity for preschool children while
schoolwork is the primary activity for children 5 years of age and over. Estimates of the
number of children with an activity limitation may differ depending on the type of disabilities
included and the methods used to identify them (<a class="bk_pop" href="#A119">1</a>).</p><p>The National Health Interview Survey identifies children with activity limitation through
questions about specific limitations in play, self-care, walking, memory, and other activities
and through a question about current use of special education or early intervention services. A
child is classified as having an activity limitation due to a chronic condition if at least one
of the conditions causing limitations is a chronic physical, mental, or emotional problem.</p><p>Comparable national data on activity limitation have been available since 1997 (see <a href="/books/n/healthus04/app1/#A512">Appendix I, National Health Interview Survey</a>). Between 1997
and 2002 the percent of children with activity limitation was 6&#x02013;7 percent
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A334/?report=objectonly" target="object">table
56</a>). The percent of children with limitation of activity has varied consistently by age
and sex. In 2001&#x02013;02 the percent of children with activity limitation was
significantly higher among school-age children than among preschoolers, primarily due to the
number of school-age children identified solely by participation in special education.
Limitation of activity occurred nearly twice as often among boys as among girls (<a class="bk_pop" href="#A120">2</a>). Physiological, maturational, behavioral, and social
differences between boys and girls have been suggested as explanations for the higher
prevalence of activity limitation in boys (<a class="bk_pop" href="#A121">3</a>).</p><p>In 2001&#x02013;02 the leading chronic health conditions causing activity limitation in
children differed by age (<a class="figpopup" href="/books/NBK20758/figure/A117/?report=objectonly" target="object" rid-figpopup="figA117" rid-ob="figobA117">figure 18</a>). Among preschool
children, the three chronic conditions most often mentioned were speech problems, asthma, and
mental retardation. Among all school-age children, learning disability and Attention Deficit
Hyperactivity Disorder (ADHD) were among the top three leading causes of activity limitation.
The third leading cause among younger school-age children was speech problems and among older
school-age children it was other mental, emotional, and behavioral problems.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA117" co-legend-rid="figlgndA117"><a href="/books/NBK20758/figure/A117/?report=objectonly" target="object" title="Figure 18" class="img_link icnblk_img figpopup" rid-figpopup="figA117" rid-ob="figobA117"><img class="small-thumb" src="/books/NBK20758/bin/pages59-64f18.gif" src-large="/books/NBK20758/bin/pages59-64f18.jpg" alt="Figure 18. Selected chronic health conditions causing limitation of activity among children by age: United States, 2001-02." /></a><div class="icnblk_cntnt" id="figlgndA117"><h4 id="A117"><a href="/books/NBK20758/figure/A117/?report=objectonly" target="object" rid-ob="figobA117">Figure 18</a></h4><p class="float-caption no_bottom_margin">Selected chronic health conditions causing limitation of activity among children by
age: United States, 2001-02.
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NOTES: Children with more than one chronic health condition causing activity <a href="/books/NBK20758/figure/A117/?report=objectonly" target="object" rid-ob="figobA117">(more...)</a></p></div></div></p><div id="A116.reflist0"><h4>References for figure 18</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A119">Newacheck PW , Strickland B , Shonkoff JP . et al. An epidemiologic profile of children with special health care
needs. <span><span class="ref-journal">Pediatrics. </span>1998;<span class="ref-vol">102</span>(1):117–21.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9651423" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9651423</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A120">Centers for Disease Control and Prevention, National Center
for Health Statistics, National Health Interview Survey, unpublished analysis.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A121">Gissler M , Jarvelin M-R , Louhiala P , Hemminki E . Boys have more health problems in childhood than girls: Follow-up of the 1987
Finnish birth cohort. <span><span class="ref-journal">Acta Paediatr. </span>1999;<span class="ref-vol">88</span>:310–4.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10229043" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10229043</span></a>]</div></dd></dl></div></div><div id="A122"><h3>Limitation of Activity: Working-Age Adults</h3><p>Measuring limitations in everyday activities due to chronic physical, mental, or emotional
problems is one way to assess the impact of health conditions on self care and social
participation (<a class="bk_pop" href="#A126">1</a>). The effect that chronic health
conditions have on activity limitation may vary with the availability of supportive and health
care services.</p><p>In the National Health Interview Survey, limitation of activity in adults includes
limitations in handling personal care needs (activities of daily living), routine needs
(instrumental activities of daily living), having a job outside the home, walking, remembering,
and other activities. Comparable national data on activity limitation have been available since
1997 (see <a href="/books/n/healthus04/app1/#A512">Appendix I, National Health Interview Survey</a>).
Between 1997 and 2002 the percent of working-age adults 18&#x02013;64 years of age reporting
any activity limitation caused by a chronic health condition remained relatively stable
(<i>Health, United States, 2004,</i>
<a href="/books/n/healthus04/trend-tables/table/A334/?report=objectonly" target="object">table 56</a>).</p><p>In 2000&#x02013;2002, 6 percent of younger adults 18&#x02013;44 years of age reported
limitation in activity, in contrast to 21 percent of adults 55&#x02013;64 years of age (<a class="figpopup" href="/books/NBK20758/figure/A123/?report=objectonly" target="object" rid-figpopup="figA123" rid-ob="figobA123">figure 19</a>). Differences in limitation of activity by poverty
status are substantial; the percent of poor working-age adults reporting a limitation was more
than three times that of adults with family income at 200 percent or more of the poverty level.
After adjusting for differences in age, limitation of activity was about the same for men and
women. Limitation of activity varies modestly by race and Hispanic origin from 8 percent of
Hispanic persons to 12 percent of non-Hispanic black persons.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA123" co-legend-rid="figlgndA123"><a href="/books/NBK20758/figure/A123/?report=objectonly" target="object" title="Figure 19" class="img_link icnblk_img figpopup" rid-figpopup="figA123" rid-ob="figobA123"><img class="small-thumb" src="/books/NBK20758/bin/pages59-64f19.gif" src-large="/books/NBK20758/bin/pages59-64f19.jpg" alt="Figure 19. Limitation of activity caused by 1 or more chronic health conditions among working-age adults by selected characteristics: United States, 2000&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA123"><h4 id="A123"><a href="/books/NBK20758/figure/A123/?report=objectonly" target="object" rid-ob="figobA123">Figure 19</a></h4><p class="float-caption no_bottom_margin">Limitation of activity caused by 1 or more chronic health conditions among working-age
adults by selected characteristics: United States, 2000&#x02013;2002.
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NOTES: Data are for the civilian <a href="/books/NBK20758/figure/A123/?report=objectonly" target="object" rid-ob="figobA123">(more...)</a></p></div></div></p><p>Health surveys that measure limitation of activity have typically asked about chronic
conditions causing these restrictions. Health conditions usually refer to broad categories of
disease and impairment rather than medical diagnoses and reflect the understanding the general
public has of factors causing disability or limitation of activity (<a class="bk_pop" href="#A127">2</a>). Among working-age adults, arthritis and other musculoskeletal conditions
were the most frequently mentioned chronic conditions causing limitation of activity (<a class="figpopup" href="/books/NBK20758/figure/A124/?report=objectonly" target="object" rid-figpopup="figA124" rid-ob="figobA124">figure 20</a>). Among persons 18&#x02013;44 years of age,
mental illness was the second most prevalent cause of activity limitation. Among older
working-age adults (45&#x02013;64 years), heart disease was the second most frequently
mentioned condition. Persons who reported more than one chronic health condition as the cause
of their activity limitation were counted in each category.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA124" co-legend-rid="figlgndA124"><a href="/books/NBK20758/figure/A124/?report=objectonly" target="object" title="Figure 20" class="img_link icnblk_img figpopup" rid-figpopup="figA124" rid-ob="figobA124"><img class="small-thumb" src="/books/NBK20758/bin/pages59-64f20.gif" src-large="/books/NBK20758/bin/pages59-64f20.jpg" alt="Figure 20. Selected chronic health conditions causing limitation of activity among working-age adults by age: United States, 2000&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA124"><h4 id="A124"><a href="/books/NBK20758/figure/A124/?report=objectonly" target="object" rid-ob="figobA124">Figure 20</a></h4><p class="float-caption no_bottom_margin">Selected chronic health conditions causing limitation of activity among working-age
adults by age: United States, 2000&#x02013;2002.
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NOTES: Persons may report more than one chronic health <a href="/books/NBK20758/figure/A124/?report=objectonly" target="object" rid-ob="figobA124">(more...)</a></p></div></div></p><div id="A122.reflist0"><h4>References for figures 19 and 20</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A126">Guralnik JM , Fried LP , Salive ME . Disability as a public health outcome in the aging population. <span><span class="ref-journal">Annu Rev Public Health. </span>1996;<span class="ref-vol">17</span>:25–46.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/8724214" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 8724214</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A127">Fujiura GT, Rutkowski-Kmitta V. Counting disability. In:
Albrecht GL, Seelman KD, Bury M, eds. Handbook of disability studies. Thousand Oaks,
California: Sage Publications, 69&#x02013;96, 2001.</div></dd></dl></div></div><div id="A128"><h3>Limitation of Activity: Adults 65 Years of Age and Over</h3><p>The ability to perform basic activities of daily living (ADL) such as bathing, dressing, and
using the toilet, is an indicator of the health and functional well-being of the older
population. Being limited in ADLs compromises the quality of life of older persons and often
results in the need for informal or formal caregiving services, including
institutionalization.</p><p>The Medicare Current Beneficiary Survey reports the health and health care utilization of a
representative sample of Medicare beneficiaries of all ages and in all types of residences,
both institutional and noninstitutional. Respondents are asked about their level of difficulty
and the kind of assistance received in performing six ADLs: bathing or showering, dressing,
eating, getting in or out of bed or chairs, walking, and using the toilet. The definition of
limitation here includes persons who have difficulty and who receive help or supervision
performing at least one of the six activities.</p><p>From 1992 to 2002 the percent of all Medicare beneficiaries 65 years of age and over who were
limited in at least one of six ADLs declined from 16 percent to 14 percent (<a class="figpopup" href="/books/NBK20758/figure/A129/?report=objectonly" target="object" rid-figpopup="figA129" rid-ob="figobA129">figure 21</a>). During the same period the percent of Medicare
beneficiaries 65 years of age and over who were limited in ADLs ranged between 10&#x02013;12
percent for noninstitutionalized beneficiaries and between 86&#x02013;93 percent for
institutionalized beneficiaries. In 2002, 11 percent of noninstitutionalized and 90 percent of
institutionalized beneficiaries were limited in at least one of six ADLs. About 5 percent of
Medicare beneficiaries 65 years of age and over are institutionalized. Over time, the
distinction between noninstitutionalized and institutionalized settings has blurred as
&#x02018;&#x02018;assisted living&#x02019;&#x02019; facilities have become more
prominent. Trends in activity limitation for both noninstitutionalized and institutionalized
beneficiaries may be affected by the emergence of assisted living and other types of
residential settings for older Americans.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA129" co-legend-rid="figlgndA129"><a href="/books/NBK20758/figure/A129/?report=objectonly" target="object" title="Figure 21" class="img_link icnblk_img figpopup" rid-figpopup="figA129" rid-ob="figobA129"><img class="small-thumb" src="/books/NBK20758/bin/pages59-64f21.gif" src-large="/books/NBK20758/bin/pages59-64f21.jpg" alt="Figure 21. Limitation of activities of daily living among Medicare beneficiaries 65 years of age and over: United States, 1992&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA129"><h4 id="A129"><a href="/books/NBK20758/figure/A129/?report=objectonly" target="object" rid-ob="figobA129">Figure 21</a></h4><p class="float-caption no_bottom_margin">Limitation of activities of daily living among Medicare beneficiaries 65 years of age
and over: United States, 1992&#x02013;2002.
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NOTES: Percents are age adjusted. Limitation of activities <a href="/books/NBK20758/figure/A129/?report=objectonly" target="object" rid-ob="figobA129">(more...)</a></p></div></div></p><p>Among noninstitutionalized older Medicare beneficiaries, the percent limited in ADLs was
higher for women than men and rises with age for both women and men. For the oldest age group,
persons 85 years of age and over, 27 percent of women and 24 percent of men received help or
supervision with at least one basic activity of daily living in 2002. Among persons in
institutions, nearly all, regardless of age, received help or supervision with ADLs (89 percent
of men and 90 percent of women) (<a class="bk_pop" href="#A131">1</a>).</p><p>Some studies show that limitations in certain aspects of disability have declined among the
older population, including the ability to perform physical tasks such as walking up steps and
reaching arms overhead and the ability to perform instrumental activities of daily living
(IADLs) such as shopping and managing money (<a class="bk_pop" href="#A132">2&#x02013;5</a>). Evidence on the trends in ADL limitation is mixed, but a recent study
shows declines in certain measures of ADL limitation beginning in the mid-1990s (<a class="bk_pop" href="#A136">6</a>). More studies over a longer time period are needed to
determine whether a sustained overall decline in ADL limitation is occurring.</p><div id="A128.reflist0"><h4>References for figure 21</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A131">Centers for Medicare and Medicaid Services, Medicare Current
Beneficiary Survey, Access to Care files, unpublished analysis.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A132">Freedman V , Martin L . Understanding trends in functional limitations among older
Americans. <span><span class="ref-journal">AJPH. </span>1998;<span class="ref-vol">88</span>:1457–62.</span> [<a href="/pmc/articles/PMC1508476/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC1508476</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/9772844" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9772844</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A133">Lentzner HR, Weeks JD, Feldman JJ. Changes in disability in
the elderly population: Preliminary results from the Second Supplement on Aging. Paper
presented at the annual meetings of the Population Association of America. Chicago, Illinois:
April 1998.</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A134">Crimmins E , Saito Y , Reynolds S . Further evidence on recent trends in the prevalence and incidence of
disability among older Americans from two sources: The LSOA and the NHIS. <span><span class="ref-journal">J. Gerontol. </span>1997;<span class="ref-vol">52B</span>(2):S59–71.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9060986" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9060986</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A135">Manton KG , Gu X . Changes in the prevalence of chronic disability in the United States black and
nonblack population above 65 from 1982 to 1999. <span><span class="ref-journal">PNAS. </span>2001;<span class="ref-vol">98</span>(11):6354–9.</span> [<a href="/pmc/articles/PMC33472/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC33472</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/11344275" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11344275</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="A136">Freedman VA, Crimmins E, Schoeni RF, Spillman B, Aykan H,
Kramarow E, Land K, Lubitz J, Manton K, Martin LG, Shinberg D, Waidmann T. Resolving
inconsistencies in old-age disability: Report from a technical working group. Demography
41(3):417&#x02013;41. August 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15461008" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 15461008</span></a>]</div></dd></dl></div></div></div><div id="A137"><h2 id="_A137_">Mortality</h2><div id="A138"><h3>Life Expectancy</h3><p>Life expectancy is a measure often used to gauge the overall health of a population. As a
summary measure of mortality, life expectancy represents the average number of years of life
that could be expected if current death rates were to remain constant. Shifts in life
expectancy are often used to describe trends in mortality. Life expectancy at birth is strongly
influenced by infant and child mortality. Life expectancy later in life reflects death rates at
or above a given age and is independent of the effect of mortality at younger ages (<a class="bk_pop" href="#A141">1</a>).</p><p>During the 20th century, life expectancy at birth increased from 48 to 74 years of age for
men and from 51 to almost 80 years of age for women (<a class="figpopup" href="/books/NBK20758/figure/A139/?report=objectonly" target="object" rid-figpopup="figA139" rid-ob="figobA139">figure
22</a>). Improvements in nutrition, housing, hygiene, and medical care contributed to
decreases in death rates throughout the lifespan. Prevention and control of infectious diseases
had a profound impact on life expectancy in the first half of the 20th century (<a class="bk_pop" href="#A142">2</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA139" co-legend-rid="figlgndA139"><a href="/books/NBK20758/figure/A139/?report=objectonly" target="object" title="Figure 22" class="img_link icnblk_img figpopup" rid-figpopup="figA139" rid-ob="figobA139"><img class="small-thumb" src="/books/NBK20758/bin/pages65-70f22.gif" src-large="/books/NBK20758/bin/pages65-70f22.jpg" alt="Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 1991&#x02013;2001." /></a><div class="icnblk_cntnt" id="figlgndA139"><h4 id="A139"><a href="/books/NBK20758/figure/A139/?report=objectonly" target="object" rid-ob="figobA139">Figure 22</a></h4><p class="float-caption no_bottom_margin">Life expectancy at birth and at 65 years of age by sex: United States,
1991&#x02013;2001.
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NOTE: See Data Table for data points graphed and
additional notes.</p></div></div></p><p>Life expectancy at age 65 years also increased during the last century. Among men, life
expectancy at age 65 years rose from 12 to 16 years and among women from 12 to 19 years of age.
In contrast to life expectancy at birth, which increased sharply early in the century, life
expectancy at age 65 years improved primarily after 1950. Improved access to health care,
advances in medicine, healthier lifestyles, and better health before age 65 years are factors
underlying decreased death rates among older Americans (<a class="bk_pop" href="#A143">3</a>).</p><p>While the overall trend in life expectancy for the United States was upward throughout the
20th century, the gain in years of life expectancy for women generally exceeded that for men
until the 1970s, widening the gap in life expectancy between men and women. The increasing gap
during those years is attributed to increases in male mortality due to ischemic heart disease
and lung cancer, both of which increased largely as the result of men&#x02019;s early and
widespread adoption of cigarette smoking (<a class="bk_pop" href="#A144">4</a>). After the
1970s the gain in life expectancy for men exceeded that for women and the gender gap in life
expectancy began to narrow. Between 1990 and 2001 the total gain in life expectancy for women
was 1 year compared with more than 2 years for men, reflecting proportionately greater
decreases in heart disease and cancer mortality for men than for women and proportionately
larger increases in chronic lower respiratory disease mortality among women (<a class="bk_pop" href="#A144">4</a>).</p><p>Longer life expectancies at birth in many other developed countries suggest the possibility
of improving longevity in the United States (<i>Health, United States, 2004</i>,
<a href="/books/n/healthus04/trend-tables/table/A304/?report=objectonly" target="object">table 26</a>). Decreasing death rates of less advantaged
groups could raise life expectancy in the United States (<i>Health, United States,
2004</i>, <a href="/books/n/healthus04/trend-tables/table/A305/?report=objectonly" target="object">table 27</a>).</p><div id="A138.reflist0"><h4>References for figure 22</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A141">Arriaga EE . Measuring and explaining the change in life expectancies. <span><span class="ref-journal">Demography. </span>1984;<span class="ref-vol">21</span>(1):83–96.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/6714492" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 6714492</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A142">Centers for Disease Control and Prevention. Achievements in public health, 1900&#x02013;1999: Control of infectious
diseases. <span><span class="ref-journal">MMWR. </span>1999;<span class="ref-vol">48</span>(29):621–9.</span></div></dd><dt>3.</dt><dd><div class="bk_ref" id="A143">Fried LP . Epidemiology of aging. <span><span class="ref-journal">Epidemiol Rev. </span>2000;<span class="ref-vol">22</span>(1):95–106.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10939013" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10939013</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A144">Arias E. United States life tables, 2001. National vital
statistics reports; vol 52 no 13. Hyattsville, Maryland: National Center for Health
Statistics. 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15008552" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 15008552</span></a>]</div></dd></dl></div></div><div id="A145"><h3>Infant Mortality</h3><p>Infant mortality, the risk of death during the first year of life, is related to the
underlying health of the mother, public health practices, socioeconomic conditions, and
availability and use of appropriate health care for infants and pregnant women. Disorders
related to short gestation and low birthweight, and congenital malformations are the leading
causes of death during the first month of life (neonatal mortality). Sudden Infant Death
Syndrome (SIDS) and congenital malformations rank as the leading causes of infant deaths after
the first month of life (postneonatal mortality) (<a class="bk_pop" href="#A149">1</a>).</p><p>Between 1950 and 2001 the infant mortality rate declined by almost 77 percent (<a class="figpopup" href="/books/NBK20758/figure/A146/?report=objectonly" target="object" rid-figpopup="figA146" rid-ob="figobA146">figure 23</a>). In 2002 the infant mortality rate increased to
7.0 infant deaths per 1,000 live births up from 6.8 in 2001 (<a class="bk_pop" href="#A150">2</a>,<a class="bk_pop" href="#A151">3</a>). This was the first year since 1958 that
the rate has not declined or remained unchanged. Based on an analysis of the preliminary data,
the rise in infant mortality was attributed to an increase in neonatal infant deaths (infants
less than 28 days old). Two-thirds of all infant deaths occur during the neonatal period
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A300/?report=objectonly" target="object">table
22</a>). Provisional counts of infant deaths for the first 9 months of 2003 suggest an
improvement in the infant mortality rate for 2003. However, the provisional data are not stable
enough to determine if the improvement is large enough to bring the rate down to the
historically low level reached in 2001.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA146" co-legend-rid="figlgndA146"><a href="/books/NBK20758/figure/A146/?report=objectonly" target="object" title="Figure 23" class="img_link icnblk_img figpopup" rid-figpopup="figA146" rid-ob="figobA146"><img class="small-thumb" src="/books/NBK20758/bin/pages65-70f23.gif" src-large="/books/NBK20758/bin/pages65-70f23.jpg" alt="Figure 23. Infant, neonatal , and postneonatal mortality rates: United States, 1950&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA146"><h4 id="A146"><a href="/books/NBK20758/figure/A146/?report=objectonly" target="object" rid-ob="figobA146">Figure 23</a></h4><p class="float-caption no_bottom_margin">Infant, neonatal , and postneonatal mortality rates: United States,
1950&#x02013;2002.
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NOTES: Infant is defined as under 1 year of age, neonatal as under 28 days of age, and
postneonatal as <a href="/books/NBK20758/figure/A146/?report=objectonly" target="object" rid-ob="figobA146">(more...)</a></p></div></div></p><p>Declines in infant mortality over the past five decades have been linked to improved access
to health care, advances in neonatal medicine, and public health education campaigns such as
the &#x02018;&#x02018;Back to Sleep&#x02019;&#x02019; campaign to curb fatalities
caused by SIDS (<a class="bk_pop" href="#A152">4</a>).</p><p>Infant mortality rates have declined for all racial and ethnic groups, but large disparities
remain (<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A297/?report=objectonly" target="object">table
19</a>). During 1999&#x02013;2001 the infant mortality rate was highest for infants of
non-Hispanic black mothers (<a class="figpopup" href="/books/NBK20758/figure/A147/?report=objectonly" target="object" rid-figpopup="figA147" rid-ob="figobA147">figure 24</a>) (<a class="bk_pop" href="#A153">5</a>). Infant mortality rates were also high among infants of
American Indian or Alaska Native mothers, Puerto Rican mothers, and Hawaiian mothers. Infants
of mothers of Chinese origin had the lowest infant mortality rates.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA147" co-legend-rid="figlgndA147"><a href="/books/NBK20758/figure/A147/?report=objectonly" target="object" title="Figure 24" class="img_link icnblk_img figpopup" rid-figpopup="figA147" rid-ob="figobA147"><img class="small-thumb" src="/books/NBK20758/bin/pages65-70f24.gif" src-large="/books/NBK20758/bin/pages65-70f24.jpg" alt="Figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999&#x02013;2001." /></a><div class="icnblk_cntnt" id="figlgndA147"><h4 id="A147"><a href="/books/NBK20758/figure/A147/?report=objectonly" target="object" rid-ob="figobA147">Figure 24</a></h4><p class="float-caption no_bottom_margin">Infant mortality rates by detailed race and Hispanic origin of mother: United States,
1999&#x02013;2001.
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NOTES: Infant is defined as under 1 year of age. Persons of Hispanic origin may be <a href="/books/NBK20758/figure/A147/?report=objectonly" target="object" rid-ob="figobA147">(more...)</a></p></div></div></p><div id="A145.reflist0"><h4>References for figures 23 and 24</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A149">Anderson RN, Smith BL. Deaths: Leading causes for 2001.
National vital statistics reports; vol 52 no 9. Hyattsville, Maryland: National Center for
Health Statistics. 2003. [<a href="https://pubmed.ncbi.nlm.nih.gov/14626726" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14626726</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A150">Kochanek KD, Martin JA. Supplemental analyses of recent trends
in infant mortality. Health E Stats; Hyattsville, Maryland. National Center for Health
Statistics. 2004. Available at: <a href="http://www.cdc.gov/nchs/products/pubs/pubd/hestats/infantmort/infantmort.htm" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.cdc.gov/nchs/products<wbr style="display:inline-block"></wbr>​/pubs/pubd/hestats<wbr style="display:inline-block"></wbr>​/infantmort/infantmort.htm</a>.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A151">Kochanek KD, Smith BL. Deaths: Preliminary data for 2002.
National vital statistics reports; vol 52 no 13. Hyattsville, Maryland: National Center for
Health Statistics. 2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/14998175" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14998175</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A152">American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. <span><span class="ref-journal">Pediatrics. </span>1992;<span class="ref-vol">89</span>(6):1120–6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/1503575" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 1503575</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A153">Data from the 2000&#x02013;2002 linked birth and infant
death file were not available to be included in this report. See <a href="http://www.cdc.gov/nchs" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.cdc.gov/nchs</a> for updated
information.</div></dd></dl></div></div><div id="A154"><h3>Leading Causes of Death for All Ages</h3><p>In 2002 a total of 2.4 million deaths were reported in the United States. The overall
age-adjusted death rate was 42 percent lower in 2002 than it was in 1950. The reduction in
overall mortality during the last half of the 20th century was driven mostly by declines in
mortality for such leading causes of death as heart disease, stroke, and unintentional injuries
(<a class="figpopup" href="/books/NBK20758/figure/A155/?report=objectonly" target="object" rid-figpopup="figA155" rid-ob="figobA155">figure 25</a>).</p><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA155" co-legend-rid="figlgndA155"><a href="/books/NBK20758/figure/A155/?report=objectonly" target="object" title="Figure 25" class="img_link icnblk_img figpopup" rid-figpopup="figA155" rid-ob="figobA155"><img class="small-thumb" src="/books/NBK20758/bin/pg70f25.gif" src-large="/books/NBK20758/bin/pg70f25.jpg" alt="Figure 25. Death rates for leading causes of death for all ages: United States, 1950&#x02013;2002." /></a><div class="icnblk_cntnt" id="figlgndA155"><h4 id="A155"><a href="/books/NBK20758/figure/A155/?report=objectonly" target="object" rid-ob="figobA155">Figure 25</a></h4><p class="float-caption no_bottom_margin">Death rates for leading causes of death for all ages: United States,
1950&#x02013;2002.
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NOTES: Rates are age adjusted. Causes of death shown are the five leading causes of death
for all ages <a href="/books/NBK20758/figure/A155/?report=objectonly" target="object" rid-ob="figobA155">(more...)</a></p></div></div><p>Throughout the second half of the 20th century, heart disease was the leading cause of death
and stroke was the third leading cause. In 2002 the death rate for heart disease was 59 percent
lower than the rate in 1950. The death rate for stroke declined 69 percent since 1950
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A314/?report=objectonly" target="object">tables
36</a> and <a href="/books/n/healthus04/trend-tables/table/A315/?report=objectonly" target="object">37</a>). Heart disease and stroke mortality
are associated with risk factors such as high blood cholesterol, high blood pressure, smoking,
and dietary factors. Other important factors include socioeconomic status, obesity, and
physical inactivity. Factors contributing to the decline in heart disease and stroke mortality
include better control of risk factors, improved access to early detection, and better
treatment and care, including new drugs and expanded uses for existing drugs (<a class="bk_pop" href="#A157">1</a>).</p><p>Cancer was the second leading cause of death throughout the period. Overall cancer death
rates rose between 1960 and 1990 and then reversed direction. Between 1990 and 2002 overall
death rates for cancer declined more than 10 percent. In the 1980s cancer death rates for
females increased faster and in the 1990s declined more slowly than rates for males, reducing
the disparity in cancer death rates. Rates for males were 63 percent higher than rates for
females in 1980 and 46 percent higher in 2002. The trend in the overall cancer death rate
reflects the trend in the death rate for lung cancer (<i>Health, United States,
2004</i>, <a href="/books/n/healthus04/trend-tables/table/A316/?report=objectonly" target="object">tables 38</a> and <a href="/books/n/healthus04/trend-tables/table/A317/?report=objectonly" target="object">39</a>). Since 1970 the death rate for lung cancer for the total population has
been higher than the death rate for any other cancer site. Lung cancer is strongly associated
with smoking.</p><p>Chronic lower respiratory disease (CLRD) was the fourth leading cause of death in 2002. The
death rate for CLRD in 2002 was 54 percent higher than the rate in 1980. The upward trajectory
for CLRD death rates is a result of steadily increasing death rates for females, which
increased more than 150 percent between 1980 and 2002, while death rates for males increased
only 7 percent. The increasing trend for females is most noticeable for females age 55 years
and over (<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A319/?report=objectonly" target="object">table
41</a>). CLRD is strongly associated with smoking.</p><p>The fifth leading cause of death in 2002 was unintentional injuries. Death rates for
unintentional injuries declined during the period 1950&#x02013;1992. Since 1992, however,
unintentional injury mortality has increased slightly. Despite recent increases, the death rate
for unintentional injuries in 2002 was still 53 percent lower than the rate in 1950. The risk
of death due to unintentional injuries is greater for males than females (<i>Health,
United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A307/?report=objectonly" target="object">table 29</a>) and the risk
varies with age. For males age 15&#x02013;64 years in 2002, the risk of death due to
unintentional injuries was 2&#x02013;3 times the risk for females of those ages. For ages
under 15 years and 65 years and over, the gender disparity was smaller. The risk of death due
to unintentional injuries increased steeply after age 64 years for both males and females.</p><p>Although overall unintentional injury mortality has increased slightly since the early 1990s,
the trend in motor vehicle-related injury mortality, which accounts for approximately one-half
of all unintentional injury mortality, has been generally downward since the 1970s
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A322/?report=objectonly" target="object">table
44</a>). The decline in death rates for motor vehicle-related injuries is a result of safer
vehicles and highways; behavioral changes such as increased use of safety belts, child safety
seats, and motorcycle helmets; and decreased drinking and driving (<a class="bk_pop" href="#A158">2</a>).</p><p>Death rates increase with age for chronic diseases such as heart disease, cancer, stroke, and
chronic lower respiratory diseases, as well as for unintentional injuries. Death rates for
black persons exceed those for white persons of the same gender for each of these causes.
Socioeconomic factors are strongly associated with risk of death. Adult males and females with
a high school education or less had death rates more than twice as high as the rates for those
with more than a high school education in 2002 (<i>Health, United States, 2004</i>,
<a href="/books/n/healthus04/trend-tables/table/A312/?report=objectonly" target="object">table 34</a>).</p><div id="A154.reflist0"><h4>References for figure 25</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A157">Centers for Disease Control and Prevention. Decline in deaths from heart disease and stroke&#x02014;United States,
1900&#x02013;1999. <span><span class="ref-journal">MMWR. </span>1999;<span class="ref-vol">48</span>(30):649–56.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10488780" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10488780</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A158">Centers for Disease Control and Prevention. Motor-vehicle safety: A 20th century public health achievement. <span><span class="ref-journal">MMWR. </span>1999;<span class="ref-vol">48</span>(18):369–74.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10369577" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10369577</span></a>]</div></dd></dl></div></div></div><div id="A159"><h2 id="_A159_">Special Feature: Drugs</h2><div id="A160"><h3>Overall Drug Use</h3><p>Drugs&#x02014;both prescription and nonprescription&#x02014;are becoming a more
frequently utilized therapy for reducing morbidity and mortality, and improving the quality of
life of Americans. Factors affecting the increase in utilization of medications include the
growth of third-party insurance coverage for drugs, the availability of effective new drugs,
marketing to physicians and increasingly directly to consumers, and clinical guidelines
recommending increased use of medications for conditions such as high cholesterol, high blood
pressure, chronic asthma, and diabetes (<a class="bk_pop" href="#A171">1</a>,<a class="bk_pop" href="#A172">2</a>). This increased utilization is reflected in higher
expenditures. Between 1995 and 2002 expenditures for prescription drugs grew at a faster rate
than expenditures for other types of health care (<i>Health, United States, 2004</i>,
<a href="/books/n/healthus04/trend-tables/table/A399/?report=objectonly" target="object">table 118</a>).</p><p>The National Health and Nutrition Examination Survey (NHANES) collects data on the
prescription drug use of survey participants during in-person household interviews. Between
1988&#x02013;94 and 1999&#x02013;2000 NHANES data show that the percent of Americans of all
ages who reported using any prescribed medication during the past month increased from 39 to 44
percent (age adjusted; <a class="figpopup" href="/books/NBK20758/figure/A161/?report=objectonly" target="object" rid-figpopup="figA161" rid-ob="figobA161">figure 26</a>). During the same
period the percent of persons who reported using three or more drugs in the past month
increased from 12 to 17 percent (age adjusted) of the population. Perhaps most striking is the
increase in the percent of older persons who reported taking three or more prescribed
medications during a one-month period&#x02014;almost one-half of those 65 and over in
1999&#x02013;2000&#x02014;compared with just over one-third in 1988&#x02013;94.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA161" co-legend-rid="figlgndA161"><a href="/books/NBK20758/figure/A161/?report=objectonly" target="object" title="Figure 26" class="img_link icnblk_img figpopup" rid-figpopup="figA161" rid-ob="figobA161"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f26.gif" src-large="/books/NBK20758/bin/pages71-88f26.jpg" alt="Figure 26. Percent of persons reporting prescription drug use in the past month by age: United States, 1988-94 and 1999-2000." /></a><div class="icnblk_cntnt" id="figlgndA161"><h4 id="A161"><a href="/books/NBK20758/figure/A161/?report=objectonly" target="object" rid-ob="figobA161">Figure 26</a></h4><p class="float-caption no_bottom_margin">Percent of persons reporting prescription drug use in the past month by age: United
States, 1988-94 and 1999-2000.
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NOTES: All ages data are age adjusted. See Data Table for data points graphed, standard
errors, <a href="/books/NBK20758/figure/A161/?report=objectonly" target="object" rid-ob="figobA161">(more...)</a></p></div></div></p><p>Prescription drug use is greater among middle-aged and older adults than among younger
persons. Prevalence of many chronic conditions and diseases increases with age, as does use of
medications designed to help control or prevent complications associated with those conditions.
In 1999&#x02013;2000, about one-quarter of children reported taking at least one prescription
medication while more than 60 percent of middle-aged adults and more than 80 percent of older
adults reported taking at least one prescription drug during the past month.</p><p>Use of prescription drugs differs by race and ethnicity (<i>Health, United States,
2004</i>, <a href="/books/n/healthus04/trend-tables/table/A893/?report=objectonly" target="object">table 86</a>). Adults of Mexican origin
are less likely to report having taken a prescribed medication in the past month than either
non-Hispanic black or non-Hispanic white adults. In part this is because use of medications is
strongly related to access to medical care and the ability to pay for medications once
prescribed (<a class="bk_pop" href="#A171">1</a>,<a class="bk_pop" href="#A173">3</a>). Americans of Mexican descent are less likely to have health insurance, which often
covers some prescription drug expenses, than those in other racial and ethnic groups
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A410/?report=objectonly" target="object">table
129</a>).</p><p>Data on drugs associated with medical visits are available from the National Ambulatory
Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS
Outpatient Department Component). These data are abstracted from medical records of physician
office and hospital outpatient department visits and include information on the number and type
of prescription and nonprescription drugs, immunizations, allergy shots, and anesthetics that
were prescribed, ordered, supplied, administered, or continued during the visit.</p><p>Data from NAMCS and NHAMCS provide information on overall medication prescribing patterns in
addition to documenting the burden and complexity that medication management presents to the
health care system and to consumers. Estimates of the percent of visits with drugs recorded on
the visit record from NAMCS and NHAMCS (<a class="figpopup" href="/books/NBK20758/figure/A162/?report=objectonly" target="object" rid-figpopup="figA162" rid-ob="figobA162">figure 27</a>)
complement the population-based data from NHANES (<a class="figpopup" href="/books/NBK20758/figure/A161/?report=objectonly" target="object" rid-figpopup="figA161" rid-ob="figobA161">figure
26</a>), which provide a snapshot of prescription drugs reported at the time of in-person
interviews. Because NAMCS and NHAMCS data include information only on persons who have accessed
the medical care system, they do not represent the number or percent of people in the Nation
currently taking a specific drug. Rather, the visit-level data provide a snapshot of how drugs
are being prescribed or provided to people who receive care from office-based physicians and
hospital outpatient departments.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA162" co-legend-rid="figlgndA162"><a href="/books/NBK20758/figure/A162/?report=objectonly" target="object" title="Figure 27" class="img_link icnblk_img figpopup" rid-figpopup="figA162" rid-ob="figobA162"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f27.gif" src-large="/books/NBK20758/bin/pages71-88f27.jpg" alt="Figure 27. Percent of physician office and hospital outpatient department visits with 5 or more drugs prescribed, ordered, or provided by age: United States, 1995-2002." /></a><div class="icnblk_cntnt" id="figlgndA162"><h4 id="A162"><a href="/books/NBK20758/figure/A162/?report=objectonly" target="object" rid-ob="figobA162">Figure 27</a></h4><p class="float-caption no_bottom_margin">Percent of physician office and hospital outpatient department visits with 5 or more
drugs prescribed, ordered, or provided by age: United States, 1995-2002.
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NOTE: See Data Table for data <a href="/books/NBK20758/figure/A162/?report=objectonly" target="object" rid-ob="figobA162">(more...)</a></p></div></div></p><p>Almost two-thirds (62 percent) of visits to physician offices and hospital outpatient
departments in 2001&#x02013;02 had at least one drug associated with the visit (<a class="bk_pop" href="#A174">4</a>). Between 1995&#x02013;96 and 2001&#x02013;02 the
number of drugs recorded during physician office and hospital outpatient department visits
increased from 1.1 to 1.5 billion. Rates of visits with at least one drug mentioned are higher
for women than men, in part reflecting women&#x02019;s overall higher rate of visits to
physician offices and hospital outpatient departments (<i>Health, United States,
2004,</i>
<a href="/books/n/healthus04/trend-tables/table/A890/?report=objectonly" target="object">tables 83</a> and <a href="/books/n/healthus04/trend-tables/table/A894/?report=objectonly" target="object">87</a>) (<a class="bk_pop" href="#A175">5</a>).</p><p>Between 1995&#x02013;96 and 2001&#x02013;02, visits to physician offices and hospital
outpatient departments with five or more medications increased from 4 to 7 percent (age
adjusted) of all visits. The increase in the percent of visits with five or more drugs recorded
during visits varied substantially by age (<a class="figpopup" href="/books/NBK20758/figure/A162/?report=objectonly" target="object" rid-figpopup="figA162" rid-ob="figobA162">figure 27</a>).
During this period the percent of visits with five or more drugs tripled for children younger
than age 18 years, although the percent of children&#x02019;s visits with five or more drugs
mentioned was still small in 2001&#x02013;02 (less than 3 percent). Between 1995&#x02013;96
and 2001&#x02013;02 the percent of adults&#x02019; visits with five or more drugs mentioned
increased about 60 percent, depending on the age group. The largest absolute percentage point
increase was for persons age 75 and over. In 1995&#x02013;96, 13 percent of visits for
persons in this oldest age group had five or more drugs recorded on the visit record; by
2001&#x02013;02 more than 20 percent of visits had five or more drugs recorded.</p><p>The remainder of this special feature on drugs delves further into drug prescribing and
utilization patterns by focusing on specific types or therapeutic classes of
drugs&#x02014;that is, drugs generally prescribed for specific conditions or
reasons&#x02014;and how drug use varies by age, gender, and race. Drugs that showed
particularly large increases since 1995 are highlighted, as well as drugs commonly used by
persons in specific age groups. While not all classes of drugs can be examined in detail in
this feature, trends in ambulatory care visits associated with commonly used drugs, as well as
trends in the percent of persons who reported taking a drug during a one-month period, show the
extent to which large changes in practice patterns and utilization can occur in a relatively
short time period.</p><p>Several different measures of drug use are presented in this special feature. Data in some
figures are presented as visit rates, that is, the number of visits with specific drugs of
interest recorded per 100 persons (<a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">figures
32</a>&#x02013;<a class="figpopup" href="/books/NBK20758/figure/A164/?report=objectonly" target="object" rid-figpopup="figA164" rid-ob="figobA164">35</a>). In some instances information
is presented as a percent of visits with specific drugs recorded among visits for a specific
diagnosis, asthma (<a class="figpopup" href="/books/NBK20758/figure/A165/?report=objectonly" target="object" rid-figpopup="figA165" rid-ob="figobA165">figures 28</a> and <a class="figpopup" href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-figpopup="figA166" rid-ob="figobA166">29</a>). Data in other charts are presented as the percent of persons reporting
specific drug use in the past month (<a class="figpopup" href="/books/NBK20758/figure/A167/?report=objectonly" target="object" rid-figpopup="figA167" rid-ob="figobA167">figures 30</a> and
<a class="figpopup" href="/books/NBK20758/figure/A168/?report=objectonly" target="object" rid-figpopup="figA168" rid-ob="figobA168">31</a>). Finally, <a class="figpopup" href="/books/NBK20758/figure/A169/?report=objectonly" target="object" rid-figpopup="figA169" rid-ob="figobA169">figure
36</a> presents the percent of visits with a specific class of drugs (selective COX-2
NSAIDs) recorded among visits with a broader class of drugs (all NSAIDs) recorded.<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA163" co-legend-rid="figlgndA163"><a href="/books/NBK20758/figure/A163/?report=objectonly" target="object" title="Figure 32" class="img_link icnblk_img figpopup" rid-figpopup="figA163" rid-ob="figobA163"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f32.gif" src-large="/books/NBK20758/bin/pages71-88f32.jpg" alt="Figure 32. Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults 18 years of age and over by sex: United States, 1995-2002." /></a><div class="icnblk_cntnt" id="figlgndA163"><h4 id="A163"><a href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-ob="figobA163">Figure 32</a></h4><p class="float-caption no_bottom_margin">Selective serotonin reuptake inhibitor (SSRI) antidepressant drug visits among adults
18 years of age and over by sex: United States, 1995-2002.
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NOTE: Selective serotonin reuptake inhibitor <a href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-ob="figobA163">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA164" co-legend-rid="figlgndA164"><a href="/books/NBK20758/figure/A164/?report=objectonly" target="object" title="Figure 35" class="img_link icnblk_img figpopup" rid-figpopup="figA164" rid-ob="figobA164"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f35.gif" src-large="/books/NBK20758/bin/pages71-88f35.jpg" alt="Figure 35. Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex and age: United States, 1995-2002." /></a><div class="icnblk_cntnt" id="figlgndA164"><h4 id="A164"><a href="/books/NBK20758/figure/A164/?report=objectonly" target="object" rid-ob="figobA164">Figure 35</a></h4><p class="float-caption no_bottom_margin">Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex
and age: United States, 1995-2002.
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NOTES: Cholesterol-lowering statin drug visits are physician office <a href="/books/NBK20758/figure/A164/?report=objectonly" target="object" rid-ob="figobA164">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA165" co-legend-rid="figlgndA165"><a href="/books/NBK20758/figure/A165/?report=objectonly" target="object" title="Figure 28" class="img_link icnblk_img figpopup" rid-figpopup="figA165" rid-ob="figobA165"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f28.gif" src-large="/books/NBK20758/bin/pages71-88f28.jpg" alt="Figure 28. Percent of asthma visits with quick-relief and long-term control drugs prescribed, ordered, or provided: United States, 1995-2002." /></a><div class="icnblk_cntnt" id="figlgndA165"><h4 id="A165"><a href="/books/NBK20758/figure/A165/?report=objectonly" target="object" rid-ob="figobA165">Figure 28</a></h4><p class="float-caption no_bottom_margin">Percent of asthma visits with quick-relief and long-term control drugs prescribed,
ordered, or provided: United States, 1995-2002.
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version
NOTES: Asthma visits are physician office and hospital outpatient <a href="/books/NBK20758/figure/A165/?report=objectonly" target="object" rid-ob="figobA165">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA166" co-legend-rid="figlgndA166"><a href="/books/NBK20758/figure/A166/?report=objectonly" target="object" title="Figure 29" class="img_link icnblk_img figpopup" rid-figpopup="figA166" rid-ob="figobA166"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f29.gif" src-large="/books/NBK20758/bin/pages71-88f29.jpg" alt="Figure 29. Percent of asthma visits with selected asthma drugs prescribed, ordered, or provided: United States, 1995-2002." /></a><div class="icnblk_cntnt" id="figlgndA166"><h4 id="A166"><a href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-ob="figobA166">Figure 29</a></h4><p class="float-caption no_bottom_margin">Percent of asthma visits with selected asthma drugs prescribed, ordered, or provided:
United States, 1995-2002.
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NOTES: Asthma visits are physician office and hospital outpatient department <a href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-ob="figobA166">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA167" co-legend-rid="figlgndA167"><a href="/books/NBK20758/figure/A167/?report=objectonly" target="object" title="Figure 30" class="img_link icnblk_img figpopup" rid-figpopup="figA167" rid-ob="figobA167"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f30.gif" src-large="/books/NBK20758/bin/pages71-88f30.jpg" alt="Figure 30. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by sex and age: United States, 1988-94 and 1999-2000." /></a><div class="icnblk_cntnt" id="figlgndA167"><h4 id="A167"><a href="/books/NBK20758/figure/A167/?report=objectonly" target="object" rid-ob="figobA167">Figure 30</a></h4><p class="float-caption no_bottom_margin">Percent of adults 18 years of age and over reporting antidepressant drug use in the
past month by sex and age: United States, 1988-94 and 1999-2000.
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NOTE: See Data Table for data points graphed,
specific <a href="/books/NBK20758/figure/A167/?report=objectonly" target="object" rid-ob="figobA167">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA168" co-legend-rid="figlgndA168"><a href="/books/NBK20758/figure/A168/?report=objectonly" target="object" title="Figure 31" class="img_link icnblk_img figpopup" rid-figpopup="figA168" rid-ob="figobA168"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f31.gif" src-large="/books/NBK20758/bin/pages71-88f31.jpg" alt="Figure 31. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by race and ethnicity: United States, 1988-94 and 1999-2000." /></a><div class="icnblk_cntnt" id="figlgndA168"><h4 id="A168"><a href="/books/NBK20758/figure/A168/?report=objectonly" target="object" rid-ob="figobA168">Figure 31</a></h4><p class="float-caption no_bottom_margin">Percent of adults 18 years of age and over reporting antidepressant drug use in the
past month by race and ethnicity: United States, 1988-94 and 1999-2000.
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version
NOTES: Data are age adjusted. All <a href="/books/NBK20758/figure/A168/?report=objectonly" target="object" rid-ob="figobA168">(more...)</a></p></div></div><div class="iconblock whole_rhythm clearfix ten_col fig" id="figA169" co-legend-rid="figlgndA169"><a href="/books/NBK20758/figure/A169/?report=objectonly" target="object" title="Figure 36" class="img_link icnblk_img figpopup" rid-figpopup="figA169" rid-ob="figobA169"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f36.gif" src-large="/books/NBK20758/bin/pages71-88f36.jpg" alt="Figure 36. Percent of nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2 NSAIDs prescribed, ordered, or provided among adults 18 years of age and over by age: United States, 1999-2002." /></a><div class="icnblk_cntnt" id="figlgndA169"><h4 id="A169"><a href="/books/NBK20758/figure/A169/?report=objectonly" target="object" rid-ob="figobA169">Figure 36</a></h4><p class="float-caption no_bottom_margin">Percent of nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2
NSAIDs prescribed, ordered, or provided among adults 18 years of age and over by age: United
States, 1999-2002.
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<a href="/books/NBK20758/figure/A169/?report=objectonly" target="object" rid-ob="figobA169">(more...)</a></p></div></div></p><div id="A160.reflist0"><h4>References for figures 26 and 27</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A171">Berndt ER . The U.S. pharmaceutical industry: Why major growth in times of cost
containment? <span><span class="ref-journal">Health Aff. </span>2001;<span class="ref-vol">20</span>(2):100–14.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11260932" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11260932</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A172">Chockley N. The emerging impact of direct-to-consumer
prescription drug advertising. Testimony before the Subcommittee on Consumer Affairs, Foreign
Commerce and Tourism of the Senate Committee on Commerce, Science and Transportation. July
24, 2001.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A173">Poisal JA , Murray L . Growing differences between Medicare beneficiaries with and without drug
coverage. <span><span class="ref-journal">Health Aff. </span>2001;<span class="ref-vol">20</span>(2):74–85.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11260961" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11260961</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A174">Centers for Disease Control and Prevention, National Center
for Health Statistics, National Ambulatory Medical Care Survey and National Hospital
Ambulatory Medical Care Survey, unpublished data.</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A175">Weissman CS. Women&#x02019;s use of health care. In Falik M,
Collins K, eds. Women&#x02019;s Health: The Commonwealth Fund Survey. Baltimore, Maryland:
The Johns Hopkins University Press, 1996.</div></dd></dl></div><div id="A160.reflist1"><h4>References for figures 28 and 29</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A177">National Center for Health Statistics. Asthma prevalence,
health care use and mortality, 2000&#x02013;2001. Available from <a href="http://www.cdc.gov/nchs/products/pubs/pubd/hestats/asthma/asthma.htm" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.cdc.gov/nchs/products<wbr style="display:inline-block"></wbr>​/pubs/pubd/hestats/asthma/asthma<wbr style="display:inline-block"></wbr>​.htm</a> accessed on
January 6, 2004.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A178">National Asthma Education and Prevention Program. Guidelines
for the diagnosis and management of asthma: expert panel report 2. NIH Publication No.
97&#x02013;4051. Bethesda, MD: National Heart, Lung, and Blood Institute. 1997. Available
from <a href="http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.nhlbi.nih.gov/guidelines<wbr style="display:inline-block"></wbr>​/asthma/asthgdln.pdf</a> accessed on January 6,
2004.</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A179">Weiss KB , Sullivan SD . The health economics of asthma and rhinitis: Assessing the economic
impact. <span><span class="ref-journal">J Allergy Clin Immunol. </span>2001;<span class="ref-vol">107</span>(1):3–8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11149982" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11149982</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A180">Akinbami LJ , Schoendorf KC . Trends in childhood asthma: Prevalence, health care utilization, and
mortality. <span><span class="ref-journal">Pediatrics. </span>2002;<span class="ref-vol">110</span>(2):315–22.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12165584" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12165584</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A181">NAEPP Expert Panel Report. Guidelines for the diagnosis and
management of asthma&#x02014;update on selected topics 2002. Update 2002: Expert Panel
Report. Available from <a href="http://www.nhlbi.nih.gov/guidelines/asthma/index.htm" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.nhlbi.nih.gov/guidelines<wbr style="display:inline-block"></wbr>​/asthma/index.htm</a>.</div></dd><dt>6.</dt><dd><div class="bk_ref" id="A182">Stafford RS , Ma J , Finkelstein SN . et al. National trends in asthma visits and asthma pharmacotherapy,
1978&#x02013;2002. <span><span class="ref-journal">J Allergy Clin Immunol. </span>2003;<span class="ref-vol">111</span>(4):729–35.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12704350" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12704350</span></a>]</div></dd></dl></div></div><div id="A183"><h3>Asthma Drugs</h3><p>Asthma is a chronic lung disease that affects breathing. It is characterized by episodes of
inflammation and narrowing of small airways in response to
&#x02018;&#x02018;triggers,&#x02019;&#x02019; which include allergens, infections,
exercise, or exposure to respiratory irritants, such as tobacco smoke and pollutants. These
attacks or episodes may involve shortness of breath, cough, wheezing, chest pain or tightness,
mucus production, or a combination of these symptoms (<a class="bk_pop" href="#A177">1</a>,<a class="bk_pop" href="#A178">2</a>). Asthma is a leading cause of childhood
illness and a leading cause of disability and health care expenditures for adults (<a class="bk_pop" href="#A179">3</a>). In 2000 alone, over 10 million visits to private
physician offices and hospital outpatient departments, about 2 million visits to hospital
emergency departments, and almost half a million hospitalizations with a diagnosis of asthma on
the medical record were reported (<a class="bk_pop" href="#A177">1</a>).</p><p>The proportion of persons reporting that they had at least one asthma episode or attack
during the past 12 months (asthma attack prevalence) has remained fairly stable during 1997 to
2001 (39&#x02013;43 per 1,000 population). Asthma attack prevalence rates decrease with age,
and are higher among non-Hispanic black persons than among either non-Hispanic white or
Hispanic persons. Among adults, women have a higher asthma attack prevalence rate than men,
while among children under 18 years of age, boys have a 30 percent higher rate than girls
(<a class="bk_pop" href="#A177">1</a>).</p><p>Complications and mortality from the disease are largely preventable with adequate medical
care, use of medications, and patient and family education about the disease (<a class="bk_pop" href="#A180">4</a>). Drugs for asthma are categorized into two general
classes: quick-relief (rescue) drugs used to treat acute symptoms and attacks, and long-term
control drugs (prevention-focused) for achieving and maintaining control of persistent asthma
(<a class="bk_pop" href="#A178">2</a>). The types of medicines prescribed for asthma are
dictated by the severity of the disease. National Asthma Education and Prevention Program
(NAEPP) clinical guidelines issued in 1997, and updated in 2002, recommend some type of daily
long-term control drug in addition to quick-relief drugs for persons with all but the least
severe type of asthma.</p><p>Consistent with NAEPP guidelines, between 1995&#x02013;96 and 2001&#x02013;02 utilization
of long-term control drugs for asthma increased (<a class="figpopup" href="/books/NBK20758/figure/A165/?report=objectonly" target="object" rid-figpopup="figA165" rid-ob="figobA165">figure
28</a>). Between 1995&#x02013;96 and 1997&#x02013;98, for patients with a diagnosis of
asthma recorded on the visit record, the percent of visits to physician offices and hospital
outpatient departments where a long-term control drug was prescribed, provided, or continued
surpassed the percent of asthma visits with a quick-relief drug. In 2001&#x02013;02, 55
percent of visits for asthma patients had a long-term control drug mentioned, compared with
only 39 percent in 1995&#x02013;96. While both quick-relief and long-term control drugs are
indicated by the guidelines, the higher rates of long-acting asthma drugs compared with
quick-relief drugs may be in part due to reporting practices during asthma visits. Quick-relief
asthma drugs may be underreported because nonsymptomatic patients may have a rescue drug but
are not currently using it and thus fail to report it during the visit. While asthma may be a
condition recorded on the medical record it may not be the primary reason for the specific
sampled visit, so physicians may not ask about
&#x02018;&#x02018;as-needed&#x02019;&#x02019; drugs. In addition, since only six drugs
were recorded per visit, infrequently used rescue drugs may be more likely to be omitted.</p><p>The types of long-term preventive drugs for asthma that are available has been changing.
There was a rapid change in prescribing practices following the availability and marketing of
new types or classes of long-acting asthma drugs. Specifically there has been a recent rise in
prescribing of two classes of drugs&#x02014;leukasts (leukotriene modifiers) and inhaled
corticosteroids&#x02014;while cromolyns (cromolyn sodium and nedrocromil) are rarely
mentioned on visit records (<a class="figpopup" href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-figpopup="figA166" rid-ob="figobA166">figure 29</a>).</p><p>Leukasts include two recently available brand name drugs: Accolate<sup>&#x000ae;</sup>
and Singulair. Since the approval by the Food and Drug Administration of
Accolate<sup>&#x000ae;</sup> in February 1998 and Singulair<sup>&#x000ae;</sup> in
1999, recorded use of these drugs in physician office and hospital outpatient visits for asthma
patients has increased. By 2001&#x02013;02 nearly 15 percent of asthma visits had a
long-acting leukast drug associated with the visit. Use of leukasts appears to be substituting
for the older class of cromolyns, possibly because leukasts are easier to administer. Leukasts
are administered in an oral tablet form, while cromolyns are inhaled multiple times per
day.</p><p>In 2001&#x02013;02 inhaled corticosteroids were the most commonly prescribed long-term
control drug class during physician office and hospital outpatient department visits for asthma
patients. The NAEPP considers corticosteroids the most potent and consistently effective
long-term control medication for asthma. Inhaled corticosteroids are preferred over oral
steroids because they have fewer side-effects than the more systemic oral corticosteroids.
NAEPP guidelines state that oral corticosteroids should be used at their lowest effective dose
to reduce toxicity (<a class="bk_pop" href="#A181">5</a>).</p><p>New asthma drugs continue to become available. Advair<sup>&#x000ae;</sup>, a combination
drug including both an inhaled corticosteroid and a long-acting bronchodilator, entered the
market in 2001. Data from other drug databases suggest that it is being increasingly prescribed
and is in part replacing use of other types of long-acting bronchodilators, consistent with the
slight decline in their use in recent years shown on <a class="figpopup" href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-figpopup="figA166" rid-ob="figobA166">figure
29</a> (<a class="bk_pop" href="#A182">6</a>). In 2001&#x02013;02
Advair<sup>&#x000ae;</sup> was prescribed, ordered, provided, or continued during 16
percent of physician office and hospital outpatient department visits that had an asthma
diagnosis recorded on the visit record.</p></div><div id="A184"><h3>Antidepressant Drugs: Adults</h3><p>Depression and other forms of mental illness are critical public health issues in America
today. In 2001&#x02013;02 more than 1 in 10 noninstitutionalized adult Americans were
estimated to have had a major depressive disorder at some point in their lifetime, with 6.6
percent having a major depressive episode during the past 12 months (<a class="bk_pop" href="#A186">1</a>). Nearly three-fourths of individuals reporting a major depressive episode
in their lifetime also met the criteria for other mental disorders such as anxiety disorder and
substance use disorder (<a class="bk_pop" href="#A186">1</a>). The detrimental effects of
depressive symptoms on quality of life and daily functioning have been estimated to equal or
exceed those of heart disease and exceed those of diabetes, arthritis, and gastrointestinal
disorders (<a class="bk_pop" href="#A187">2</a>). Increased rates of depression and
depressive symptoms have been reported for patients with diabetes, chronic pain,
gastrointestinal complaints, migraine headaches, cancer, acquired immunodeficiency syndrome,
Alzheimer-type dementia, and various neurologic conditions such as Parkinson&#x02019;s
disease and stroke (<a class="bk_pop" href="#A188">3</a>).</p><p>Prescriptions for antidepressants have been rising. This rise is associated with the
introduction of a new class of drugs known as selective serotonin reuptake inhibitors (SSRIs)
first marketed in the United States in 1988 (<a class="bk_pop" href="#A189">4</a>). SSRIs
include the brand names Celexa<sup>&#x000ae;</sup>, Lexapro<sup>&#x000ae;</sup>,
Luvox<sup>&#x000ae;</sup>, Paxil<sup>&#x000ae;</sup>, Prozac<sup>&#x000ae;</sup>,
and Zoloft<sup>&#x000ae;</sup>. Because of greater ease of use, improved safety, and more
manageable side effects, SSRIs have been widely adopted by both psychiatrists and primary care
physicians as the first-line treatment for depression (<a class="bk_pop" href="#A190">5</a>,<a class="bk_pop" href="#A191">6</a>). SSRIs are approved and marketed for the
treatment of mental disorders other than depression including obsessive compulsive disorder,
panic disorder, anxiety disorders, and premenstrual dysphoric disorder. The substantial
increase in the prescription of antidepressants also suggests widespread
&#x02018;&#x02018;off-label&#x02019;&#x02019; (other than FDA-approved uses) use for
subsyndromal mental health conditions and a variety of physical disorders (<a class="bk_pop" href="#A192">7</a>,<a class="bk_pop" href="#A193">8</a>).</p><p>The National Health and Nutrition Examination Survey (NHANES) collects data on the use of
prescription drugs during the past month. Between 1988&#x02013;94 and 1999&#x02013;2000 the
percent of adults in the civilian noninstitutionalized population who reported using an
antidepressant during the past month increased from 3 to 7 percent (age adjusted; data table
for <a class="figpopup" href="/books/NBK20758/figure/A167/?report=objectonly" target="object" rid-figpopup="figA167" rid-ob="figobA167">figure 30</a>). Use among women rose from 3 to 10
percent and use among men from 2 to 4 percent. During this period antidepressant use among
adults in all age groups doubled or tripled. In both time periods, antidepressant use by women
was greater than for men and greater for adults 45 years of age and over than for younger
adults. In 1999&#x02013;2000, 13 percent of women 45&#x02013;64 years of age reported
antidepressant use in the past month.</p><p>Differences in use of antidepressants (both SSRIs and non-SSRIs) varied considerably by race
and ethnicity. In both 1988&#x02013;94 and 1999&#x02013;2000 a larger percentage of
non-Hispanic white adults reported use of antidepressants than non-Hispanic black and Mexican
adults. Between the two time periods, differences in the use of antidepressants by non-Hispanic
white and non-Hispanic black and Mexican adults widened (<a class="figpopup" href="/books/NBK20758/figure/A168/?report=objectonly" target="object" rid-figpopup="figA168" rid-ob="figobA168">figure
31</a>). In 1988&#x02013;94 the percentage of non-Hispanic white adults using
antidepressants was about 1.4 times the percentage among non-Hispanic black and Mexican adults.
By 1999&#x02013;2000 use among non-Hispanic white adults was three times that among
non-Hispanic black and Mexican adults. Differences in the types of antidepressant used also
varied considerably by race and ethnicity. In 1999&#x02013;2000 nearly two-thirds of
non-Hispanic white adults taking antidepressants reported use of an SSRI in contrast to less
than one-half of non-Hispanic black and Mexican adults. Limited access to health care, lower
rates of health insurance coverage, and out-of-pocket cost of medical care as well as cultural
factors, have been suggested as explanations for the lower percentage of black and Mexican
adults reporting use of antidepressants (<a class="bk_pop" href="#A194">9</a>,<a class="bk_pop" href="#A195">10</a>).</p><p>Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital
Medical Care Survey (NHAMCS-OPD) show that antidepressants rank among the most frequently
prescribed drugs for adults treated in physician offices or hospital outpatient clinics. In
2001&#x02013;02 the average annual number of adult visits with an antidepressant was 57.6
million. Between 1995&#x02013;96 and 2001&#x02013;02 the adult antidepressant visit rate
(i.e., the number of visits with an antidepressant drug per 100 persons age 18 and over)
increased from 17 to 28 per 100 adults (data table for <a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">figure
32</a>). This increase in the antidepressant visit rate reflected the rapid rise in visits
with an SSRI prescribed, ordered, or provided. Between 1995&#x02013;96 and 2001&#x02013;02
the SSRI visit rate among adults doubled and the fraction of antidepressant visits with an SSRI
drug increased from 54 to 65 percent. Throughout the period, a very small percentage
(0.3&#x02013;0.5 percent) of antidepressants visits included both an SSRI and a non-SSRI
antidepressant.</p><p>Between 1995&#x02013;96 and 2001&#x02013;02 the antidepressant visit rate among women was
double the rate among men (data table for <a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">figure 32</a>).
During this period women also had higher SSRI visit rates. Trends in the SSRI visit rate for
men and women show a widening of the difference between men and women since 1995&#x02013;96
(data table for <a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">figure 32</a>). By 2001&#x02013;02 the
SSRI visit rate of 25 per 100 women was 2.4 times the rate for men. The disparity in the
antidepressant and SSRI visit rates of men and women exceeded the difference observed between
men and women in the overall rate of visits to office-based physicians and hospital outpatient
departments (<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A890/?report=objectonly" target="object">table 83</a>).</p><p>The rate of visits with an antidepressant increased markedly for adults in all age groups
between 1995&#x02013;96 and 2001&#x02013;02 data ( table for <a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">figure 32</a>). Throughout the period, the antidepressant visit rate was higher
among middle aged and older adults than among younger adults. The SSRI visit rate increased
among adults in all age groups with the largest change observed among older adults. The lower
occurrence of side effects with SSRIs has contributed to the rapid adoption of these drugs for
treatment of late-life depression and other disorders in the older population (<a class="bk_pop" href="#A196">11</a>).</p><p>Since the marketing of Prozac<sup>&#x000ae;</sup>, the first SSRI, new formulations of
anti-depressants have become available. Studies suggest that an even wider array of effective
antidepressants will be available in the future for the treatment of depression and other
conditions (<a class="bk_pop" href="#A197">12</a>).</p><div id="A184.reflist0"><h4>References for figures 30, 31, and 32</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A186">Kessler RC , Berglund P , Demler O . et al. The epidemiology of major depressive disorder: Results from the National
Comorbidity Survey Replication (NCS-R). <span><span class="ref-journal">JAMA. </span>2003;<span class="ref-vol">289</span>(23):3095–3105.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12813115" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12813115</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A187">Wells KB , Stewart A , Hays RD . et al. The functioning and well being of depressed patients: results from the Medical
Outcomes Study. <span><span class="ref-journal">JAMA. </span>1989;<span class="ref-vol">262</span>(7):914–9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/2754791" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 2754791</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A188">Burvill PW . Recent progress in the epidemiology of major depression. <span><span class="ref-journal">Epidemiol Rev. </span>1995;<span class="ref-vol">17</span>(1):21–31.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/8521939" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 8521939</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A189">Pincus HA , Tanielian TL , Marcus SC . et al. Prescribing trends in psychotropic medications: Primary care, psychiatry, and
other medical specialties. <span><span class="ref-journal">JAMA. </span>1998;<span class="ref-vol">279</span>(7):526–31.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9480363" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 9480363</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A190">U.S. Department of Health and Human Services. Mental health: A
report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of Mental Health. 1999.</div></dd><dt>6.</dt><dd><div class="bk_ref" id="A191">Ornstein S , Stuart G , Jenkins R . Depression diagnoses and antidepressant use in primary care practices: a study
from the Practice Partner Research Network (PPRNet). <span><span class="ref-journal">J Fam Pract. </span>2000;<span class="ref-vol">49</span>(1):68–72.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10678342" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10678342</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="A192">Foote SM , Etheredge L . Increasing use of new prescription drugs: A case study. <span><span class="ref-journal">Health Aff. </span>2000;<span class="ref-vol">19</span>(4):165–70.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10916970" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10916970</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="A193">Stone KJ , Viera AJ , Parman CL . Off-label applications for SSRIs. <span><span class="ref-journal">Am Fam Physician. </span>2003;<span class="ref-vol">68</span>(3):498–504.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12924832" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12924832</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="A194">Melfi CA , Croghan TW , Hanna MP , Robinson RL . Racial variation in antidepressant treatment in a Medicaid
population. <span><span class="ref-journal">J Clin Psychiatry. </span>2000;<span class="ref-vol">61</span>(1):16–21.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10695640" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10695640</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="A195">Miranda J , Cooper LA . Disparities in care for depression among primary care patients. <span><span class="ref-journal">J Gen Intern Med. </span>2004;<span class="ref-vol">19</span>(2):120–6.</span> [<a href="/pmc/articles/PMC1492138/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC1492138</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15009791" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 15009791</span></a>]</div></dd><dt>11.</dt><dd><div class="bk_ref" id="A196">Sambamoorthi U , Olfson M , Walkup JT , Crystal S . Diffusion of new generation antidepressant treatment among elderly diagnosed
with depression. <span><span class="ref-journal">Med Care. </span>2003;<span class="ref-vol">41</span>(1):180–94.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12544554" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12544554</span></a>]</div></dd><dt>12.</dt><dd><div class="bk_ref" id="A197">Holden C . Future brightening for depression treatments. <span><span class="ref-journal">Science. </span>2003;<span class="ref-vol">302</span>(5646):810–3.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14593164" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14593164</span></a>]</div></dd></dl></div></div><div id="A198"><h3>Stimulants and Antidepressant Drugs: School-Age Children</h3><p>Substantial increases have occurred over the past 15 years in the prescription of
psychotropic drugs for the treatment of mental disorders in children (<a class="bk_pop" href="#A202">1</a>,<a class="bk_pop" href="#A203">2</a>). Pediatric use of psychotropic
drugs is frequently &#x02018;&#x02018;off-label,&#x02019;&#x02019; relying on results
from studies of adults due to limited research on the safety and efficacy of these medications
in children. Even when the safety and short-term efficacy of psychotropic medications have been
established, prescription of these drugs for behavioral and emotional disorders in children has
been controversial (<a class="bk_pop" href="#A204">3</a>). For all classes of psychotropic
drugs, more extensive information is needed to determine the long-term effects of these
medications on the health and development of children (<a class="bk_pop" href="#A205">4</a>).</p><p>Attention Deficit Hyperactivity Disorder (ADHD) is a frequently diagnosed behavioral disorder
affecting approximately 3 to 7 percent of the school-age population (<a class="bk_pop" href="#A206">5</a>). Children with this disorder experience symptoms related to inattention
and hyperactivity-impulsivity, and frequently have significant problems with schoolwork and
peer relationships. While a variety of drug and nondrug therapies have been developed to treat
children with ADHD, there has been a trend toward more widespread prescription of stimulant
drugs (<a class="bk_pop" href="#A202">1</a>). The annual number of visits by school-age
children 5&#x02013;17 years of age to physician offices and hospital outpatient departments
with a stimulant drug prescribed, ordered, or provided increased from 2.6 million in
1994&#x02013;96 to over 5.0 million in 2000&#x02013;2002 (<a class="bk_pop" href="#A207">6</a>). The stimulant visit rate among boys was about 2.5&#x02013;3 times the visit rate
among girls reflecting the higher prevalence of identified ADHD in boys compared with girls
(<a class="figpopup" href="/books/NBK20758/figure/A199/?report=objectonly" target="object" rid-figpopup="figA199" rid-ob="figobA199">figure 33</a>) (<a class="bk_pop" href="#A208">7</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA199" co-legend-rid="figlgndA199"><a href="/books/NBK20758/figure/A199/?report=objectonly" target="object" title="Figure 33" class="img_link icnblk_img figpopup" rid-figpopup="figA199" rid-ob="figobA199"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f33.gif" src-large="/books/NBK20758/bin/pages71-88f33.jpg" alt="Figure 33. Stimulant drug visits among children 5&#x02013;17 years of age by sex: United States, 1994-2002." /></a><div class="icnblk_cntnt" id="figlgndA199"><h4 id="A199"><a href="/books/NBK20758/figure/A199/?report=objectonly" target="object" rid-ob="figobA199">Figure 33</a></h4><p class="float-caption no_bottom_margin">Stimulant drug visits among children 5&#x02013;17 years of age by sex: United
States, 1994-2002.
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PowerPoint
</p></div></div></p><p>Depression, an important mood disorder in children, has been estimated to occur in 2 percent
of elementary school-aged children and 4 to 8 percent of adolescents (<a class="bk_pop" href="#A209">8</a>). Children with depression are at greater risk for suicide, poor academic
outcomes, problems with alcohol and illicit drugs, and troubled relationships with their
families and peers (<a class="bk_pop" href="#A204">3</a>). While psychotherapy has been
the traditional treatment for childhood depression, an increasing number of children are now
being treated with antidepressants. Between 1994&#x02013;96 and 2000&#x02013;2002 the
annual number of visits by school-age children 5&#x02013;17 years of age with an
antidepressant increased from 1.1 million to 3.1 million. While the antidepressant visit rate
was similar for boys and girls (<a class="figpopup" href="/books/NBK20758/figure/A200/?report=objectonly" target="object" rid-figpopup="figA200" rid-ob="figobA200">figure 34</a>), it was more
than twice as high among adolescents as younger school-age children. In 2000&#x02013;2002 the
antidepressant visit rate was 3.4 per 100 children 5&#x02013;11 years of age and 8.8 per 100
adolescents 12&#x02013;17 years of age (data table for <a class="figpopup" href="/books/NBK20758/figure/A200/?report=objectonly" target="object" rid-figpopup="figA200" rid-ob="figobA200">figure
34</a>).<div class="iconblock whole_rhythm clearfix ten_col fig" id="figA200" co-legend-rid="figlgndA200"><a href="/books/NBK20758/figure/A200/?report=objectonly" target="object" title="Figure 34" class="img_link icnblk_img figpopup" rid-figpopup="figA200" rid-ob="figobA200"><img class="small-thumb" src="/books/NBK20758/bin/pages71-88f34.gif" src-large="/books/NBK20758/bin/pages71-88f34.jpg" alt="Figure 34. Antidepressant drug visits among children 5&#x02013;17 years of age by Sex: United States, 1994-2002." /></a><div class="icnblk_cntnt" id="figlgndA200"><h4 id="A200"><a href="/books/NBK20758/figure/A200/?report=objectonly" target="object" rid-ob="figobA200">Figure 34</a></h4><p class="float-caption no_bottom_margin">Antidepressant drug visits among children 5&#x02013;17 years of age by Sex: United
States, 1994-2002.
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NOTES: Stimulant drug visits are physician office and hospital outpatient department
visits <a href="/books/NBK20758/figure/A200/?report=objectonly" target="object" rid-ob="figobA200">(more...)</a></p></div></div></p><p>Between 1994&#x02013;96 and 2000&#x02013;2002 the percentage of visits with one of the
newer class of antidepressants, selective serotonin reuptake inhibitors (SSRI), increased
markedly from 43 to 67 percent of all antidepressant visits (<a class="bk_pop" href="#A207">6</a>). Given recent concerns about the safety of some SSRIs for the treatment of
childhood and adult depression, monitoring trends in the prescription of these antidepressants
is critical (<a class="bk_pop" href="#A210">9</a>).</p><div id="A198.reflist0"><h4>References for figures 33 and 34</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A202">Olfson M , Marcus SC , Weissman MM , Jensen PS . National trends in the use of psychotropic medications by
children. <span><span class="ref-journal">J Am Acad Child Adolesc Psychiatry. </span>2002;<span class="ref-vol">41</span>(5):514–21.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12014783" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12014783</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A203">Zito JM , Safer DJ , dosRies S . et al. Rising prevalence of antidepressants among US youths. <span><span class="ref-journal">Pediatrics. </span>2002;<span class="ref-vol">109</span>(5):721–7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11986427" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11986427</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A204">U.S. Department of Health and Human Services. Mental health: A
report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of Mental Health. 1999.</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A205">Jensen PS , Bhatara VS , Vitiello B . et al. Psychoactive medication prescribing practices for U.S. children: gaps between
research and clinical practice. <span><span class="ref-journal">J Am Acad Child Adolesc Psychiatry. </span>1999;<span class="ref-vol">38</span>(5):557–65.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10230187" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10230187</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A206">American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. Fourth Edition, Text revision. Washington D.C.: American
Psychiatric Association. 2000.</div></dd><dt>6.</dt><dd><div class="bk_ref" id="A207">Centers for Disease Control and Prevention, National Center
for Health Statistics, National Ambulatory Medical Care Survey and National Hospital
Ambulatory Medical Care Survey, unpublished analysis.</div></dd><dt>7.</dt><dd><div class="bk_ref" id="A208">Bloom B, Cohen RA, Vickerie JL, Wondimu EA. Summary health
statistics for U.S. children: National Health Interview Survey, 2001. National Center for
Health Statistics. Vital Health Stat 10(216). 2003. Available from <a href="http://www.cdc.gov/nchs/data/series/sr_10/sr10_216.pdf" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.cdc.gov/nchs/data<wbr style="display:inline-block"></wbr>​/series/sr_10/sr10_216.pdf</a> accessed on January 9,
2004. [<a href="https://pubmed.ncbi.nlm.nih.gov/15791762" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 15791762</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="A209">Olfson M , Gameroff MJ , Marcus SC , Waslick BD . Outpatient treatment of child and adolescent depression in the United
States. <span><span class="ref-journal">Arch Gen Psychiatry. </span>2003;<span class="ref-vol">60</span>:1236–42.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14662556" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14662556</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="A210">FDA Talk Paper. FDA issues public health advisory on cautions
for use of antidepressants in adults and children. March 22, 2004. Available from <a href="http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01283.html" ref="pagearea=cite-ref&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www<wbr style="display:inline-block"></wbr>​.fda.gov/bbs/topics<wbr style="display:inline-block"></wbr>​/ANSWERS/2004/ANS01283.html</a> accessed on March 24,
2004.</div></dd></dl></div></div><div id="A211"><h3>Cholesterol-Lowering Drugs</h3><p>Heart disease is the leading cause of death in the United States, accounting for about
one-half of all deaths. Elevated serum cholesterol is a major risk factor for heart disease
(<a class="bk_pop" href="#A213">1</a>). National guidelines suggest that the desired
serum total cholesterol level is 200 milligrams per deciliter (mg/dL) or lower (<a class="bk_pop" href="#A213">1</a>). In the past two decades, public awareness about the
importance of measuring and controlling cholesterol levels has grown. In 1999&#x02013;2002,
17 percent of adults aged 20 and over had high serum cholesterol levels of 240 mg/dL or higher
(<i>Health, United States, 2004</i>, <a href="/books/n/healthus04/trend-tables/table/A346/?report=objectonly" target="object">table
68</a>).</p><p>Cholesterol levels can be reduced by lifestyle modifications, including eating a diet low in
saturated fat, losing excess weight, and increasing physical activity. If such modifications do
not reduce cholesterol to acceptable levels, or patients are at elevated risk for
cardiovascular disease, then drug therapy is warranted. The National Cholesterol Education
Panel appointed by the National Heart, Lung, and Blood Institute, issued new recommendations in
2001, and again in 2004, that increased the number of Americans who are candidates for
cholesterol-lowering drugs.</p><p>There are four major classes of cholesterol-lowering drugs: statins, bile acid sequestrants,
nicotinic acid, and fibrates. Statins are generally considered to be safe and effective in
reducing cholesterol levels and coronary heart disease mortality and morbidity (<a class="bk_pop" href="#A214">2</a>). Because they are effective and well tolerated, statins
have become the drug class of choice for cholesterol-lowering drug therapy. Statins include the
brand names Lipitor<sup>&#x000ae;</sup>, Pravachol<sup>&#x000ae;</sup>,
Zocor<sup>&#x000ae;</sup>, and others.</p><p>Physician office and hospital outpatient department visits by adults 45 years and over with
cholesterol-lowering drugs prescribed, provided, or continued increased from 16 visits per 100
persons in 1995&#x02013;96 to 44 per 100 persons in 2001&#x02013;02. Ninety-one percent of
visits where cholesterol-lowering drugs were recorded involved statins in 2001&#x02013;02.
Though statins are effective at reducing cholesterol concentrations, some patients do not reach
the target cholesterol levels. Recent research has found that the use of statin drugs with
additional cholesterol-lowering drugs (combination therapy) can increase the likelihood of
attaining target levels (<a class="bk_pop" href="#A214">2</a>). In 2001&#x02013;02 the
visit rate for combination therapy was 1.4 visits per 100 persons aged 45 years and over, a
small fraction of the visit rate involving statins (40 visits per 100 persons) (<a class="bk_pop" href="#A215">3</a>). It is likely that combination therapy will continue to
expand as physicians alter their prescribing patterns based on the recent evidence.</p><p>Statin visit rates have grown irrespective of age or gender (<a class="figpopup" href="/books/NBK20758/figure/A164/?report=objectonly" target="object" rid-figpopup="figA164" rid-ob="figobA164">figure 35</a>). For both men and women 45&#x02013;64 years of age, the statin visit rate
increased more than three-fold between 1995&#x02013;96 and 2001&#x02013;02. The increase in
the statin visit rate was greater for women than men for these working-age adults. In
1995&#x02013;96 the statin visit rates were similar for men and women 65 years of age and
over. For men aged 65 years and over, the statin visits rate increased more than 250 percent
over this time period while the increase in the rate for women 65 years of age and over was
only 180 percent. By 2001&#x02013;02 statin visit rates for men in this age group were about
25 percent higher than for women.</p><div id="A211.reflist0"><h4>References for figure 35</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A213">National Cholesterol Education Program. . Executive summary of the third report of the national cholesterol education
program (NCEP) expert panel on detection, evaluation, and treatment of high blood
cholesterol in adults (adult treatment panel III). <span><span class="ref-journal">JAMA. </span>2001;<span class="ref-vol">285</span>(19):2486–97.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11368702" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 11368702</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A214">Maron DJ , Fazio S , Linton MF . Current perspectives on statins. <span><span class="ref-journal">Circulation. </span>2000;<span class="ref-vol">101</span>(2):207–13.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10637210" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10637210</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A215">Centers for Disease Control and Prevention, National Center
for Health Statistics, National Ambulatory Medical Care Survey and National Hospital
Ambulatory Medical Care Survey, unpublished analysis.</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A216">LaRosa JC . What do the statins tell us? <span><span class="ref-journal">Am Heart J. </span>2002;<span class="ref-vol">144</span>(6, Part 2 Suppl):S21–S26.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12486412" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12486412</span></a>]</div></dd></dl></div></div><div id="A217"><h3>Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)</h3><p>Nonsteroidal anti-inflammatory drugs, known as NSAIDs, are used to control pain and reduce
inflammation. Their use is widespread; more than 70 million prescriptions are dispensed and
billions of nonprescription pills are purchased annually in the United States (<a class="bk_pop" href="#A219">1</a>). There are two classes of NSAIDs: nonselective COX
inhibitors and selective COX-2 inhibitors. The nonselective COX inhibitors or traditional
NSAIDs are effective in controlling pain and reducing inflammation, with the most widely used
being ibuprofen and naproxen. For this analysis aspirin was not included as a traditional NSAID
because of its common use for cardiac conditions. A small but important proportion of patients
with prolonged use of traditional NSAIDs may develop gastrointestinal (GI) side effects, such
as bleeding and ulcers. Ulcer complications from traditional NSAID use have been estimated to
contribute to as many as 103,000 hospitalizations and 16,500 deaths each year (<a class="bk_pop" href="#A219">1</a>).</p><p>Since 1999 three new NSAIDs have been introduced&#x02014;celecoxib
(Celebrex<sup>&#x000ae;</sup>); rofecoxib (Vioxx<sup>&#x000ae;</sup>); and valdecoxib
(Bextra<sup>&#x000ae;</sup>). These medications, known as COX-2 NSAIDs, are similar in
efficacy to traditional NSAIDs but are believed to have a lower incidence of GI side effects
(<a class="bk_pop" href="#A220">2&#x02013;4</a>). Because of the lower incidence of GI
side effects, COX-2 NSAIDs were heralded as a welcome alternative to traditional NSAIDs. As the
use of COX-2 NSAIDs has become widespread, however, a clearer profile of the potential side
effects has emerged. The evidence for the lower incidence of side effects is mixed and
controversial, and evidence continues to be collected as to their benefit relative to their
substantially higher cost (<a class="bk_pop" href="#A221">3</a>,<a class="bk_pop" href="#A223">5</a>,<a class="bk_pop" href="#A224">6</a>).</p><p>Since the introduction of COX-2 NSAIDs, their use has become widespread. In 2001&#x02013;02
COX-2 NSAIDs accounted for 51 percent of NSAID visits to physician offices and hospital
outpatient departments among adults 18 years of age and over, surpassing traditional NSAIDs
(data table for <a class="figpopup" href="/books/NBK20758/figure/A169/?report=objectonly" target="object" rid-figpopup="figA169" rid-ob="figobA169">figure 36</a>). This dramatic growth in
COX-2 NSAID prescriptions is evident in all adult age groups in 2001&#x02013;02. For those
18&#x02013;44 years of age, about one-third of NSAID visits involved a COX-2 NSAID. For those
aged 45&#x02013;64 years, COX-2 NSAIDs accounted for more than one-half of the NSAID visits.
Among those aged 65 years and over, COX-2 NSAIDs accounted for two-thirds of NSAID visits
(<a class="figpopup" href="/books/NBK20758/figure/A169/?report=objectonly" target="object" rid-figpopup="figA169" rid-ob="figobA169">figure 36</a>).</p><p>The use of all classes of NSAIDs has been increasing. Between 1995&#x02013;96 and
2001&#x02013;02 NSAID visits among adults increased from 20 to 27 visits per 100 population.
Historically, women have higher NSAID use than men (<i>Health, United States,
2004</i>, <a href="/books/n/healthus04/trend-tables/table/A894/?report=objectonly" target="object">table 87</a>). In 2001&#x02013;02 the
rate of NSAID use was about 50 percent higher for women than men. Since the introduction of
COX-2 NSAIDs, both men and women have increasingly switched to COX-2 from traditional
NSAIDs.</p><p>The growth in the use of COX-2 NSAIDs is likely due to several factors. Extensive marketing
of these new drugs to physicians and consumers may account for some of the increased use. About
80 percent of promotional spending for all drugs is targeted toward physicians. In recent
years, spending on direct-to-consumer (DTC) advertising for all drugs tripled, to
$2.7 billion in 2001 (<a class="bk_pop" href="#A225">7</a>). COX-2 NSAIDs are
among the most heavily advertised medications to consumers (<a class="bk_pop" href="#A225">7</a>). It is estimated that almost one-third of consumers discussed a DTC advertisement
with their physicians, which supports the evidence that spending on DTC ads is having an impact
on the quantity of prescriptions dispensed (<a class="bk_pop" href="#A225">7</a>).</p><div id="A217.reflist0"><h4>References for figure 36</h4><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A219">Wolfe MM , Lichtenstein DR , Singh G . Medical progress: Gastrointestinal toxicity of nonsteroidal antiinflammatory
drugs. <span><span class="ref-journal">N Engl J Med. </span>1999;<span class="ref-vol">340</span>(24):1888–99.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10369853" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10369853</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A220">Silverstein FE , Faich G , Goldstein JL . et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory
drugs for osteoarthritis and rheumatoid arthritis: The CLASS study: A randomized controlled
trial. <span><span class="ref-journal">JAMA. </span>2000;<span class="ref-vol">284</span>(10):1247–55.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10979111" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 10979111</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="A221">Stichtenoth DO , Fr&#x000f6;lich JC . The second generation of COX-2 inhibitors: What advantages do the newest
offer? <span><span class="ref-journal">Drugs. </span>2003;<span class="ref-vol">63</span>(1):33–45.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12487621" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12487621</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="A222">Lisse JR , Perlman M , Johansson G . et al. Gastrointestinal tolerability and effectiveness of rofecoxib versus naproxen
in the treatment of osteoarthritis: A randomized, controlled trial. <span><span class="ref-journal">Ann Intern Med. </span>2003;<span class="ref-vol">139</span>(7):539–46.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14530224" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 14530224</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="A223">Juni P , Rutjes A , Dieppe P . Are selective COX 2 inhibitors superior to traditional nonsteroidal
anti-inflammatory drugs? Adequate analysis of the CLASS trial indicates that this may not be
the case. <span><span class="ref-journal">BMJ. </span>2002;<span class="ref-vol">324</span>(7349):1287–8.</span> [<a href="/pmc/articles/PMC1123260/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC1123260</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/12039807" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12039807</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="A224">Wright JM . The double-edged sword of COX-2 selective NSAIDs. <span><span class="ref-journal">Can Med Assoc J. </span>2002;<span class="ref-vol">167</span>(10):1131–7.</span> [<a href="/pmc/articles/PMC134294/" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pmc">PMC free article<span class="bk_prnt">: PMC134294</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/12427705" ref="pagearea=cite-ref&amp;targetsite=entrez&amp;targetcat=link&amp;targettype=pubmed">PubMed<span class="bk_prnt">: 12427705</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="A225">U.S. General Accounting Office. Prescription drugs: FDA
oversight of direct-to-consumer advertising has limitations. GAO-03&#x02013;177.
Washington, DC: U.S. General Accounting Office. 2002.</div></dd></dl></div></div></div><div id="A226"><h2 id="_A226_">Technical Notes</h2><div id="A227"><h3>Data Sources and Comparability</h3><p>Data for <i>The Chartbook on Trends in the Health of Americans</i> come from
numerous surveys and data systems and cover a broad range of years. Readers are referred to
<a href="/books/n/healthus04/app1/">Appendix I</a> for detailed descriptions of the specific
data sources. Readers must be aware that major changes resulting from survey redesign, as well
as changes in data collection methodology, the wording and order of questions, interruptions or
changes in timing of data collection, and data coding systems may affect data continuity and
interpretation of trends. For example, the National Health Interview Survey was redesigned in
1997 to improve its efficiency and flexibility. These changes affect comparisons before and
after 1997 for many measures (see <a href="/books/n/healthus04/app1/#A512">Appendix I, National Health
Interview Survey</a>).</p></div><div id="A228"><h3>Data Presentation</h3><p>Many measures in <i>The Chartbook on Trends in the Health of Americans</i> are
shown separately for persons of different ages because of the strong effect age has on most
health outcomes. Selected figures in the chartbook also highlight current differences in health
and health determinants by variables such as sex, race, and Hispanic origin. Some estimates are
age adjusted using the age distribution of the 2000 standard population and this is noted in
the excel spreadsheets that accompany each chart (see <a href="/books/n/healthus04/app2/">Appendix
II, Age adjustment</a>). Time trends for some measures are not presented because of the
relatively short amount of time that comparable national estimates are available. For some
charts, data years are combined to increase sample size and reliability of the estimates.</p><div id="A229"><h4>Graphic Presentation</h4><p>Line charts for which only selected years of data are displayed have dot markers on the data
years. Line charts for which data are displayed for every year in the trend are shown without
the use of dot markers. Most trends are shown on a linear scale to emphasize absolute
differences over time. The linear scale is the scale most frequently used and recognized, and
it emphasizes the absolute changes between data points over time (1). The time trend for
overall mortality measures is shown on a logarithmic scale to emphasize the rate of change and
to enable measures with large differences in magnitude to be shown on the same chart (<a class="figpopup" href="/books/NBK20758/figure/A155/?report=objectonly" target="object" rid-figpopup="figA155" rid-ob="figobA155">figure 25</a>). Logarithmic (or log) scales emphasize the
relative or percentage change between data points. Readers are cautioned that one potential
disadvantage to log scale is that the absolute magnitude of changes may appear less dramatic
(2). When interpreting data on a log scale, the following points should be kept in mind:</p>
<ol><li id="A230" class="half_rhythm"><div>A sloping straight line indicates a constant rate (not amount) of increase or decrease in
the values,</div></li><li id="A231" class="half_rhythm"><div>A horizontal line indicates no change,</div></li><li id="A232" class="half_rhythm"><div>The slope of the line indicates the rate of increase or decrease, and</div></li><li id="A233" class="half_rhythm"><div>Parallel lines, regardless of their magnitude, depict similar rates of change (1).</div></li></ol>
</div><div id="A234"><h4>Tabular Presentation</h4><p>Following the Technical Notes are data tables that present the data points graphed in each
chart. Some data tables contain additional data that were not graphed because of space
considerations. Standard errors for data points are provided for many measures. Additional
information clarifying and qualifying the data are included in table notes and <a href="/books/n/healthus04/app2/">Appendix II</a> references.</p></div></div><div id="A235"><h3>Special Feature: Drugs</h3><p>Drug data presented in <i>The Chartbook on Trends in the Health of Americans</i>
are primarily from three sources: the National Health and Nutrition Examination Survey
(NHANES), the National Ambulatory Medical Care Survey (NAMCS), and the National Hospital
Ambulatory Medical Care Survey (NHAMCS) Hospital Outpatient Department Component (NHAMCS-OPD).
The NHANES provides a snapshot of all prescribed drugs reported by a sample of the civilian
noninstitutionalized population for a 1-month period. Drug information from NHANES is collected
during an in-person interview conducted in the participant&#x02019;s home. The NAMCS and
NHAMCS-OPD provide a picture of both prescription and nonprescription drugs that are
prescribed, ordered, supplied, administered, or continued during physician office and hospital
outpatient department visits.</p><p><i>NHANES Prescription Drug Data</i>: NHANES III was conducted from 1988 through
1994. Starting in 1999 the NHANES is continuously in the field. Drug data are currently
available for 1999&#x02013;2000 while other data including obesity, serum cholesterol, and
hypertension are available for a 4-year period (1999&#x02013;2002). The questionnaire
administered to all participants included a question on whether they had taken a prescription
drug in the past month. Those who answered &#x02018;&#x02018;yes&#x02019;&#x02019; were
asked to show the interviewer the medication containers for all the prescriptions. For each
drug reported, the interviewer entered the product&#x02019;s complete name from the
container. If no container was available, the interviewer asked the participant to verbally
report the name of the drug. Additionally, participants were asked how long they had been
taking the drug and the main reason for use.</p><p>All reported medication names were converted to their standard generic ingredient name. For
multi-ingredient products, the ingredients were listed in alphabetical order and counted as one
drug (i.e., Tylenol #3 would be listed as Acetaminophen; Codeine). No trade or
proprietary names were provided on the data file.</p><p>More information on prescription drug data collection and coding in the NHANES
1999&#x02013;2000 can be found at <a href="http://www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf</a> and more information on
NHANES III prescription drug data collection and coding can be found at <a href="http://www.cdc.gov/nchs/data/nhanes/nhanes3/PUPREMED-acc.pdf" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www.cdc.gov/nchs/data/nhanes/nhanes3/PUPREMED-acc.pdf</a>. Also see <a href="/books/n/healthus04/app1/#A500">Appendix I, National Health and Nutrition Examination
Survey</a>.</p><p><i>NAMCS/NHAMCS Drug Data</i>: Data collection in the <i>NAMCS/NHAMCS</i>
is from the medical record rather than from individuals and provides an analytic base that
complements population-based information on ambulatory care collected through other NCHS
surveys. Participating physicians are randomly assigned to a 1-week reporting period. Hospitals
are assigned to a 4-week reporting period. During this period, data from a systematic random
sample of physician office and hospital outpatient department visits are recorded by the
physician or hospital staff on an encounter form provided by NCHS. Additionally, data are
obtained on patients&#x02019; symptoms and physicians&#x02019; diagnoses. The physician, or
other health care provider, records medications that were prescribed, ordered, supplied,
administered, or continued during the visit. Generic as well as brand name drugs are included,
as are nonprescription and prescription drugs. Up to five medications were reported per visit
until 1994; in the 1995 and subsequent NAMCS and NHAMCS surveys, up to six medications could be
listed.</p><p>For more information on drugs collected by the NAMCS/NHAMCS, see the Ambulatory Care Drug
Database at <a href="http://www2.cdc.gov/drugs/" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">www2.cdc.gov/drugs/</a>, <a href="ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NAMCS/doc01.pdf" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NAMCS/doc01.pdf</a>,
or <a href="ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc01.pdf" ref="pagearea=body&amp;targetsite=external&amp;targetcat=link&amp;targettype=uri">ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHAMCS/doc01.pdf</a>.
Also see <a href="/books/n/healthus04/app1/#A529">Appendix I, National Ambulatory Care Medical Survey
and National Hospital Ambulatory Medical Care Survey</a>, and <a href="/books/n/healthus04/app2/">Appendix II, Drugs; National Drug Code Directory (NDC)</a>.</p></div><div id="A226.reflist0"><h3>References</h3><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="A237">Page RM, Cole GE, Timmreck TC. Basic epidemiological methods
and biostatistics: A practical guidebook. Sudbury, Massachusetts: Jones and Bartlett
Publishers. 1995.</div></dd><dt>2.</dt><dd><div class="bk_ref" id="A238">Jekel JF, Elmore JG, Katz DL. Epidemiology biostatistics and
preventive medicine. Philadelphia, Pennsylvania: W.B. Saunders Company. 1996.</div></dd></dl></div></div><div id="chartbook-figures"><h2 id="_chartbook-figures_">List of Chartbook Figures</h2><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650141041952'">Population (figures 1-5)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650147387248'">Health Insurance (figures 6-7)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650147383168'">Preventive Health Care (figures 8-11)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650138639696'">Health Risk Factors (figures 12-17)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650138631504'">Limitation of Activity (figures 18-21)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650138625344'">Mortality (figures 22-25)</a>
</b>
</p><p>
<b>
<a href="#" data-jig="ncbilinksmenu" data-jigconfig="destSelector:'#idm139650140929616'">Special Feature: Drugs (figures 26-36)</a>
</b>
</p></div><div id="chartbook.sdata"><h2 id="_chartbook_sdata_">Data Tables for Figures 1&#x02013;36</h2><p id="A240"><a href="/books/NBK20758/table/A240/?report=objectonly" target="object">Data table for figure 1. Total population,
population 65 years and over and 75 years and over: United States,
1950&#x02013;2050 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A241"><a href="/books/NBK20758/table/A241/?report=objectonly" target="object">Data table for figure 2. Percent of population in
4 age groups: United States, 1950, 2000, and 2050 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A242"><a href="/books/NBK20758/table/A242/?report=objectonly" target="object">Data table for figure 3. Percent of population in
selected race and Hispanic origin groups by age: United States,
1980&#x02013;2000 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A243"><a href="/books/NBK20758/table/A243/?report=objectonly" target="object">Data table for figure 4. Poverty rates by age:
United States, 1966&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A244"><a href="/books/NBK20758/table/A244/?report=objectonly" target="object">Data table for figure 5. Low income population by
age, race, and Hispanic origin: United States, 2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A245"><a href="/books/NBK20758/table/A245/?report=objectonly" target="object">Data table for figure 6. Health insurance
coverage among persons under 65 years of age: United States,
1984&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A246"><a href="/books/NBK20758/table/A246/?report=objectonly" target="object">Data table for figure 7. No health insurance
coverage among persons under 65 years of age by selected characteristics: United States,
2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A247"><a href="/books/NBK20758/table/A247/?report=objectonly" target="object">Data table for figure 8. Early prenatal care by
race and Hispanic origin of mother: United States, 1980&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A248"><a href="/books/NBK20758/table/A248/?report=objectonly" target="object">Data table for figure 9. Early prenatal care by
detailed race and Hispanic origin of mother: United States, 2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A249"><a href="/books/NBK20758/table/A249/?report=objectonly" target="object">Data table for figure 10. Influenza and
pneumococcal vaccination among adults 65 years of age and over: United States,
1989&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A250"><a href="/books/NBK20758/table/A250/?report=objectonly" target="object">Data table for figure 11. Influenza and
pneumococcal vaccination among adults 65 years of age and over by race and Hispanic origin:
United States, 2000&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A251"><a href="/books/NBK20758/table/A251/?report=objectonly" target="object">Data table for figure 12. Cigarette smoking among
men, women, high school students, and mothers during pregnancy: United States,
1965&#x02013;2003 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A252"><a href="/books/NBK20758/table/A252/?report=objectonly" target="object">Data table for Figure 13. Current cigarette smoking among high school students by sex,
frequency, and grade level: United States, 2003 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A253"><a href="/books/NBK20758/table/A253/?report=objectonly" target="object">Data table for figure 14. High school students
not engaging in recommended amounts of physical activity (neither moderate nor vigorous) by
grade and sex: United States, 2003 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A254"><a href="/books/NBK20758/table/A254/?report=objectonly" target="object">Data table for figure 15. Adults not engaging in
leisure-time physical activity by age and sex: United States, 1998&#x02013;2002
spreadsheet Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A255"><a href="/books/NBK20758/table/A255/?report=objectonly" target="object">Data table for figure 16. Overweight and obesity
by age: United States, 1960&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A256"><a href="/books/NBK20758/table/A256/?report=objectonly" target="object">Data table for figure 17. Obesity among adults
20&#x02013;74 years of age by sex, race, and Hispanic origin: United States,
1999&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A257"><a href="/books/NBK20758/table/A257/?report=objectonly" target="object">Data table for figure 18. Selected chronic
health conditions causing limitation of activity among children by age: United States,
2001&#x02013;02 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A258"><a href="/books/NBK20758/table/A258/?report=objectonly" target="object">Data table for figure 19. Limitation of activity
caused by 1 or more chronic health conditions among working-age adults by selected
characteristics: United States, 2000&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A259"><a href="/books/NBK20758/table/A259/?report=objectonly" target="object">Data table for figure 20. Selected chronic
health conditions causing limitation of activity among working-age adults by age: United
States, 2000&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A260"><a href="/books/NBK20758/table/A260/?report=objectonly" target="object">Data table for figure 21. Limitation of
activities of daily living among Medicare beneficiaries 65 years of age and over: United
States, 1992&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A261"><a href="/books/NBK20758/table/A261/?report=objectonly" target="object">Data table for figure 22. Life expectancy at
birth and at 65 years of age by sex: United States, 1901&#x02013;2001 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A262"><a href="/books/NBK20758/table/A262/?report=objectonly" target="object">Data table for figure 23. Infant, neonatal, and
postneonatal mortality rates: United States, 1950&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A263"><a href="/books/NBK20758/table/A263/?report=objectonly" target="object">Data table for figure 24. Infant mortality rates
by detailed race and Hispanic origin of mother: United States, 1999&#x02013;2001
version Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A264"><a href="/books/NBK20758/table/A264/?report=objectonly" target="object">Data table for figure 25. Death rates for
leading causes of death for all ages: United States, 1950&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A265"><a href="/books/NBK20758/table/A265/?report=objectonly" target="object">Data table for figure 26. Percent of persons
reporting prescription drug use in the past month by age: United States, 1988&#x02013;94
and 1999&#x02013;2000 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A266"><a href="/books/NBK20758/table/A266/?report=objectonly" target="object">Data table for figure 27. Percent of physician
office and hospital outpatient department visits with 5 or more drugs prescribed, ordered, or
provided by age: United States, 1995&#x02013;2002 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A267"><a href="/books/NBK20758/table/A267/?report=objectonly" target="object">Data table for figure 28. Percent of asthma
visits with quick-relief and long-term control drugs prescribed, ordered, or provided: United
States, 1995&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A268"><a href="/books/NBK20758/table/A268/?report=objectonly" target="object">Data table for figure 29. Percent of asthma
visits with selected asthma drugs prescribed, ordered, or provided: United States,
1995&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A269"><a href="/books/NBK20758/table/A269/?report=objectonly" target="object">Data table for figure 30. Percent of adults 18
years of age and over reporting antidepressant drug use in the past month by sex and age:
United States, 1988&#x02013;94 and 1999&#x02013;2000 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A270"><a href="/books/NBK20758/table/A270/?report=objectonly" target="object">Data table for figure 31. Percent of adults 18
years of age and over reporting antidepressant drug use in the past month by race and
ethnicity: United States, 1988&#x02013;94 and 1999&#x02013;2000 Click here for
PowerPoint
Click here for spreadsheet version</a></p><p id="A271"><a href="/books/NBK20758/table/A271/?report=objectonly" target="object">Data table for figure 32 (page 1 of 2; see page 2). Selective serotonin reuptake inhibitor (SSRI)
antidepressant drug visits among adults 18 years of age and over by sex: United States,
1995&#x02013;2002 Click here
for PowerPoint 1/11/2005. Some numbers were revised. See spreadsheet. Click here for spreadsheet version</a></p><p id="A272"><a href="/books/NBK20758/table/A272/?report=objectonly" target="object">Data table for figure 32 (page 2 of 2; see page 1). Selective serotonin reuptake inhibitor (SSRI)
antidepressant drug visits among adults 18 years of age and over by sex: United States,
1995&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A273"><a href="/books/NBK20758/table/A273/?report=objectonly" target="object">Data table for figure 33. Stimulant drug visits
among children 5&#x02013;17 years of age by sex: United States,
1994&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A274"><a href="/books/NBK20758/table/A274/?report=objectonly" target="object">Data table for figure 34. Antidepressant drug
visits among children 5&#x02013;17 years of age by sex: United States,
1994&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p><p id="A275"><a href="/books/NBK20758/table/A275/?report=objectonly" target="object">Data table for figure 35. Cholesterol-lowering
statin drug visits among adults 45 years of age and over by sex and age: United States,
1995&#x02013;2002 Click here
for PowerPoint 1/11/2005. Some numbers were revised. see spreadsheet Click here for spreadsheet version</a></p><p id="A276"><a href="/books/NBK20758/table/A276/?report=objectonly" target="object">Data table for figure 36. Percent of
nonsteroidal anti-inflammatory drug (NSAID) visits with selective COX-2 NSAIDs prescribed,
ordered, or provided among adults 18 years of age and over by age: United States,
1999&#x02013;2002 Click here
for PowerPoint
Click here for spreadsheet version</a></p></div><ul style="display:none" id="idm139650141041952"><li><a class="figpopup" href="/books/NBK20758/figure/A48/?report=objectonly" target="object" rid-figpopup="figA48" rid-ob="figobA48">Total population</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A49/?report=objectonly" target="object" rid-figpopup="figA49" rid-ob="figobA49">Population by age group</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A54/?report=objectonly" target="object" rid-figpopup="figA54" rid-ob="figobA54">Population by race</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A60/?report=objectonly" target="object" rid-figpopup="figA60" rid-ob="figobA60">Poverty rates</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A61/?report=objectonly" target="object" rid-figpopup="figA61" rid-ob="figobA61">Low income</a></li></ul><ul style="display:none" id="idm139650147387248"><li><a class="figpopup" href="/books/NBK20758/figure/A69/?report=objectonly" target="object" rid-figpopup="figA69" rid-ob="figobA69">Health Insurance coverage</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A70/?report=objectonly" target="object" rid-figpopup="figA70" rid-ob="figobA70">Uninsured by selected characteristics</a></li></ul><ul style="display:none" id="idm139650147383168"><li><a class="figpopup" href="/books/NBK20758/figure/A76/?report=objectonly" target="object" rid-figpopup="figA76" rid-ob="figobA76">Early prenatal care by race</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A77/?report=objectonly" target="object" rid-figpopup="figA77" rid-ob="figobA77">Early prenatal care by detailed race</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A83/?report=objectonly" target="object" rid-figpopup="figA83" rid-ob="figobA83">Influenza and pneumococcal vaccination</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A84/?report=objectonly" target="object" rid-figpopup="figA84" rid-ob="figobA84">Influenza and pneumococcal vaccination by race</a></li></ul><ul style="display:none" id="idm139650138639696"><li><a class="figpopup" href="/books/NBK20758/figure/A85/?report=objectonly" target="object" rid-figpopup="figA85" rid-ob="figobA85">Cigarette smoking</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A93/?report=objectonly" target="object" rid-figpopup="figA93" rid-ob="figobA93">Cigarette smoking, high school students</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A101/?report=objectonly" target="object" rid-figpopup="figA101" rid-ob="figobA101">Physical activity, high school students</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A102/?report=objectonly" target="object" rid-figpopup="figA102" rid-ob="figobA102">Physical activity, adults</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A109/?report=objectonly" target="object" rid-figpopup="figA109" rid-ob="figobA109">Obesity by age</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A110/?report=objectonly" target="object" rid-figpopup="figA110" rid-ob="figobA110">Obesity by race</a></li></ul><ul style="display:none" id="idm139650138631504"><li><a class="figpopup" href="/books/NBK20758/figure/A117/?report=objectonly" target="object" rid-figpopup="figA117" rid-ob="figobA117">Activity limitation, children</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A123/?report=objectonly" target="object" rid-figpopup="figA123" rid-ob="figobA123">Activity limitation, adults</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A124/?report=objectonly" target="object" rid-figpopup="figA124" rid-ob="figobA124">Activity limitation due to chronic conditions, adults</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A129/?report=objectonly" target="object" rid-figpopup="figA129" rid-ob="figobA129">Activity limitation, Medicare beneficiaries</a></li></ul><ul style="display:none" id="idm139650138625344"><li><a class="figpopup" href="/books/NBK20758/figure/A139/?report=objectonly" target="object" rid-figpopup="figA139" rid-ob="figobA139">Life expectancy</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A146/?report=objectonly" target="object" rid-figpopup="figA146" rid-ob="figobA146">Infant, neonatal, and postneonatal mortality rates</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A147/?report=objectonly" target="object" rid-figpopup="figA147" rid-ob="figobA147">Infant mortality rates by race</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A155/?report=objectonly" target="object" rid-figpopup="figA155" rid-ob="figobA155">Leading causes of death</a></li></ul><ul style="display:none" id="idm139650140929616"><li><a class="figpopup" href="/books/NBK20758/figure/A161/?report=objectonly" target="object" rid-figpopup="figA161" rid-ob="figobA161">Prescription drug use</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A162/?report=objectonly" target="object" rid-figpopup="figA162" rid-ob="figobA162">Percent with 5 or more drugs</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A165/?report=objectonly" target="object" rid-figpopup="figA165" rid-ob="figobA165">Asthma drug visits</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A166/?report=objectonly" target="object" rid-figpopup="figA166" rid-ob="figobA166">Asthma drug visits with selected asthma drugs</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A167/?report=objectonly" target="object" rid-figpopup="figA167" rid-ob="figobA167">Antidepressants, by sex, and age</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A168/?report=objectonly" target="object" rid-figpopup="figA168" rid-ob="figobA168">Antidepressants, by race</a></li><li><a class="figpopup" href="/books/NBK20758/figure/A163/?report=objectonly" target="object" rid-figpopup="figA163" rid-ob="figobA163">Selective 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