Document 6424475

Transcription

Document 6424475

Community Health sessment 2009 Kansas City, Missouri, Health Department October 2009
Health Department
2400 Troost Avenue, Suite 4000
Kansas City, Missouri 64108
(816) 513-6252
Fax (816) 513-6293
Director’s Office
October 2009
Dear Citizens of Kansas City,
I present to you the Kansas City Health Department’s 7th annual Community Health Assessment
report.
The national initiative Healthy People 2010 has two overarching goals: 1) to help individuals of all
ages increase life expectancy and improve their quality of life, and 2) to eliminate health disparities
among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.
As a community we cannot progress towards achievement of these goals without the data provided by reports such as the Community Health Assessment report. Documenting health indicator information for Kansas City residents, however, is only the first step. We must take this information, decipher
its complete meaning, and translate the findings into community actions for the improvement of health for
all and the elimination of health disparities.
The data contained in this report and other assessments of the community’s health are critical to
helping inform all citizens and policy makers concerning improvements and deficiencies in the health status of Kansas City residents. Inequities in health between the various groups that comprise our community can be identified and, hopefully, addressed. The data also provide support for policies that affect the
public’s health as well as form the basis for community organizations seeking grants and other financial
support in their efforts to improve the health status of our community.
Since 2001, the Health Department has received funding to enhance its abilities to monitor and
respond to infectious/communicable diseases and acts of bioterrorism. Significant steps have been taken
to reduce exposure to secondhand smoke in the both the workplace and in public venues. We are now
embarking on a number of initiatives, most notably Building a Healthier Heartland, to address the complex
web of policies and behaviors that discourage healthy lifestyles and, thereby, contribute to the health
problems extracted by chronic diseases, diet, and inactivity.
Please join us in improving the health of our citizens,
Rex Archer, MD, MPH
Director, Kansas City Health Department
COMMUNITY HEALTH ASSESSMENT 2009
Kansas City, Missouri
Page 5 of 294
Table of Contents
Chapter
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Executive Summary
Health Department Priorities
Demographics
Births
Fetal and Infant Mortality
Deaths
Emergency Department Visits and Hospitalizations
Health Zones
Cancer
Cardiovascular Diseases
Asthma
Chronic Lower Respiratory Diseases
Diabetes
Obesity
Osteoporosis
Injuries and Poisonings
Disabilities
Dental Health
Tobacco Use
Alcohol Use
Drug Use
Suicide
Homicide
Intimate Partner Violence
Infectious and Communicable Diseases
Environmental Health
Journal Publications of the Kansas City Health Department, 2000-2008
Glossary
Data Sources
Index
Page
7
11
15
27
65
79
113
121
133
147
161
167
171
181
193
197
215
225
233
241
249
253
259
263
267
273
281
283
287
289
Page 7 of 294
1. Executive Summary
Kansas City continued to experience an
increase in its birth rate, continuing a trend that
began in 1995. This trend is similar to that seen
nationally and is largely driven, in recent years,
by births to Hispanic and Asian women, over
two-thirds of whom were foreign-born. The total
fertility rate for Hispanic women is more than
double that needed for maintaining the Hispanic
population, while that for non-Hispanic blacks is
slightly higher than the replacement rate and
that for non-Hispanic whites is well below the
replacement rate.
The average age of the mother at first
birth has remained fairly constant (24.4 years in
2007); it was lowest for non-Hispanic blacks
(21.7 years) and highest for Asians (27.9 years).
Trends to births to young mothers have
been mixed. The birth rate for girls 10-14 years
of age, although variable year-to-year has been
declining. For the second year in a row there
were increases in the number of births to teens
15-17 years old and 18-19 years of age which
are consistent with national trends. Hispanic
teens had birth rates 2.3 times higher for 15-17
year olds and 1.6 times higher for 18-19 year
olds than non-Hispanic blacks, the next highest
racial/ethnic group. The repeat pregnancy rate
for teens 15-19 years rose to 23.9% from 20.0%
in 2006.
At the older end of the reproductive age
spectrum, the birth rate among women >40
years of age remained constant and low with
Hispanics and Asians having rates about twice
that of Native Americans, the next highest racial/ethnic group.
Over half the birth mothers (51.9%) in
2007 were not married. The proportion of unmarried mothers varied from 27.3% for nonHispanic whites to 77.5% for non-Hispanic
blacks. Among Hispanic birth mothers 57.0%
were not married, neither were 50.2% of Native
Americans. Asians had the lowest unmarried
rate among birth mothers at 26.3%. Overall,
77.4% of birth mothers <25 years old were unmarried compared to only 31.9% of those >25
years of age.
The percent of deliveries done by Cesarean section continued to increase as it has nationally, with 27.5% of deliveries overall, and
27.9% among first times mothers being done by
C-section. Non-Hispanic whites had the highest
C-section rates. Meanwhile, the rates for preterm births, and low birthweight babies, babies
remained stable while rates for pregnancies
classified as unintended and women receiving
no or inadequate prenatal care increased. Overall, less than two thirds of pregnant women received adequate prenatal care visits, a level far
below the national Healthy People 2010 target of
90%. Non-Hispanic blacks had the lowest percentage of pregnant women who received adequate prenatal care visits.
In 2007, the number of recorded pregnancies terminated by abortion declined 3.0%.
Twenty-one percent of recorded pregnancies
were terminated through abortion. The abortion
ratio (the number of abortions per 1,000 live
births) continued to decline for non-Hispanic
blacks and were relatively constant for nonHispanic whites. Still, non-Hispanic blacks had
the highest abortion ratio of any of the racial/ethnic groups. Unmarried women had an
abortion ratio 7.7 times that of married women
and, overall, unintended pregnancies accounted
for 75% of all abortions.
Of concern is the increasing number of
pregnant women whose pre-pregnancy weight
was considered obese, the number who gain too
much weight during pregnancy, and the number
who are diabetic. Also, the decline in the pregnancy-smoking rate has stagnated in recent
years. All of these factors can have negative
influences on pregnancy outcomes.
EXECUTIVE SUMMARY
Page 8 of 294
The infant mortality rate fluctuates annually averaging 8.4 per 1,000 live births over
the past 10 years. For 2007, the rate was 8.1.
The infant mortality rate for non-Hispanic blacks
increased for the 3rd year in a row while that for
non-Hispanic whites remained variable. In 2007,
the infant mortality rate for non-Hispanic blacks
was 3.3 times higher than that for non-Hispanic
whites.
Kansas City’s overall infant mortality rate
was 62% higher than the Healthy People 2010
national objective of 5.0 per 1,000 live births
and, over the past 10 years, the rate for nonHispanic blacks has remained consistently 2-3
times higher than the national objective. The
infant mortality rate increased with decreasing
zip code level median family income. Although
infant mortality rates vary by census tract, the
higher rates for 64109, 64110, 64111, 64128,
64130, 64132, 64137, and 64147 were not significantly different from each other.
Both the number of deaths and the ageadjusted death rate declined in 2007. Men have
shorter life expectancies than women and higher
age-specific death rates starting at birth. This
was reflected in the fact that 42.0% of deaths
among men were premature (occur before 65
years of age) compared to 26.0% for women.
The highest premature death rates occurred
among Hispanics (41.4%) and non-Hispanic
blacks (42.9%) while non-Hispanic whites had
the lowest rate (28.6%).
An examination of mortality trends between 1991 and 2005, demonstrated improvement in some of the indicators for non-Hispanic
blacks. However, there was no or little improvement in the relative disparity gaps between nonHispanic blacks and non-Hispanic whites.
Cancer was the leading cause of death
in Kansas City in 2007 followed by heart disease, chronic lower respiratory diseases, stoke
and unintentional injuries. Among both men and
women, cancer and heart disease were the two
leading causes of death, however, among men
unintentional injuries were the third leading
EXECUTIVE SUMMARY
cause and among women it was stroke. Alzheimer’s disease was the 5th leading cause among
women, but was not in the top 10 causes for
males. Likewise, while homicide was 7th among
males and suicide 10th, neither of those causes
was in the top 10 for women.
Twenty-eight percent of all cancer deaths
were due to lung cancer and 86% of lung cancer
deaths among men and 72% among women
could be attributed to smoking. The lung cancer
age-adjusted death rate among men was 1.7
times higher than among women. And, among
women, the lung cancer age-adjusted death rate
was 2.0 times higher than that of breast cancer.
Non-Hispanic blacks had an age-adjusted death
rate from lung cancer that was higher than that
for non-Hispanic whites. Lung cancer death
rates declined as zip code median family incomes increased.
The age-adjusted death rates for breast
cancer in non-Hispanic blacks was 56% higher
than for non-Hispanic white women. Overall, the
age-adjusted death rate for breast cancer has
been 20-37% below the Healthy People 2010
objective since 2004.
Men were 85% more likely to die from
heart disease and 7% less likely to die from
stroke than women. Among all males who died,
22.6% died from heart disease and 3.9% from
stroke. For females, 19.0% died from heart disease and 6.7% from stroke. Non-Hispanic
whites were more likely to die from heart disease and less likely to die from stroke than nonHispanic blacks.
Over the past 10 years, the age-adjusted
death rates from chronic lower respiratory diseases has declined for both non-Hispanic whites
and non-Hispanic blacks, yet non-Hispanic
whites were 46% more likely than non-Hispanic
blacks to die. Men were 43% more likely to die
than women. Overall, the age-adjusted death
rate for chronic lower respiratory diseases was
18% below the Healthy People 2010 national
objective.
Page 9 of 294
The rate per 100 residents for emergency department visits was 46.4 while for hospitalizations it was 16.5. These rates although higher
than those in observed in 2006, they were similar to those for 2005. Injury, respiratory diseases, genitourinary tract diseases, mental disorders, and pregnancy/birth-related issues were the
leading reasons for emergency department visits. Pregnancy/birth-related issues, cardiovascular diseases, respiratory diseases, injury, and
mental disorders were the leading reasons for
hospitalizations. Fifteen percent of persons seen
in an emergency department were subsequently
admitted to a hospital. Non-Hispanic blacks and
non-Hispanic whites had the highest rates for
emergency department visits, while nonHispanic blacks and Hispanics had the highest
hospitalization rates.
Among the infectious and communicable
diseases, there was a decrease in primary and
secondary syphilis. Hospitalization rates for HIV
as well as cases of tuberculosis continued to
decline. Nearly half of the tuberculosis cases
were among foreign-born individuals. Over the
last 5 years, the percent of the children <6 years
of age who were tested for elevated blood lead
levels who had elevated levels, had declined by
more than to two-thirds to 1% which was less
than the national average of 1.4%. Ten zip
codes exceeded the Kansas City average. It is
estimated that just over 52,000 Kansas City
children have not been tested for blood lead levels.
In addition to children, data on Kansas
City adults showed that, of those tested for elevated blood lead levels, 1.6% had elevated levels.
EXECUTIVE SUMMARY
Page 11 of 294
2. Health Department Priorities
Upon review of the Community Health
Assessment 2009, Dying so Young: Infant Mortality in Kansas City, Mo, and Minority Health
Indicators, plus other reports and analyses produced by the Kansas City Health Department
involving health indicator data for the community, five (5) general areas of priority concern were
identified. The five priorities were chosen for
their pervasive effect on a wide range, and often
overlapping, public health concerns in Kansas
City. These priorities are described below and
are not assigned any hierarchical importance
relative to each other. While arguments can be
made for addressing specific health issues related to these priority areas, it was not the
Health Department’s intent to describe here
strategies and action steps, but rather to leave
that more crucial work to deliberative bodies that
can mobilize the necessary community resources, including fiscal and policy changes, to
accomplish those missions.
Health disparities
Some people live shorter and less
healthy lives than others. These disparities or
inequalities in life expectancy and health status
are influenced by many factors such as genetics, social circumstances, environmental exposures, behavioral patterns, and health care. In
addition, as the video Unnatural Causes demonstrated, the public’s health is also affected by
more “upstream” social policies. These powerful
determinants affect the social conditions into
which people are born, live and work. And, inequalities beget inequalities, and existing inequalities can compound, sustain, and reproduce a multitude of deprivations in the six core
dimensions of well-being – health, personal security, reasoning, respect, attachment, and selfdetermination. Consequently, social policy is
health policy and sound social policy is necessary to ensure everyone the opportunity for good
health.
Disparities exist in the health of individuals and groups in society with minority populations more likely to be negatively impacted.
Health care plays only a small part in health disparities while one’s social position in the society
plays a significant role. It can be debated which
health disparities are a greater affront to social
justice and therefore, more deserving of attention. The interactive nature and complexity of
health disparities present challenges in seeking
redress.
Public health is by nature population
oriented, and as a consequence, the Health Department believes that reducing premature
deaths (before 65 years of age) is a priority. The
single greatest opportunity to improve health
and reduce premature deaths lies in personal
behavior. Behavioral causes account for nearly
40% of all deaths with physical inactivity-obesity,
and smoking being the top two behavioral causes of death. Improving population health, however, also will require addressing the nonbehavioral determinants of health - social circumstances and environmental factors.
In Kansas City, between 40 and 49% of
all deaths among minority residents are premature compared to 25% of deaths among nonHispanic whites. This disparity has persisted for
at least the past 15 years. Although many health
indicators have improved among minority residents, there has been no closure of the disparity
gaps between non-Hispanic whites and the remainder of the population. Within the community, policy and behavior changes have contributed to far greater reductions in avoidable premature mortality than did improvements in medical care, except among non-Hispanic black
males.
HEALTH DEPARTMENT PRIORITIES
Page 12 of 294
Persons with lower socioeconomic status
tend to die earlier and have more disability than
those with higher socioeconomic status, and this
pattern holds true in a stepwise fashion from the
lowest to the highest classes. The uninsured are
disproportionately represented among the lowest socioeconomic classes. And, people with
lower socioeconomic status have greater exposure to environmental health-compromising
conditions such as dangerous neighborhoods,
lead paint, and lack of outlets for physical activity. Remedies for these social and environmental
determinants of health as well as health insurance coverage lie predominately in the political
arena.
Premature births
Prematurity in Kansas City is the leading
cause of infant mortality responsible for approximately 43% of all infant deaths. As elsewhere in
the nation, in Kansas City the number of premature infants has increased and currently the rate
of premature births is a little over 10% (premature births are those that occur before 37 weeks
gestation). There are significant racial disparities
in preterm births, particularly for non-Hispanic
blacks who have about a 13% premature birth
rate.
Preterm birth is associated with a variety
of adverse health outcomes, including infant
death, severe mental or physical disabilities,
diminished long-term survival, etc. Many of
these poor health outcomes extend from infancy
into childhood, adolescence and adulthood manifesting as educational and behavioral problems and increased likelihood of hospitalization.
The list of poor health outcomes continues to
expand and the severity of these adverse outcomes is correlated with younger gestational
age so that the earlier in gestation an infant is
born the higher the risk of long-term health problems.
In addition to the health problems associated with preterm birth, preterm birth is acHEALTH DEPARTMENT PRIORITIES
companied by broad and financial costs and lost
opportunities for families. The birth and hospitalization of preterm infants are associated with
maternal distress, maternal depressive symptoms, establishment of parental attachment, difficulty in maintaining employment, etc. There is
an economic burden to the family in terms of
out-of-pocket expenses and lost wages and to
the community through higher health insurance
premiums and taxes such as the Health Levy.
The societal costs are not trivial, having been
estimated nationally at roughly $51,600 per preterm infant, with two-thirds of these expenses
being for medical care. The actual cost per preterm infant is highest for those that are very
premature (less than 32 weeks gestation; about
2% of infants born in Kansas City). For example,
costs are estimated nationally at over $200,000
per infant born at 25 weeks gestation.
Obesity
Obesity, specifically childhood obesity, is
one of the more serious problems of modern
society. It has increased at an alarming rate over
the past three decades and is linked to very high
rates of chronic illnesses, much higher than living in poverty, smoking or drinking. Women suffer a disproportionate burden of illness attributable to being overweight and obesity and there
are racial/ethnic disparities. Being overweight or
obese contributes to decreased cognitive functioning in school-aged children as well as many
health and safety issues, such as shortened lifeexpectancy, increased risk of breast cancer,
complications of pregnancy, increased risk of
birth defects (2nd leading cause of infant mortality in Kansas City), impotence in males, and ability to receive certain diagnostic imaging procedures, and motor vehicle crash injury and death.
A significant number of obesity-related chronic
illnesses, such as orthopedic problems and type
2 diabetes, are now manifesting in childhood
rather than adulthood. And, recent studies suggest that health problems related to overweight
Page 13 of 294
begin as early as the first two years of life. Besides the association with chronic health conditions, obesity can have a dramatic effect on
people’s ability to manage five basic activities of
daily living: bathing, eating, dressing, walking
across a room, and getting in or out of a bed.
Obesity is a complex disease with genetic, metabolic, and behavioral determinants; with
many of the behavioral determinants influenced
by the obesogenic environment in which people
live. Examples of the obesogenic environment
include the natural and physical environment (eg
walkable neighborhoods, location of grocery
stores with fresh fruits and vegetables, recreational opportunities), public policy (eg contents
of school vending machines), food advertising
and marketing, etc. The Building a Healthier
Heartland initiative is striving to influence the
obesogenic environment in the Kansas City metropolitan area.
The economic burden of obesity is not
inconsequential being estimated at $117 billion
per year in the year 2000. More than half of the
medical care costs are paid through public funds
(Medicaid, Medicare) and about 11.6% of private
medical insurance costs are obesity related. Private insurance spending for obese persons are
56% higher than those for normal weight individuals. The 3% of the population who are morbidly obese consume more than 10% of all
health care spending.
Reducing obesity in Kansas City should
impact private health care insurance premiums
as well as publicly funded health care costs such
as the Health Levy, Medicaid, and Medicare. If
nothing is done, national projections are that the
total healthcare costs attributable to obesity/overweight will double every decade, accounting for 16-18% of the total US health care dollars
by 2030.
Infectious and communicable
diseases
Between 2003-2007, infectious and
communicable diseases were the 4th leading
cause of death in Kansas City behind cancer,
heart disease and chronic lower respiratory diseases. Infectious and communicable diseases
cause more than twice the number of deaths
than homicide, for example. In addition, infectious and communicable diseases are the 9th
leading cause of hospitalization among Kansas
City residents.
There are no good estimates of the
number of persons who contract an infectious or
communicable disease through the year, the
number of days of disability (missed days of
work or school), or the economic impact of such
diseases on the community. Yet, historic evidence clearly shows that even the fear of such
as disease like anthrax or SARS (sudden acute
respiratory syndrome) can exert severe economic losses. And, of course, epidemic or pandemic
disease can be a major cause of illness and
death, severely impacting the educational and/or
work environment and overwhelming the illness
care sector.
The control and prevention of infectious
and communicable diseases is a major responsibility of public health and more than 90% of
Kansas City residents queried believe that public
health should be preventing the spread of infectious and communicable diseases, protecting
the public from new health threats, protecting
against foodborne illnesses, and assessing and
monitoring diseases occurring within the community.
Environmental health
Improvements in environmental health
have saved more lives and improved the quality
of life for more citizens than any other public
health or medical care intervention. The first significant efforts to improve the health of populaHEALTH DEPARTMENT PRIORITIES
Page 14 of 294
tions came from the sanitary movement of the
late 1800s that stressed, among other things,
clean and safe food, beverages, and water, protection from contamination whether natural or
man-made, decent housing, and safe working
conditions.
In today’s environment, many of these
same issues are still forefront in protection of the
populace, although the constellation of specific
issues has expanded. The issues become paramount as one considers that there is now clear
scientific evidence that humans are living in an
unsustainable way, by consuming the Earth’s
limited natural resources more rapidly than they
are being replaced by nature. Consequently, a
collective human effort is needed to keep the
use of natural resources within the boundaries of
the Earth’s finite resource limitation. For society
to find “green” solutions, i.e., solutions that are
environmentally positive, becomes a critical public heath priority.
For most individuals, there are three basic microenvironments – where they live, where
they work, and where they spend their leisure
time, and these microenvironments are components of the greater environment of the community which in turn is influenced by national and
international environments, culture, economics,
etc.
Despite the health threats posed by the
environment, both natural and man-made, it is
estimated that only 5% of premature deaths now
result from environmental exposures, a vast improvement from even 50 years ago. In addition
to threats to the public’s health, a number of environmental issues, such as air quality and restaurant inspection, have direct bearing on the
community’s economic viability.
HEALTH DEPARTMENT PRIORITIES
Page 15 of 294
3. Demographics
Kansas City traces its beginnings to
1821, the year Missouri was admitted to the Union. Known as the Town of Kansas it was incorporated and granted a charter by Jackson County on June 1, 1850. When it was incorporated by
the state on February 22, 1853, it became the
City of Kansas, and in 1889, it officially became
known as Kansas City.
Located in west-central Missouri, juxtaposed with the state of Kansas, the City is the
largest municipal jurisdiction, in terms of area
and population, in Missouri and in the bi-state 17
county “combined statistical area” or CSA. According to the Census Bureau’s July 2008 population estimate, 2,070,544 persons resided in the
CSA. The counties comprising the CSA are:
Bates, Caldwell, Cass, Clay, Clinton, Jackson,
Johnson, Lafayette, Platte, and Ray in Missouri,
and Atchison, Franklin, Johnson, Leavenworth,
Linn, Miami, and Wyandotte in Kansas.
Population
Figure 3-1 Kansas City population (from
Census 2000)
600
Population x 1,000
500
400
300
200
100
0
1860 1880 1900 1920 1940 1960 1980 2000
450,375 residents to 475,830 (Table 3-1). However, in its estimates released in June 2009 it
still reflected the population at a lower count of
451,572. The Kansas City Planning and Development Department projects the July 2008
population number will be adjusted to 480,534.
More importantly, the population has been redistributing itself within the counties comprising
the City; the Clay County portion of the city
gained the most residents and had the greatest
percentage increase in population.
Characterizing Kansas City’s population
becomes more problematic the further one is
from Census 2000. The population distribution
by race/ethnicity, sex, age, and census tract
used in this report are based on the original es-
In 1853, the Town of Kansas was nearly
a square mile in size with a population of 2,500
persons. Today, Kansas City is 316 mi2 of urban
and rural environments situated within four different counties (Cass, Clay, Jackson, and
Platte). In 2000, the overall population density
was 1,407.4 persons/mi2. A small number of
farms remain within the City with less than
200 persons living on them.
Census 2000 initially reported
Table 3-1 Population estimates for Kansas City, Mo
Kansas City’s population as 441,545 of
(source: US Census Bureau)
April
Revised
which 98.8% resided in urbanized areas
2000
July
(Figure 3-1). This number was subsequentCounty
Census
2008
Population Percent
ly revised to 441,828. The Census Buportion
revision
estimate
gain/loss
change*
Cass
105
103
-2
-1.9%
reau’s annual population estimates showed
Clay
84,317
106,827
22,510
26.7%
continual growth. In response to a chalJackson
322,638
328,702
6,064
1.9%
lenge by Kansas City, the Census Bureau
Platte
34,768
40,198
5,430
15.6%
Total
441,828
475,830
34,002
7.7%
revised its July 2008 estimate from
DEMOGRAPHICS
Page 16 of 294
timate of the population in 2000, ie 441,545.
Consequently all rates, whether crude or ageadjusted, are based on those distributions, unless otherwise stated. The annual interim census estimates of population do not provide sufficient detail of the population where they could
be used in lieu of Census 2000. Based on Census 2000, age distributions by sex and zip code
can be found in Tables 3-2, 3-3 and 3-4. Maps
showing the distribution of select subpopulations
are found in Figures 3-2 through 3-6.
From the 2005-2007 American Community Survey, the
US Census Bureau estimated
Table 3-2 Distribution of the population of Kansas City, Mo, by age, sex,
that 57.6% of the
and race/ethnic group (source: Census 2000)
population were
White, nonBlack, nonPopulation
Hispanic
Hispanic
Hispanic
Age
non-Hispanic
(years)
Male
Female
Male
Female
Male
Female
Male
Female
whites, 29.1%
0-4
16,105
15,650
7,492
7,229
5,661
5,540
1,876
1,739
5-9
16,219
15,610
7,134
6,853
6,608
6,436
1,550
1,465
non-Hispanic
10-14
15,807
14,963
7,040
6,603
6,727
6,460
1,280
1,167
blacks, 2.1%
15-17
8,980
8,652
3,997
3,964
3,741
3,572
780
641
non-Hispanic
18-19
5,598
5,823
2,709
2,894
1,974
2,139
590
454
20-24
15,284
16,306
8,467
8,704
4,081
5,350
1,859
1,378
Asian, 0.2% non25-29
18,442
18,898
11,290
10,947
4,125
5,404
1,880
1,486
Hispanic Native
30-34
17,637
17,416
10,901
10,004
4,299
5,457
1,555
1,171
35-39
18,177
18,156
11,286
10,556
4,970
5,994
1,236
984
Americans, and
40-44
17,321
17,655
10,794
10,383
4,776
5,765
1,122
884
8.8% Hispanic.
45-49
14,778
15,879
9,707
9,728
3,825
4,858
744
673
50-54
12,376
13,459
8,341
8,618
2,993
3,825
624
508
Of the Hispanic
55-59
9,277
10,267
6,207
6,539
2,351
3,009
378
349
population,
60-64
6,908
8210
4,510
5,100
1,880
2,544
274
325
79.8% were Mex65-69
6,107
7,905
4,090
5,115
1,637
2,304
242
275
70-74
5,564
7,587
3,933
5,099
1,317
2,041
207
277
ican. Collectively,
75-79
4,464
6,745
3,237
4,923
1,000
1,500
154
204
minority groups
80-84
2,469
4,585
1,882
3,423
473
1,004
70
83
>85
1,628
4,638
1,235
3,537
341
940
33
87
constituted
Total
213,141 228,404 124,252 130,219 62,779
74,142
16,454
14,150
42.4% of the
population, esNative AmeriHawaiian, Pacan
Asian
cific Islander
Age
sentially un(years)
Male
Female
Male
Female
Male
Female
changed from
0-4
58
58
282
329
23
24
Census 2000. Of
5-9
76
54
259
249
11
18
10-14
78
73
247
204
24
24
the population,
15-17
48
63
163
189
17
12
92.7% were born
18-19
36
31
170
137
8
13
in the US or its
20-24
85
90
445
416
39
37
25-29
85
87
656
592
33
20
possessions, and
30-34
96
95
454
378
27
25
7.3% were for35-39
95
108
292
261
21
17
40-44
107
106
252
244
13
10
eign-born (Figure
45-49
74
100
205
291
16
12
3-7). Among the
50-54
65
73
207
265
8
11
foreign-born,
55-59
41
35
175
184
2
8
60-64
35
29
105
123
4
1
54.8% were from
65-69
16
26
60
108
0
3
Latin American,
70-74
23
20
46
63
1
3
22.2% from Asia,
75-79
11
15
26
44
2
1
80-84
4
11
20
19
0
4
10.4% from Eu>85
1
14
5
17
1
0
rope, and 10.3%
Total
1,034
1,088
4,069
4,113
250
243
from Africa.
DEMOGRAPHICS
Page 17 of 294
Table 3-3 Male age distribution by age group and zip code, Kansas City, Mo (source: Census 2000)
Zip
64012
64030
64079
64081
64101
64102
64105
64106
64108
64109
64110
64111
64112
64113
64114
64116
64117
64118
64119
64120
64123
64124
64125
64126
64127
64128
64129
64130
64131
64132
64133
64134
64136
64137
64138
64139
64145
64146
64147
64149
64151
64152
64153
64154
64155
64156
64157
64158
64160
64161
64163
64164
64165
64166
64167
No zip
Total
Total
71
14
20
8
291
284
1327
3715
3221
6041
8241
9536
4275
5580
10767
5435
6143
9525
7971
458
5277
6753
1053
3046
9926
6779
4879
11984
10814
7224
7225
10980
651
5083
6228
440
2070
603
256
178
9234
3709
1630
2204
8275
572
1587
1204
0
86
67
37
27
45
17
75
213,141
<5
4
1
2
43
27
264
229
412
563
342
117
454
605
368
517
821
558
34
438
607
114
293
909
554
353
947
861
691
469
915
43
351
437
32
95
30
116
10
711
325
137
158
729
38
211
147
5
3
3
3
2
7
16,101
5-14
1
3
1
80
14
444
411
860
1,294
519
191
728
1,011
658
959
1,297
1,228
57
842
1,071
177
684
2,024
1,332
713
2,435
1,563
1,460
945
2,160
107
715
1,010
76
245
73
96
21
1,284
646
241
262
1,366
82
327
261
15
10
7
1
7
3
9
32,026
15-19
8
1
28
16
223
277
455
755
390
132
255
486
334
384
563
530
26
351
519
69
259
847
626
373
1,029
665
690
479
926
55
336
454
27
165
35
7
10
582
279
81
107
528
68
80
45
5
3
1
1
5
2
6
14,578
20-24
38
1
54
19
153
390
281
431
802
1,195
574
120
597
425
403
787
439
24
401
552
99
191
677
432
380
713
845
546
443
671
32
427
395
11
76
30
14
6
626
174
117
178
391
30
40
43
3
2
1
1
1
3
15,284
25-34
17
1
2
2
117
40
531
780
606
863
1,410
2,726
1,246
757
1,982
937
1,110
1,854
1,286
61
911
1,261
155
431
1,306
749
822
1,370
1,872
941
933
1,551
85
905
955
60
161
66
11
15
1,439
614
405
486
1,421
60
425
298
15
9
6
1
4
1
7
36,079
35-44
2
1
5
84
35
271
734
534
1,199
1,279
1,813
668
1,108
1,727
862
1,061
1,509
1,410
68
857
1,077
172
470
1,551
991
803
1,732
1,704
1,041
1,130
1,705
134
765
1,032
79
277
98
4
31
1,645
740
321
359
1,680
104
294
266
10
15
6
5
13
3
14
35,498
45-54
2
5
1
30
20
147
458
413
861
1,076
1,238
582
1,049
1,493
800
679
1,228
1,080
63
627
776
114
303
1,078
735
632
1,224
1,408
779
1,029
1,284
94
621
789
64
314
90
4
36
1,440
492
191
264
1,186
78
121
98
15
10
7
6
5
3
12
27,154
55-64
4
4
2
4
6
82
210
206
428
573
602
346
530
896
494
420
723
697
51
382
429
63
180
663
481
378
1,034
753
549
709
802
50
383
525
38
277
71
1
26
826
248
81
187
567
65
67
38
8
7
2
1
2
2
12
16,185
65-74
1
1
2
8
51
122
151
327
310
373
235
321
891
311
383
470
458
38
256
287
52
143
497
468
271
965
590
326
623
633
36
375
381
23
250
67
1
14
394
109
33
94
247
32
14
7
6
5
6
6
3
1
3
11,671
75-8y
2
1
4
29
64
84
164
149
276
148
204
795
217
190
230
247
28
172
141
34
75
316
333
131
439
425
158
382
289
15
182
218
20
147
35
2
9
252
69
18
77
129
12
8
1
3
3
1
1
2
2
6,933
>85
1
6
26
29
41
30
62
36
54
284
29
37
43
38
8
40
33
4
17
58
78
23
96
128
43
83
44
23
32
10
63
8
35
13
5
32
31
3
1
1
1,628
DEMOGRAPHICS
Page 18 of 294
Table 3-4 Female age distribution by age group and zip code, Kansas City, Mo
2000)
Zip
64012
64030
64079
64081
64101
64102
64105
64106
64108
64109
64110
64111
64112
64113
64114
64116
64117
64118
64119
64120
64123
64124
64125
64126
64127
64128
64129
64130
64131
64132
64133
64134
64136
64137
64138
64139
64145
64146
64147
64149
64151
64152
64153
64154
64155
64156
64157
64158
64160
64161
64163
64164
64165
64166
64167
No zip
Total
Total
33
15
16
6
44
340
997
2,820
2,867
6,118
9,199
8,198
4,248
5,893
12,721
5,893
6,834
9,928
8,361
425
5,202
6,373
1032
3,227
11,257
8,098
4,974
14,617
12,861
8,898
7,717
11,925
654
5,461
7,137
536
2,383
724
383
196
9,720
3,772
1,648
2,442
8,531
524
1,614
1,201
0
80
69
27
26
41
18
80
228,404
<5
1
1
53
22
250
188
412
617
368
115
425
555
373
535
720
628
33
400
591
86
325
882
552
344
898
874
701
473
845
48
354
431
28
100
22
108
11
602
289
135
159
673
36
203
165
3
3
2
2
3
6
15,650
DEMOGRAPHICS
5-14
2
1
84
22
426
358
920
1,173
487
169
729
861
672
932
1,219
1,184
49
813
996
172
646
1,984
1,269
706
2,399
1,481
1,498
915
1,948
81
630
925
60
251
65
71
25
1,305
598
249
253
1,304
70
312
216
6
9
5
4
4
4
11
30,573
15-19
3
2
1
32
21
161
173
451
838
373
156
277
502
325
415
549
537
28
327
499
90
220
886
620
372
999
697
686
483
866
46
319
452
29
100
33
21
22
603
240
74
136
613
40
76
62
1
4
1
2
6
2
4
14,475
20-24
14
1
3
30
169
280
309
474
1,009
1,087
597
109
664
442
485
814
411
20
319
489
70
204
787
499
384
830
1,003
755
444
743
30
422
463
6
74
30
94
8
691
162
122
196
418
28
62
41
8
1
1
1
3
16,306
25-34
7
1
1
18
54
295
532
513
841
1,551
2,034
1,114
828
1,893
950
1,128
1,833
1,285
62
782
1,009
169
526
1,440
925
755
1,796
2,087
1,329
915
1,828
95
881
1,080
59
180
65
62
12
1,520
628
399
457
1,482
61
454
335
12
7
1
2
4
2
15
36,314
35-44
2
3
6
1
18
41
143
332
413
1,031
1,384
1,229
503
1,105
1,854
887
1,095
1,600
1,415
62
787
922
159
487
1,671
1,193
794
2,100
2,014
1,308
1,125
1,955
112
834
1,145
87
294
89
15
31
1,704
787
339
350
1,686
102
288
241
10
15
8
5
13
3
14
35,811
45-54
3
6
1
5
22
100
270
338
755
1,220
978
518
1,088
1,652
799
833
1,391
1,162
56
583
720
111
297
1,225
888
691
1,705
1,699
1,019
1,145
1,495
87
727
1,002
56
383
136
5
34
1,511
572
184
290
1,213
74
131
100
20
11
2
4
4
4
13
29,338
55-64
1
4
5
11
42
183
210
407
648
468
368
537
1,162
554
520
766
778
33
390
469
64
193
846
674
415
1,491
1,022
754
813
992
56
461
620
41
304
101
4
28
794
253
83
208
535
57
55
27
10
6
2
1
1
3
7
18,477
65-74
1
1
9
74
157
180
402
416
476
291
369
1,367
406
491
572
540
42
372
328
67
170
747
763
307
1,406
856
515
738
773
59
462
547
32
311
97
17
439
138
34
116
304
37
26
10
4
7
5
4
3
4
15,492
(source: Census
75-8y
1
3
77
151
133
315
267
429
259
304
1,434
402
328
351
336
30
298
259
39
114
556
531
160
735
769
243
511
396
27
265
340
63
232
73
1
8
388
85
21
160
195
15
5
3
5
6
1
1
2
3
11,330
>85
1
32
78
52
110
76
269
158
122
777
83
72
113
85
10
131
91
5
45
233
184
46
258
359
90
155
84
13
106
132
75
154
13
2
163
20
8
117
108
4
2
1
1
4,638
Page 19 of 294
Figure 3-2 Distribution of non-Hispanic
white population, Kansas City, Mo, Census 2000
Figure 3-4 Distribution of Hispanic population, Kansas City, Mo, Census 2000
Figure 3-3 Distribution of non-Hispanic
black population, Kansas City, Mo, Census 2000
Figure 3-5 Distribution of Asian population, Kansas City, Mo, Census 2000
DEMOGRAPHICS
Page 20 of 294
Figure 3-6 Distribution of Native American
population, Kansas City, Mo, Census 2000
Overall, 89.2% of the population only
speaks English at home, while 6.7% only speak
Spanish.
Among persons >5 years of age, 16.1%
have a disability; the prevalence rises with age
and 41.8% of those persons >65 years of age
have at least one disability.
Due to the small number of City residents in
Cass County and the limited number of
health events associated with them, those
residents are not included in discussions of
sub-City data comparisons.
Demographic changes
One of the most dynamic changes occurring in Kansas City as well as the nation is
the growth of the Hispanic ethnic groups (Tables
3-5 and 3-6). They comprise the largest minority
group in the nation, yet its members are quite
diverse and can be of any race. Between 2000
DEMOGRAPHICS
Figure 3-7 Percent of population who are
foreign-born, Kansas City, Mo, Census
2000
and 2007, nearly 25% of new residents in the six
core counties in the metropolitan area was Hispanic.
It is well recognized that there are ethnic
variations in Hispanic health, with Mexicans having health advantages and Puerto Ricans having
disparities.1 Mexicans are the predominant Hispanic ethnicity in Kansas City. Because Hispanic
ethnicity is not recorded on most health records
utilized for the preparation of this Community
Health Assessment document, the term “Hispanic” will refer to all Hispanics irrespective of race
or national origin. Also, the health, life expectancy and mortality patterns among immigrant populations differ from those of native-born residents,2 but again nativity typically is not captured.
An important issue in defining the health
status of minority groups is that of inconsistencies in self-reported ethnicity and ethnicity recorded in records held by the medical care provider or public health agency.3 This is particularly a problem for Hispanics, Native Americans,
Page 21 of 294
es are influenced by birth
1970
1980
1990
2000
White, non-Hispanic
378,003
75%
305,176
68%
282,730
65%
254,471
58%
rates, life exBlack, non-Hispanic
112,005
22%
122,018
27%
128,003
29%
136,921
31%
pectancy beHispanic
13,493
3%
14,703
3%
17,017
4%
30,604
7%
tween the raOther
3,568
1%
6,262
1%
7,396
2%
19,549
5%
Total
507,087
448,159
435,146
441,545
cial and ethnic
groups as well
as the fact that
Table 3-6 Contribution of Hispanics to population growth, 2000 and
persons migrating to
2007 (source: US Census Bureau)
Kansas City tend to
2000
2007
be younger in age
County
Total
Hispanic Percent
Total
Hispanic Percent
Clay
184,006
6,594
3.6
211,952
10,174
4.8
and more likely male.
Jackson
654,880
35,160
5.4
666,890
50,017
7.5
A surrogate measure
Platte
73,781
2,211
3.0
84,881
3,480
4.1
Cass
82,092
1,816
2.2
97,133
3,205
3.8
of the migrant differJohnson
451,086
17,957
4.0
526,319
30,527
5.8
ence is that among
Wyandotte
157,882
25,257
16.0
153,856
34,640
22.5
Hispanics 20-44
Metropolitan
1,603,727
88,995
5.5
1,741,031
132,043
7.6
area
years of age, males
account for 57% of
the group. This can
be
compared
to
51%
of whites in the
Table 3-7 Percentage of racial and ethnic groups,
same age group being male and only
Kansas City, Mo (source: Census 2000)
Age
White
Black
43% of non-Hispanic blacks being
group
non-Hispanic non-Hispanic
Hispanic
male.
(years)
Pop. 254,471
Pop. 136,921
Pop. 30,604
While the age distributions for
0-4
5.8
8.2
11.8
5-9
5.5
9.5
9.9
Kansas City and the balance of each of
10-14
5.4
9.6
8.0
the three counties (Clay, Jackson, and
15-19
4.9
8.3
8.1
20-29
15.5
13.8
21.6
Platte) are not significantly different, the
30-39
16.8
15.1
16.2
racial and ethnic differences are mar40-49
15.9
14.0
11.2
50-59
11.7
8.9
6.1
kedly different (Table 3-8). The resi60-69
7.4
6.1
3.6
dents of non-City portions of each of the
70-79
6.8
4.3
2.8
three counties are predominately non>80
4.0
2.0
0.9
Hispanic white, while only about 58% of
the City residents are non-Hispanic
and certain Asian sub-groups. As additional ethwhite. The percentage of the population of the
nic groups become added to administrative
City that is non-Hispanic black is 12-15 times
forms in the medical and public health arenas
that of the non-City portions of either Clay or
misclassification will assume greater imporPlatte counties, and more than five times that of
tance.
the non-City portion of Jackson County.
Overall, the Hispanic
tion in Kansas City is significantly
younger than either non-Hispanic
Table 3-8 Racial and ethnic distribution for Kansas City
vs balance of the counties (source: Census 2000)
whites or non-Hispanic blacks (Table
Racial/Ethnic
Kansas
Jackson
Platte
3-7 and Figure 3-8). These
Table 3-5 Changes in racial/ethnic composition, Kansas City, Mo
Group
White, non-Hispanic
Black, non-Hispanic
Hispanic
City
Clay Co
Co
Co
57.9%
30.7%
6.9%
92.5%
2.0%
2.8%
88.1%
5.8%
2.8%
92.0%
2.5%
2.5%
DEMOGRAPHICS
Page 22 of 294
Kansas City’s population is aging as
measured by the number of persons >65 years
of old per 100 persons <15 years old. This
nomenon is a major issue in terms of healthcare
and other social and economic costs worldwide
as the persons 65 years old will soon outnumber
children <5 years old. Declining fertility and improved health and longevity are the key demographic factors driving this trend. The aging
dex for Kansas City mirrors that for Missouri
(Figure 3-9).
More than 40 languages other than English are spoken by Kansas City residents >5
years of age, (Table 3-9). However, language
issues are not restricted to the foreign-born residents of the community although the ability to
speak English well is considerably less in this
group. For example, 3.2% of native-born residents speak Spanish and, of these Spanish
speakers, 12% speak English less than well.
Nationally, 22% of residents speak a language
other than English at home compared to the
10.8% in Kansas City (Figure 3-10).4
Multiple studies document that quality of
health care is compromised when patients who
speak no or little English do not get qualified
medical interpreters.5 These patients' quality of
care is inferior, and more interpreter errors occur
with untrained ad hoc interpreters. In medical
centers the most common interpretation mistakes are ones of omission; medically important
information not correctly translated or incorrectly
translated, including medical histories, drug allergies, and dosages of medicines.6 Other stu-
Figure 3-8 Population structure for Kansas City, Mo, total population and select subpopulations (source: Census 2000)
DEMOGRAPHICS
Page 23 of 294
1950
1960
1970
1990
2000
54.8
64
43.4
42.8
1940
64.7
61
39.8
42.5
1930
41.3
44.6
25.2
29.7
1920
36.8
43.9
26.3
26
Index = # persons =>65
yr old per 100 persons
<15 yr old
60.5
57.7
Figure 3-9 Aging index
15.4
16.6
dies have found that Spanish
speaking patients are admitted to
hospitals more often because doctors may fear lawsuits and chose
the safest route when faced with
confusion over language.
The increasing cultural and
linguistic diversity of the Kansas
City population poses challenges to
the delivery of maternal and child
health services. According to the
Centers for Disease Control and
Prevention, approximately 20% of
all US births in 2000 were to women who themselves were born outside of the 50 states and District of
Columbia.7 In Missouri, 6% of
births were to women in this group,
while in Kansas it was 12.3%. Among
Kansas City residents, 13.2% of
women giving birth 2007 were foreignborn.
1910
Missouri
1980
Kansas City
Table 3-9 Language skills of native and foreign-born
residents, Kansas City, Mo (source: Census 2000)
Spanish
IndoEuropean
Asian/Pacific
Island
Other
Native-born
Speak
3.2%
1.2%
1.6%
0.6%
English < than well
12.0%
0.8%
12.0%
2.4%
41.8%
48.9%
13.4%
37.0%
20.0%
31.0%
7.2%
22.0%
Foreign-born
Households
Speak
English < than well
The American Community
Survey 2005-2007 estimated that 56.6% of
households in Kansas City were families,
36.0% were persons living alone, and 8.9%
were persons >65 years of age. The persons
living in these households constituted 98.4%
of the population. Women headed 27.8% of
family households. Based on Census 2000
data, the number of households headed by a
woman in the Jackson County portion of Kansas City was double that for the remainder of
the county and more than twice that for the
portions of the City within Clay and Platte
counties (Table 3-10). Within the City as a
whole, 61.4% of households headed by women
had children <18 years of age. Households
headed by a man, with no wife present, were
4.0% of all family households and 49.2% of
those households had children <18 years of age.
Overall, single parent households were 4.9
Table 3-10 Households in Kansas City compared
to balance of three counties
Kansas City
Clay Co
Jackson Co
Platte Co
Balance of
Clay Co
Jackson Co
Platte Co
Households
Family
households
Female
head
33,263
136,168
14,480
68.8%
55.3%
64.0%
15.2%
32.7%
14.6%
39,295
130,126
14,798
69.3%
69.9%
74.1%
14.3%
16.1%
11.0%
times more likely be headed by a woman.
DEMOGRAPHICS
Page 24 of 294
Figure 3-10 Percent of persons who do
not speak English at home, Kansas City,
Mo, Census 2000
Children living in poverty
The American Community Survey 20052007 estimated that 13.8% of families and
17.5% of all residents in Kansas City had income in the prior year below the poverty level
(Figure 3-11). The rate for families headed by a
woman was 34.5% compared to just 4.8% for
married couples.
One of the best available proxy indicators of children living in poverty or among working poor families is the number of children participating in the Free and Reduced Lunch (FRL)
Program financed by the US Department of
Agriculture (USDA). Eligibility is determined by
multiplying the federal income poverty guidelines
by 1.30 for free meals or 1.85 for reduced cost
meals. Table 3-11 shows the number of children
enrolled by FRL for each of the 15 public school
districts serving Kansas City residents; there
was no 2008 data for charter schools. The Missouri Department of Elementary and Secondary
DEMOGRAPHICS
Figure 3-11 Percent of families living in
poverty, Kansas City, Mo, Census 2000
Education did not break this data down by grade
level or by race/ethnicity. According to the USDA, between February 2008 and February 2009,
there was an 8.3% increase in free-lunches and
a 3.4% increase in reduced-price lunches provided through schools in Missouri.
Overall, 39% of the children attending
public school districts that serve Kansas City
can be considered as living in poverty or in very
poor families; this is significantly lower than that
reported statewide. Children living in poverty are
at greater risk for poor health, lower educational
achievement, increased criminal activity, use of
alcohol and other drugs, and are more likely to
grow up in unsafe communities.
Employment and housing
The American Community Survey 20052007 estimated that 68.8% of the population >16
years of age was in the workforce and that 8.1%
were unemployed (Figure 3-12). Among families
with children <6 years of age, 69.4% had both
Page 25 of 294
and by college are shown in Figures 313 and 3-14.
(source: Missouri Department of Elementary and Secondary EducaCommuting to work is done
tion, www.dese.mo.gov)
principally by cars/trucks/vans (80.4%)
Free/reduced
conveying lone occupants, 9.4% carSchool District
Enrollment
lunch
Percent
Belton
4,625
1,757
38.5
pool, 3.5% use public transportation,
Blue Springs
13,734
2,417
17.8
2.2% walk, 1.5% use other means,
Center
2,346
1,418
59.9
and 3.0% work from home.
Grandview
3,903
2,390
69.6
Hickman Mills
6,902
4,922
74.0
By occupation, 34.7% of KanIndependence
10,707
4,841
47.3
sas City residents are employed in
Kansas City
22,479
17,729
80.5
Kearny
3,580
334
9.4
management, professional and related
Lee’s Summit
16,986
2,112
13.0
occupations, 27.8% in sales and office
Liberty
9,557
1,462
15.3
North Kansas City
17,552
6,714
38.7
occupations, 17.8% in service occupaPark Hill
9,873
2,025
20.8
tions, 12.6% in production, transportaPlatte County
2,971
589
20.0
tion, and material moving occupations,
Raytown
8,720
4,022
46.2
Smithville
2,188
204
9.7
7.0% in construction, extraction, mainTotal
136,123
52,936
38.9
tenance and repair occupations, and
Missouri
894,608
367,724
42.1
0.1% in farming, fishing, and forestry
occupations. Of the workforce, 80.9%
are
private
wage and salary workers, 13.5% are
Figure 3-12 Percent of population >16
government
workers, and 5.5% are self emyears old in workforce, Kansas City, Mo,
ployed workers in their own not incorporated
Census 2000
Table 3-11 Percent of children enrolled in school
free/reduced lunch programs, Kansas City, Mo, 2008
Figure 3-13 Percent of population with a
high school education but not a bachelor’s degree, Kansas City, Mo, Census
2000
parents working. With children 6 to 17 years of
age, in 74.2% of families both parents were in
the work force. The distributions of the population by high school graduation or equivalency
DEMOGRAPHICS
Page 26 of 294
Figure 3-14 Percent of population with a
bachelor’s or higher degree, Kansas City,
Mo, Census 2000
and Suburban America Report Series. SUNY Downstate
Medical Center, Brooklyn.
www.hscbklyn.edu/urbansoc_healthdata/Urban%20Center%
20Website/web%20design2/Director%20Message.htm.
5
Flores G. 2005. The impact of medical interpreter services
on the quality of health care: a systematic review. Med Care
Res Rev.62:255-299.
6
Flores G et al. 2003. Errors in medical interpretation and
their potential clinical consequences in pediatric encounters.
Pediatrics 111:6-14.
7
Sappenfield B et al. 2002. State-specific trends in US live
births to women born outside the 50 states and the District of
Columbia – United States, 1990 and 2000. MMWR Morb
Mort Wkly Rep 51:1091-1095.
businesses. Of occupied housing units, 58.8%
are owner-occupied and 41.2% are renteroccupied. Among renters, 36.9% spend >35% of
their household income for rent. For owneroccupied housing units with a mortgage, only
16.0% spend >35% of their household income
on housing costs. Telephone service is not
available in 5.8% of housing units.
Literature cited
1 Z
sembik BA, Fennell D. Ethnic variations in health and the
determinants of health among Latinos. Soc Sci Med
2005;61:55-63.
2
Singh GK, Miller BA. 2004. Health, life expectancy, and
mortality patterns among immigrant populations in the United
States. Can J Public Health 95:14-21.
3
Gomez, SL et al. 2005. Inconsistencies between selfreported ethnicity and ethnicity recorded in a health maintenance organization. Ann Epidemiol 15:71-79.
4
Andrulis DP, et al. 2003. Dynamics of race, culture, and
key indicators of health in the Nation’s 100 largest cities and
their suburbs. The Social and Health Landscape of Urban
DEMOGRAPHICS
Page 27 of 294
4. Births
Editors Note: the total number of events
described in the text and tables may vary.
This is due to the fact that any given birth or
fetal death certificate may be incompletely
filled out, resulting in missing data items.
What is presented in this report, therefore,
is based on valid data, meaning only
records that had information for the primary
data item of interest were used.
Trends
and ethnicity is shown in Table 4-3. Overall,
29% of infants born in 2007 were the 3rd or higher order child to that mother. For non-Hispanic
whites and Asians, the percentages were 24%
and 27%, respectively, while for non-Hispanic
blacks it was 34% and for Hispanics 38%. Native Americans had the highest percentage at
46%, however, this group only recorded 48
births. Almost 8% of the non-Hispanic black
women had their 5th, 6th, or 7th live birth during
the year, compared to 6.2% for Hispanics and
3.4% of non-Hispanic whites.
The number of live births to Kansas City
residents has been increasing since 1994 with
8,011 births recorded in 2007, a 2% increase
Fertility rate
over births in 2006 (Figure 4-1). Over the last 5
The general fertility rate is calculated by
years, the number of births to Kansas City residividing the number of live births (regardless of
dents was driven almost entirely by minority
mother’s age) by the number of women 15-44
populations (Tables 4-1 and 4-2). The increase
years of age and then multiplying by 1,000. The
in births mirrors that nationally; in 2007, births
2007 rate for Kansas City was 77.8 or 12%
nationally increased ~1%1 while in Kansas City
higher than the 2007 national rate of 69.5 (Table
they increased by almost 4%. Nationally, the
4-4).2 General fertility rates vary by
number of registered births reached the highest
race/ethnicity. Nationally, second generation
number ever recorded. In Kansas City, 13.2% of
Hispanic women have lower fertility rates than
live births were to mothers who were born in
either foreign-born Hispanics or those were born
foreign countries; among Hispanics and Asians
approximately 7 out of every
10 birth mothers were foreign-born. The crude birth
Figure 4-1 Number of live births to Kansas City, Mo, residents
rate (number of births divided by the population
8,011
7,963
7,858
7,768
[2007 July estimate] times
7,574
7,450
7,313 7,314
7,307 7,302 7,345 7,367 7,354
1,000 persons) for Kansas
7,176
6,882 6,975
City was 16.8; the Missouri
6,617 6,710
rate was 13.9 and the national rate was 14.3. In Kansas City, 50.5% of birth
mothers had Medicaid for
insurance.
Birth order by race
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07
BIRTHS
Page 28 of 294
Table 4-1 Birth trends, Kansas City, Mo, 2003-2007
Race/ethnicity
Total
2003
2004
2005
2006
2007
Change
from 2003
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/Not listed
Total
16,432
13,571
6,284
1,082
253
625
38,247
3,297
2,556
1,152
160
64
125
7,354
3,255
2,582
1,282
186
49
96
7,450
3,247
2,652
1,271
233
50
121
7,574
3,297
2,865
1,257
252
42
145
7,858
3,336
2,916
1,322
251
48
138
8,011
1.2%
14.1%
14.8%
56.9%
-25.0%
10.4%
8.9%
Table 4-2 Percent of foreign-born birth mothers, Kansas
City, Mo, 2007
Multiple births
In 2007, of the 8,011 live
births there were 7,741 (96.6%) singleton, 250 (3.1%) twin, and 20
Race/ethnicity
Total
White, non3,208
98.8
39
1.2
3,247
(0.2%) triplet births. Compared to
Hispanic
2006, the number of triplet births
Black, non2,680
99.1
25
0.9
2,705
increased 66.6% from 12 to 20,
Hispanic
Hispanic
383
32.8
784
67.2
1,167
while twin births declined 4.6% from
Asian
57
29.5
136
70.5
193
262 to 250. Multiple births were
Native American
47
97.9
1
2.1
48
Other/not listed
122
98.4
2
1.6
124
more common among non-Hispanic
Total
6,497
86.8
987
13.2
7,484
whites and non-Hispanic blacks
than other racial/ethnic
groups (Figure 4-3).
Table 4-3 Birth order by race/ethnicity, Kansas City, Mo, 2007
Nationally, the percent
Birth order of child
st
nd
rd
th
th
th
th
of births to triplets and
Race/ethnicity
1
2
3
4
5
6
7
Total
higher orders of birth
White, non1,542
971
497
184
73
34
8
3,309
Hispanic
has been declining,
Black, non1,099
781
492
272
131
80
14
2,869
while the twin birth rate
Hispanic
Hispanic
457
355
289
128
61
14
7
1,311
has remained unAsian
97
85
45
16
4
2
1
250
changed at about 3%.
Native American
14
12
12
6
2
2
0
48
Other/not listed
70
26
20
15
3
2
1
137
In Kansas City, twins
Total
3,279
2,230
1,355
621
274
134
31
7,924
account for most of the
multiple births. Natural
3
conception accounts for
to native-born parents (third generation).
67% of twins and only 18% of triplet and higher
Another measure is the total fertility rate
order births.4
(TFR) which summarizes the potential for a givWhere birth mother was born
United States
Foreign country
Number Percent Number Percent
en generation to exactly replace itself; generally
considered 2,100 births per 1,000 women 15-44
years of age (Figure 4-2). As a whole, Kansas
City’s population was above the replacement
rate; however, this was not true for non-Hispanic
whites. The national TFR has been just above
the replacement rate following decades (19722005) of being below replacement.
BIRTHS
Page 29 of 294
Table 4-4 General fertility rates per 1,000 women 15-44 years old by
race/ethnicity, Kansas City, Mo1
White,
nonHispanic
All
Black,
nonHispanic
N=57,452
N=33,681
National N=102,906
2003
66.1
71.4
57.4
75.9
2004
66.3
72.3
56.7
76.7
2005
66.7
73.6
56.5
78.7
2006
68.5
76.1
57.4
85.1
2007
69.5
77.8
58.1
86.6
1
Kansas City rates based on Census 2000 population estimates
Year
Hispanic
Asian
Native
American
N=6,998
164.6
183.2
180.6
179.3
188.9
N=2,217
72.2
83.9
78.5
113.2
113.2
N=580
110.3
84.5
86.2
70.7
82.8
Figure 4-2 Total fertility rates by
race/ethnicity, Kansas City, Mo, 2007
Sex ratio
Fetal deaths and abortions
In addition to live births, pregnancies
4.0%
0.0%
2.4%
2.1%
0.0%
2.4%
2.0%
1.9%
3.4%
3.7%
2.9%
4.7%
3.7%
3.9%
8.3%
The sex ratio (male:female) at birth is an
5202.1
important demographic indicator (Table 4-5). For
Replacement rate = 2,100 births example, the “doubling time” of a population (the
per 1,000 women (straight line number of years required for the population to
double its size) increases as the ratio of males
2521.0
2338.4
1841.5
to females rises. Data about the sex ratio is also
necessary to understanding trends in infant
morbidity, such as low birthweight and mortality,
since male infants are more susceptible to illTotal
White, non- Black, nonHispanic
ness and have higher infant mortality rates.5
Hispanic
Hispanic
Throughout life males experience
higher death rates and have lower life expectancy than females.
Figure 4-3 Rates of multiple births by race/ethnicity, Kansas
Since 1971, the ratio of
City, Mo, 2005-2007
male:female births in the US has
2005 2006 2007
been declining.6 In Kansas City,
between 2003 and 2007, while
there were 13% more Native
American, 10% more Asian, 7%
more non-Hispanic white, and 2%
more Hispanic boys born than
girls; the sex ratio for nonHispanic blacks was essentially
White, nonBlack, nonHispanic
Asian
Native American
equal.
Hispanic
Hispanic
can result in fetal deaths (stillbirths) and abortions. Fetal deaths are discussed in the Fetal &
Infant Mortality section of this report.
One in five pregnancies worldwide ends
BIRTHS
Page 30 of 294
Table 4-5 Sex ratios at birth by race/ethnicity, Kansas City, Mo
White
Year
2003
2004
2005
2006
2007
Total
Sex ratio
M
Black
F
1,683
1,612
1,695
1559
1,656
1,591
1,715
1,581
1,726
1,610
8,475
7,953
1.07:1
M
F
1,285
1,271
1,281
1,295
1,328
1,324
1,426
1,436
1,476
1,440
6,796
6,766
1.00:1
Hispanic
M
F
M
588
564
645
637
642
629
623
634
672
650
3,170
3,114
1.02:1
in an abortion.7 Yet, in the US, both the number
of abortions and the abortion rate had long-term
declines; the literature is unclear as to whether
these declines are continuing.8 9 10 A decrease
in the abortion rates among teenagers and
women 20-24 years old accounts for much of
the overall decline. And, while abortion rates
have declined for all groups, there remain racial/ethnic disparities reflecting differing patterns
of contraceptive use, pregnancy, and childbearing. Nearly half of the women who had an abortion had a previous abortion, and >60% of women who have an abortion have children. Recent
studies suggest that having an abortion does not
cause psychological distress or a “post-abortion
syndrome”.11
Missouri recorded a 22.3% decline in
abortions between 1996 and 2005. While the
number of abortions increased 1.8% in 2006,
that year was the second lowest number of
abortions reported for Missouri residents since
1975.
In 2007, 21.4% of recorded pregnancies
among Kansas City residents were terminated
via abortion, for an abortion rate (number of
abortions per 1,000 women 15-44 years of age)
of 21.3 and an abortion ratio (number of abortions per 1,000 live births) of 273.4. Between
1998 and 2007, the number of documented legal
abortions performed on Kansas City residents
declined 10.9% while the abortion ratio declined
20.2% (Figure 4-4).The abortion ratio in 2007
was highest for non-Hispanic blacks (353.6)
(Figure 4-5). Table 4-6 shows the number of
BIRTHS
Asian
F
83
77
100
86
127
106
128
124
129
122
567
515
1.10:1
Native
American
M
F
Other/Not
listed
M
F
39
25
24
25
27
23
22
20
22
26
134
119
1.13:1
61
64
41
54
49
72
71
74
73
65
295
329
0.90:1
Figure 4-4 Abortions and the corresponding abortion ratios, Kansas City,
Mo
2,459 2,498 2,509 2,462 2,383 2,414 2,204 2,074 2,252 2,190
342.7 341.9 342.2 334.6 323.5 332.9 297 273.8 286.6 273.4
Abortions
Ratio
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
abortions by marital status, age, and
race/ethnicity. Unmarried women had an abortion ratio that was 7.7 times higher than that for
married women (Table 4-7).
Abortion ratios are higher among women
whose pregnancies were administratively classified as unintended (Table 4-8). Unintended
pregnancies accounted for 75.4% of all abortions experienced by Kansas City women in
2007. Among women whose pregnancies were
classified as intended, 51.4% of abortions were
obtained by non-Hispanic whites, while among
those pregnancies classified as unintended,
51.5% of abortions were obtained by nonHispanic blacks.
Page 31 of 294
Figure 4-5 Abortion ratio trends, Kansas City, Mo
273.4
243.4
353.6
174.7
402.4
Asian
286.6
279.0
360.6
178.2
273.8
127.9
2003
Hispanic
273.3
238.7
367.1
191.1
283.3
381.7
296.2
267.4
425.0
433.1
2002
161.5
306.2
253.9
146.5
302.6
250.4
148.3
310.8
254.2
2001
Black, non-Hispanic
427.8
White, non-Hispanic
436.5
445.1
Total
2005
2006
2007
2004
Table 4-6 Abortions by race/ethnicity, age and marital status, Kansas City, Mo, 2007
Age
15-19 y
20-29 y
30-39 y
40-49 y
Total
White,
nonHispanic
1
42
47
6
96
Black,
nonHispanic
1
29
38
7
75
Hispanic
2
20
12
2
36
Asian
1
15
8
1
25
Native
American
0
1
0
1
2
Not
listed
0
0
0
0
0
Total
5
107
105
17
234
Unmarried
<15 y
15-19 y
20-29 y
30-39 y
40-49 y
Total
5
112
446
132
12
707
5
155
594
182
19
955
2
25
134
29
5
195
0
11
45
15
2
73
0
2
5
2
0
9
0
0
3
1
0
4
12
305
1,227
361
38
1,943
Marital status
not listed
20-29 y
30-39 y
10-49 y
Total
5
3
1
9
0
1
0
1
0
0
0
0
2
1
0
3
0
0
0
0
0
0
0
0
7
5
1
13
Married
Table 4-7 Abortion ratios by marital status and age group, Kansas City, Mo, 2007
Age
(years)
Married
Total1
Unmarried
Births
Abortions
Ratio
Births
Abortions
Ratio
10-14
0
0
0.0
17
12
705.9
15-17
11
0
0.0
338
110
325.4
18-19
62
5
80.6
590
195
330.5
20-24
588
36
61.2
1,606
682
424.7
25-29
1,367
71
51.9
947
545
575.5
30-34
1,181
69
58.4
447
238
532.4
35-39
537
36
67.0
184
123
668.5
>40
104
17
163.5
30
38
1,266.7
Total
3,850
234
60.8
4,159
1,943
467.2
1
Includes 13 women for whom age was known but marital status was not recorded
Births
17
349
652
2,194
2,314
1,628
721
134
8,009
Abortions
12
110
200
721
620
311
160
56
2,190
Ratio
705.9
315.2
306.7
328.6
267.9
191.0
221.9
417.9
273.4
BIRTHS
Page 32 of 294
Table 4-8 Abortions by race/ethnicity, age and administratively classified pregnancy intention, Kansas City, Mo, 2007
Intended
Unintended
Age
15-19 y
20-29 y
30-39 y
40-49 y
Total
White,
nonHispanic
21
158
85
13
277
Black,
nonHispanic
16
106
42
16
180
Hispanic
3
28
7
2
40
<15 y
15-19 y
20-29 y
30-39 y
40-49 y
Total
5
92
335
97
6
535
5
140
517
179
10
851
2
24
126
34
5
191
Preterm births – KCMo Health
Department Priority
Preterm births are classified as “very
preterm”, ie gestation <32 weeks, “moderately
preterm”, ie gestation 32-33 weeks; and “late
preterm”, ie gestation 34-36 weeks.12 In 2007,
2.0% of infants born in the US were very premature, 1.6% moderately preterm, and 9.0% late
preterm.
The Missouri birth certificate has two estimates of gestation; one based on the last menstrual period and the other on the physician’s
clinical estimate. It has been suggested that using the former to estimate gestational age may
overestimate both preterm and post-term birth
rates.13 14 Consequently, this report for Kansas
City uses the physician’s clinical estimate of
gestation.
Preterm birth (<37 weeks gestation) is
strong predictor of infant mortality and morbidity,
and has been shown to be significantly associated with a number of poor health outcomes.
In comparison, full-term infants experience much
lower rates of health problems throughout their
lives.1516 The severity of adverse outcomes is
inversely correlated with gestational age meaning the earlier in gestation an infant is born, the
higher the risk of long-term problems.17 Although
survival has improved for infants born <28
BIRTHS
Asian
2
28
7
1
38
0
10
34
17
2
63
Native
American
1
2
0
1
4
Other/Not
listed
0
0
0
0
0
Total
43
322
141
33
539
0
1
4
2
0
7
0
0
3
1
0
4
12
267
1,019
330
23
1,651
weeks gestation, >25% of survivors experience
disabilities including behavioral problems.18 The
literature indicates that while survival of infants
24 to 25 weeks of age has increased significantly, there has been no improvement for those
born at 22 or 23 weeks gestation.19 In Kansas
City, prematurity is the leading cause of infant
death; 43% of infant deaths between 2003 and
2007 were attributable to prematurity.
Nearly 75% of all preterm births are late
preterm and these infants are still at higher risk
of illness and death than term infants.20 Less
than 10% of late preterm births are “elective”;21
however, the risks of continuing a pregnancy
should be carefully balanced against the risks of
delivery and the associated risk of prematurity.22
23
This is of increasing importance in late preterm pregnancy when medical or obstetric complications frequently warrant delivery.24
Preterm births are a significant economic burden particularly since the preliminary 2007
US preterm birth rate was 12.7. The Committee
on Understanding Premature Birth and Assuring
Healthy Outcomes estimated that the US economic burden is $26.2 billion, or roughly $51,600
per preterm infant, with two-thirds of the expenses going to medical care.25 In November
2008, the March of Dimes gave the state of Missouri a “F” rating for its progress in meeting the
Page 33 of 294
Table 4-9 Births by length of gestational
period, Kansas City, Mo
Figure 4-6 Changes in percent of births
by gestational age <32 weeks and 32-36
weeks, Kansas City, Mo, comparing 2007
to 2000
Length of gestation (weeks)
Year
Total
births
<32
32-33
34-36
>37
2003
7,285
2.1%
1.2%
6.5%
90.3%
2004
7,344
2.0%
1.3%
6.6%
90.1%
2005
7,493
2.2%
1.3%
7.2%
89.4%
2006
7,810
2.0%
1.2%
7.0%
89.9%
2007
7,963
2.0%
1.3%
6.6%
90.1%
Yr 2010 objectives: 7.6% for all preterm babies, 6.4%
for gestation of 32-36 weeks, and 1.1% for gestation of
<32 weeks
All births
White, non-Hispanic
Black, non-Hispanic
Hispanic
11.6%
8.1%
1.2%
-3.5%
-4.6%
-3.9%
-10.3%
Healthy People 2010 objectives for preterm
births (www.marchofdimes.com).
The preterm birth rate in Kansas City has
been stable in recent years; it was 10.0% in
2007 (Table 4-9). The 2007 rates for very premature and moderately premature were 91%
and 23% higher, respectively, that the national
Healthy People 2010 goals. As shown in Table
4-10, prematurity rates vary by race/ethnicity
being highest among non-Hispanic blacks and
lowest amongst Hispanics. Comparing live births
in Kansas City during 2007 to those in 2000,
both very preterm and moderately preterm births
increased among non-Hispanic blacks, while
declining among non-Hispanic whites and Hispanics (Figure 4-6).
-17.3%
<32 weeks
32-36 weeks
Racial disparity in preterm births is a persistent feature of perinatal epidemiology. Its
consistency is not only an outcome of reproductive interest but may function as a persistent inequality to which women are exposed over
time.26 Non-Hispanic blacks in the US have a
60% higher risk for preterm delivery than nonHispanic whites and many factors have been
proposed to explain this disparity, including genetics.27 28
Socioeconomic factors, including residence, have been shown to be correlated with
Table 4-10 Births by gestational age and race/ethnicity, Kansas City, Mo
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/Not listed
Total
Year
2007
2003-2007
2007
2003-2007
2007
2003-2007
2007
2003-2007
2007
2003-2007
2007
2003-2007
2007
2003-2007
<32 weeks
Births
%
39
212
104
449
17
95
2
9
0
1
2
15
164
781
1.2
1.3
3.6
3.3
1.3
1.5
0.8
0.9
0
0.4
1.5
2.4
2.1
2.1
Gestational age
32-36 weeks
Births
%
>37 weeks
Births
%
Total
237
1,217
266
1,290
86
376
19
77
3
17
16
55
627
3,032
3,030
14,751
2,541
11,796
1,212
5,788
225
960
45
229
119
558
7,172
34,082
3,306
16,180
2,911
13,535
1,315
6,259
246
1,046
48
247
137
628
7,963
37,895
7.2
7.5
9.1
9.5
6.5
6.0
7.7
7.4
6.3
6.9
11.7
8.8
7.9
8.0
91.7
91.2
87.3
87.2
92.2
92.5
91.5
91.8
93.8
92.7
86.9
88.9
90.1
89.9
BIRTHS
Page 34 of 294
disparities in preterm birth rates.29 30
Table 4-12 Birthweight distribution by race/ethnicity,
31
Women who are less educated,
Kansas City, Mo, 2007
unmarried at the time of birth, who
Weight in grams
5001,5002,500are at extremes of age, have birth
Race/ethnicity
<500 1,499 2,499
3,999
>4,000
Total
spacing of <18 m, who start prenatal
White, non-Hispanic
3
33
167
2,816
317
3,336
st
Black, non-Hispanic
13
82
275
2,429
112
2,911
care after the 1 trimester, and who
Hispanic
3
13
57
1,115
133
1,321
are Medicaid recipients are at inAsian
0
3
13
221
14
251
creased risk of having a preterm
Native American
0
0
4
69
5
48
Other/not listed
0
2
15
114
7
138
birth.32 Smoking during pregnancy is
Total
19
133
531
6,764
588
8,005
associated with a 20% increase in
% of births
0.2
1.7
6.6
84.5
7.3
100.0
risk of a preterm birth and this risk
increases dramatically if the woman
birth weights and longer pregnancies.37
also drinks and/or uses drugs.33 Induced and
Low birthweight accompanies preterm
spontaneous abortions have been associated
34
births and has a variety of causes, such as inwith a subsequent risk of preterm birth.
adequate prenatal care, poor nutrition, alcohol
On the positive side, there is growing
consumption, and maternal work.38 39 In 2007,
evidence that women can reduce the chances of
the national low birthweight rate was 8.2%.
very preterm births by 50-70% if they take folic
Trend data on low birthweight suggest
acid supplements for at least a year before be35
that
increasing
numbers of older mothers (decoming pregnant.
layed childbearing) play an important role in the
increasing rate of low birthweight infants.40 Subsequent health and development issues exist for
Birthweight
preterm and low birthweight infants, particularly
Birthweight issues generally are divided
very preterm or very low birthweight infants.41
into those birthweights that are low (<2,500 g)
In 2007, there were 682 low birthweight
and those that are very high (>4,000 g). Of the
babies born in Kansas City. The rate, 8.5%, was
two, more public health resources are devoted
70% higher than the Healthy People 2010 natowards low birthweights.
tional objective of 5.0. The rate of low birthVariation in birthweight may be deterweight was highest for women <20 years of age,
mined, at least in part, by fetal growth in the first
particularly for those <17 years old (Table 4-11).
12 weeks after conception.36 Fetal size in the 2nd
The distribution of birthweights by race/ethnicity
trimester is a determinant of birth weight and
is shown in Table 4-12, while Table 4-13 shows
pregnancy duration, small fetuses having lower
Table 4-13 Birthweight distribution, Kansas City, Mo, 2003-2007
Table 4-11 Percent of low birthweight
infants by mother’s age, Kansas City,
Mo, 2007
Birth weight
<2,500 grams
Age
(yr)
<17
18-19
20-34
>35
Total
BIRTHS
Births
34
63
505
80
682
%
9.3
9.7
8.2
9.4
8.5
Year
>2,500 grams
Births
332
588
5,628
774
7,322
%
90.7
90.3
91.8
90.6
91.5
Total
366
651
6,133
854
8,004
Births
Birthweight in grams
500- 1,500<500 1,499 2,499 >2,500
2003
7,345
0.3%
1.7%
6.4%
91.7%
2004
7,442
0.3%
1.5%
6.9%
91.2%
2005
7,571
0.2%
1.7%
7.6%
90.5%
2006
7,855
0.4%
1.4%
6.9%
91.2%
2007
8,005
0.2%
1.7%
6.6%
91.5%
Yr 2010 objectives: 5.0% for all babies <2,500 gm and
0.9% for babies <1,500 gm
Page 35 of 294
Low birthweight does not take into account the gestational age of the infant. Another
measure of intrauterine growth outcome is
small-for-gestational-age (SGA) which is defined
Other/not listed
10.2%
as an infant whose birthweight is in the lowest
10th percentile for the corresponding gestational
Native American
5.9%
age. The term is not synonymous with intrauteAsian
7.3%
rine growth restriction (IGR) which reflects a
Hispanic
5.8%
slowing of fetal growth due to various in utero
Black, non-Hispanic
12.4%
pathological processes. It has been reported
White, non-Hispanic
7.0%
that people born SGA are at increased risk for
heart disease during adulthood and that excess
weight and body fat may exacerbate this risk; as
adults they are nearly twice as likely to be obese
that birthweight distribution has remained conthan individuals born at an appropriate size for
stant over the last 5 years. For the period 2003gestation.42 The risk for SGA is highest during
2007, the rate of low birthweight babies was
first pregnancies and among younger mothers
highest among non-Hispanic blacks and lowest
and non-Hispanic blacks. Using the Oken et al
among Hispanics (Figure 4-7). The literature
growth scale,43 12.0% of Kansas City infants
reports that the rates of low birthweight babies
born in 2007 were classified as SGA (Table 4born to mothers who were foreign-born are low15). Non-Hispanic blacks had the highest risk for
er than for those born to US-born mothers and
SGA (17.0%) and that risk was more than twice
the same is true in Kansas City (Table 4-14).
that for non-Hispanic
whites.
At the opposite
Table 4-14 Percent of low birthweight births by mother’s natality,
end
of
the
intrauterine
Kansas City, Mo, 1990-2007
Birthweight
growth spectrum are in<2,500 g
>2,500 g
fants classified as largeBirths Percent Births Percent Total
for-gestational-age (LGA).
US-born
4,178
6.8
56,969
93.2
61,147
These are infants whose
Foreign-born
85
6.8
1,173
93.2
1,258
White
Total
4,263
6.8
58,142
93.2
62,405
birthweight exceeds the
US-born
6,171
13.2
40,630
86.8
46,801
90th percentile for gestaForeign-born
79
10.2
697
89.8
776
Black
tional age. In Kansas City,
Total
6,250
13.1
41,327
86.9
47,577
4.8% of infants born in
US-born
378
7.4
4,737
92.6
5,115
2007 were classified as
Foreign-born
411
5.2
7,478
94.8
7,889
Hispanic
Total
789
6.1
12,215
93.9
13,004
LGA. The proportion of
US-born
48
7.5
593
92.5
641
babies who were LGA has
Foreign-born
109
6.6
1,547
93.4
1,656
Asian
not changed since 1990.
Total
157
6.8
2,140
93.2
2,297
Over the 18 year period
US-born
55
6.6
775
93.4
830
Native Amerithere were no significant
Foreign-born
2
14.3
12
85.7
14
can
Total
57
6.8
787
93.2
844
trends by race or sex. In
US-born
81
10.4
697
89.6
778
2007, 8.1% of nonNot
Foreign-born
54
6.6
760
93.4
814
Hispanic white boys were
listed/specified
Total
135
8.5
1,457
91.5
1,592
LGA as were 4.5% of
Figure 4-7 Percent of low birthweight infants by race/ethnicity, Kansas City, Mo,
2003-2007
BIRTHS
Page 36 of 294
2007), while both
males and females
had significant deLarge for
Births
%
Total
clines among those
193
5.8
3,301
born >10.1 lb (males
61
2.1
2,892
2.2% in 2007 versus
74
5.6
1,312
10
4.1
246
females 0.6% in
4
8.3
48
2007). The lower
5
3.7
136
347
4.4
7,935
percentages of heavy
birthweight babies
among non-Hispanic
blacks are offset by a higher percentage of low
birthweight babies than among non-Hispanic
whites.
Table 4-15 Birthweight distribution by normal, small for gestational age
(SGA) and large for gestational age (LGA), Kansas City, Mo, 2007
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/not listed
Total
Normal
Births
%
2,842
2,338
1,110
204
37
106
6,637
Small for
Births
%
86.1
80.8
84.6
82.9
77.7
77.9
83.6
266
493
128
32
7
25
951
8.1
17.0
9.8
13.0
14.6
18.4
12.0
non-Hispanic white girls. Only 2.9% of nonHispanic black boys and 1.6% of non-Hispanic
black girls were LGA. Maternal diabetes is the
most common risk factor for LGA.
An examination of trends in heavy birthweight for term gestation, singleton births in
Kansas City for 1990 to 2007, found a barely
significant downward trend in babies born >8.8
lb (4,000 gm) while the decline for babies >10.1
lb (4,500 gm) was highly significant.44
In 2007, 8.2% of babies born in Kansas
City were >8.8 lb and 1.1% were >10.1 lb. There
was a significant decline in the percent of nonHispanic white babies born >8.8 lb (10.5% in
2007) but not for non-Hispanic black babies
(4.4% in 2007). Non-Hispanic whites also experienced a highly significant decline in the percent
of babies born >10.1 lb (1.4% in 2007) while the
rate for non-Hispanic blacks remained unchanged (0.3% in 2007). Males drove the decline among non-Hispanic whites born >8.8 lb
(13.5% in 2007 versus 7.3% for females in
Figure 4-8 Rate of unintended deliveries,
Kansas City, Mo
38.1% 38.5% 37.8% 37.9% 38.2% 38.7% 39.0% 39.9%
2000
BIRTHS
2001
2002
2003
2004
2005
2006
2007
Unintended pregnancies
In the US, 49% of all pregnancies are
unintended although there is a difference between “unwanted” and “mistimed” pregnancies.45
Nearly half of unintended pregnancies represent
contraceptive failure (not using any method of
contraception in the month they conceived or
method failure),46 whereas the other half results
from failure to use contraception.47 48 Women
who have had an unplanned pregnancy in the
past are at risk of future unplanned pregnancies,
regardless of other risk factors such as age and
education.49
Administratively, unintended deliveries
are defined as those to teenagers <18 years old,
or to women 18-35 years old with spacing <12
months since a prior birth, or unmarried and
lacking a college education. Unintended deliveries are associated with prenatal behaviors that
increase the risk of poor pregnancy outcomes,50
eg, higher rates of inadequate prenatal care, low
, and infant mortality as well as decreased life
opportunities and heavier demands on public
services.51
In Kansas City, during 2007, there were
3,197 (39.9%) unintended pregnancies resulting
in live births. Between 2000 and 2007, the overall percentage of deliveries that were unintended
Page 37 of 294
Figure 4-9 Rates of unintended deliveries
resulting in live births by race/ethnicity,
Figure 4-10 Age distribution of births by
<20 y
80.6%
59.9%
20-34 y
=>35 y
74.6%
72.9%
53.0%
41.7%
19.0%
17.1%
5.6%
Hispanic
Hispanic
Asian
Native
American
has remained relatively constant (Figure 4-8).
There is considerable disparity among the racial
and ethnic groups regarding live births resulting
from unintended pregnancies (Figure 4-9). In
2007, the rate of unintended births for nonHispanic blacks was 3.2 times higher than that
for non-Hispanic whites, while the rates for Hispanics was 2.8 times higher. Native Americans
also had a high rate but this was among a small
number of live births. The rate for Asians was
lower than that for non-Hispanic whites.
Age of birth mother
13.8%
White, nonHispanic
20.1%
7.0%
15.7%
Black, nonHispanic
9.8%
Hispanic
fluences on the health of the baby,53 but, overall,
paternal contributions to birth outcomes are
poorly characterized.54 Table 4-16 shows the
number of births in Kansas City during 2007 by
mother’s age while Figure 4-10 shows that a
larger percentage of live births to non-Hispanic
blacks and Hispanics occur in women <20 years
old than among non-Hispanic whites. Conversely, they have fewer births among women >35
years old.
Nationally, the average age at first birth
was 25.0 years in 2006.55 In Kansas City, the
average age at first birth was 24.4 years (Figure
4-11). There is variability between racial/ethnic
groups, with non-Hispanic black mothers being
the youngest and Native Americans the oldest
The age of the birth mother can influence the health
outcome of the
Table 4-16 Births by age group, Kansas City, Mo, residents, 2007
baby, particularWhite,
Black,
ly at the lower
Total
nonnonNative
and upper ends
Ages
births Hispanic Hispanic Hispanic
Asian
American
of the reproduc10-14 y
17
1
8
7
0
1
15-17 y
349
51
198
86
1
1
tive life of a
18-19 y
652
135
379
114
8
6
woman.52 There
20-24 y
2,194
682
1,043
375
41
10
25-29 y
2,314
1,101
703
383
78
11
are some data
30-34 y
1,629
907
380
227
82
11
to suggest that
35-39 y
721
381
171
116
35
5
teenage fathers
40-44 y
129
75
32
13
6
3
45-49 y
4
3
1
0
0
0
also may have
>50 y
1
0
1
0
0
0
deleterious inTotal
8,010
3,336
2,916
1,321
251
48
Other/Not
listed
0
12
10
43
38
22
13
0
0
0
138
BIRTHS
Page 38 of 294
(Figure 4-12). Of public health concern are births
to teenagers and women >40 years of age.
Pregnancy among Kansas City teenagers
ranked 6th among the top community concerns
expressed by citizens during a community health
assessment conducted by the Kansas City
Health Commission.
In Kansas City, teen mothers have higher rates of premature births (Figure 4-13), low
birthweight babies, inadequate prenatal care,
infant mortality, pregnancy-smoking, use of
Figure 4-11 Mother’s average age at first
birth, Kansas City, Mo
24.3
24.4
24.5
24.4
24.3
24.4
24.3
24.1
2000
2001
2002
2003
2004
2005
2006
2007
White, non-Hispanic
Black, non-Hispanic
drugs during pregnancy, and use of alcohol during pregnancy, than mothers >20 years of age.
They also are more likely to be unmarried and
be a Medicaid recipient.
There are three different indicators for
births to teenage mothers: births to girls 10-14
years of age; births to women 15-19 years old;
and, the teenage pregnancy rate. The first two
indicators are based on the mother’s age and
ignore marital status. The teenage pregnancy
rate includes all live births, induced abortions
and fetal deaths to women 15-19 years old.
10-14 year olds
Nationally, births to girls who are 10-14
years old have been declining. In 2007, the rate
was 0.6 per 1,000 girls 10-14 years old. In Kansas City the 2007 rate was 1.1 (Figure 4-14).
BIRTHS
Hispanic
Asian
22.8
29.5
26.1
22.2
23.3
27.9
27.6
27.0
22.7
2007
26.6
2006
26.4
2005
22.4
23.1
2004
22.9
21.7
21.9
21.6
21.6
21.4
26.6
26.9
26.7
26.5
23.4
2003
22.4
Figure 4-12 Mother’s average age at first birth, by race/ethnicity, Kansas City, Mo
Native American
Figure 4-13 Preterm and term births by
mother’s age, Kansas City, Mo, 2003-2007
Preterm
87.6%
12.4%
10-14
88.4%
11.6%
15-19
Term
90.6%
90.1%
9.9%
9.4%
20-29
30-39
87.2%
12.8%
=>40
Age group (years)
There were 17 births and 12 abortions to girls
10-14 years old. Eight births were to nonHispanic blacks, 7 to Hispanics, and 1 each to
non-Hispanic whites and Native Americans.
Page 39 of 294
Figure 4-14 Live births per 1,000 women 10-14 years of age, Kansas City, Mo
Total
3.2
2.6
White
2.6
2.2
1.1
0.9
2000
Black
1.3
2.2
2.0
1.3
1.8
1.5
1.1
0.8
0.4
1.1
1.0
2001
2002
2003
1.2
1.1
0.0
0.2
2006
2007
0.1
0.3
2004
In general, 10-14 year old mothers are
less likely to receive timely prenatal care compared to mothers in older age groups. Compared with mothers 20-39 years old, infants born
to mothers 10-14 years of age experience almost twice the rates of preterm birth and low
birthweight. The infant mortality rate is 2 to 3
times higher than that for infants of mothers 2044 years old. These young mothers also are
more likely to suffer hypertension and eclampsia.
0.9
2005
year olds), 310 induced abortions (110 to 15-17
years old, 200 to 18-19 years old), and 1,001
live births (349 to 15-17 years old, 652 to 18-19
years old). The teen pregnancy rate for year was
91.0 per 1,000 women 15-19 years old (53.2 for
15-17 year olds, 147.3 for 18-19 year olds).
The annualized birth rates for young
women are shown in Figures 4-16. Rates were
highest for Hispanic women, followed by those
for non-Hispanic blacks. Non-Hispanic whites
and Asians had the lowest rates. Encouragingly,
in Kansas City, the percent of repeat pregnancies among women 15-19 years of age decreased 9.5% between 2000 and 2007 (Figure
4-17). The annualized rates for repeat pregnancies by race/ethnicity for the period 2003-2007
are shown in Figure 4-18. Teenagers who give
birth twice as adolescents have worse outcomes
15-19 years old
In Kansas City, birth rates to women 1519 years old rose in 2006 and 2007 following
years of decline (Figure 4-15); this trend was
consistent with that nationally. In 2007, the national birth rate
for 15-19 year
Figure 4-15 Live births per 1,000 women 15-19 years of age, Kansas City,
olds increased
Mo
to 42.5 (22.2 for
15-17 year olds
and 73.9 for 1819 year olds).
In Kansas City, women
15-19 years old
experienced 7
fetal deaths (1
to 15-17 year
olds, 6 to 18-19
Total
114.4
15-17 y
18-19 y
110.8
113.2
109.4
106.0
102.5
72.6
69.0
68.0
65.0
64.0
61.4
44.5
40.8
37.7
35.1
35.7
33.9
2000
2001
2002
2003
2004
2005
108.4
112.0
67.3
69.2
39.6
40.3
2006
2007
BIRTHS
Page 40 of 294
White,
nonHispanic
Black,
nonHispanic
The proportion of births to unmarried
women in the US continues to increase and
reached a record high of 39.7% in 2007 – 27.8%
for whites, 71.6% for blacks, 51.3% for Hispanics, 16.9% for Asians, and 65.2% for Native
Americans. Rates vary considerably by age; typBIRTHS
262.6
116.1
Asian
19.0
45.3
13.8
Hispanic
Native
American
Figure 4-17 Repeat pregnancies for women 15-19 years of age, Kansas City, Mo
26.4% 26.4%
2000
2001
24.8%
2002
23.1% 23.3% 24.0%
2003
2004
2005
23.9%
20.0%
2006
2007
Figure 4-18 Annualized repeat pregnancies rates for women 15-19 years of age
by race/ethnicity, Kansas City, Mo, 20032007
Native American
Asian
Marital status
117.6
18-19 y
160.3
15-17 y
50.2
In the US, the number of births to women in their 30s, 40s and 50s have increased at
the same time the number of women in these
age groups has been declining. Increasing maternal age, however, is associated with significantly elevated risks for pregnancy complications and adverse outcomes which vary by parity.57 58 59
The rates of births to women >40 years
old in Kansas City have been variable, averaging 1.8% since 2000 (Figure 4-19). For the period, 2003-2007, Hispanics and Asians had the
highest rates of births to women >40 years old
(Figure 4-20) while non-Hispanic blacks had the
lowest. In 2007, 96.3% of births to women >40
years old were among those 40-44 years of age.
Among women 40-44 years old, approximately a third of all pregnancies end in miscarriage. The miscarriage rate increases for women
>45 years old, with more than half of pregnancies ending in miscarriage. The risk of fetal
death is doubled for women in their 40s compared to women in their 20s. In addition, babies
born to women in their 40s are more likely to
have lower birthweights. At age 45, there’s a 1 in
30 chance of delivering an infant with Down
syndrome and a 1 in 21 chance of having a baby
with any chromosomal abnormality. For a 49
year old woman, those risks rise to 1 in 11 and 1
in 8, respectively.
51.0
Women >40 years old
Figure 4-16 Annualized live birth rates per
1,000 women 15-17 years old and 18-19
years old, Kansas City, Mo, 2003-2007
14.3
in their 2nd pregnancy compared to teenagers
who are giving birth for the first time.56
5.0%
4.5%
Hispanic
4.9%
Black, non-Hispanic
4.8%
White, non-Hispanic
4.0%
ically lowest for young teenagers and women
Page 41 of 294
>35 years of age and highest for women in their
early 20s. In 1970, 50% of births to unmarried
women were to teenagers; however, in 2007
only 23% of such births were to teens.60
During 2007, 51.9% of birth mothers in
Kansas City were unmarried. Between 2003 and
2007, 77.4% of women <25 years old who gave
birth were not married, compared to 31.9% of
women >25 years old (Figure 4-21). The overall
proportions of women who were not married
were 27.3% for non-Hispanic whites, 77.5% for
non-Hispanic blacks, 57.0% for Hispanics,
26.3% for Asians, 50.2% for Native Americans,
and 53.0% for women of other race/ethnicity or
for whom no race/ethnicity was listed (Table 417). The distribution of unmarried mothers by zip
code is displayed in Table 4-18.
There are two types of living situations
into which children of unmarried mothers may be
born. There is cohabitation where the birth
mother and another person live together in a
marriage-like relationship; the other person may
be the biological father or a step-parent. The
other situation is where the biological parents
are not married and the woman does not live in
a household arrangement described above. Although the living arrangement for unmarried
birth mothers cannot be determined from the
birth certificates, national surveys suggest that
just over half are cohabitation arrangements.61
Hispanic and non-Hispanic white women are
more likely than non-Hispanic black women to
have a cohabitation arrangement. Among unmarried women over age 20 who have a birth,
more than one-half do so within a cohabiting
relationship. And, women with high educational
attainment are much less likely to have a birth
outside of marriage, but if they do it is likely that
birth occurred within a cohabiting union. Approximately 70% of births to cohabiting women are
unintended which is somewhat less than the
approximate 75% rate for those not in a cohabiting relationship.
Figure 4-19 Percentage of births to women >40 years of age, Kansas City, Mo
2.0%
1.5%
1.5%
2000
2001
2002
2.1%
2.0%
1.8%
1.7%
2004
2005
2006
2007
1.6%
2003
Figure 4-20 Annualized rates per 1,000 for
births to women >40 years of age, Kansas
City, Mo, 2002-20061
11.3
10.8
5.8
4.0
3.2
White, non- Black, non- Hispanic
Hispanic Hispanic
Asian
Native
American
1
Rate is calculated by births to women 40-54 years old divided by number of women 40-50 years old multiplied by
1,000
Figure 4-21 Percent of births to women
who were not married, Kansas City, Mo,
2003-2007
92.4%
70.7%
39.7%
24.7% 24.5% 26.0%
<20
20-24
25-29
30-34
35-39
40-44
32.5%
=>45
BIRTHS
Page 42 of 294
Table 4-17 Percent of births to unmarried women by age group and race/ethnicity, Kansas
City, Mo, 2003-2007
Total
Age
<20 y
20-24 y
25-29 y
30-34 y
35-39 y
40-44 y
>45 y
Total
Births
4,832
10,853
10,724
7,860
3,280
661
40
38,250
Unmarried
4,464
7,677
4,260
1,938
805
172
13
19,329
White, non-Hispanic
%
92.4
70.7
39.7
24.7
24.5
26.0
32.5
50.5
Births
1,028
3,524
5,074
4,489
1,910
58
8
16,091
Unmarried
889
1,866
982
441
237
58
8
4,481
%
85.2
65.4
48.4
40.5
35.4
39.8
0
57.0
Births
44
181
329
355
128
28
1
1,066
Unmarried
40
95
73
48
20
4
0
280
Hispanic
Age
<20 y
20-24 y
25-29 y
30-34 y
35-39 y
40-44 y
>45 y
Total
Births
995
1,892
1,797
1,092
424
88
0
6,288
Unmarried
848
1,238
870
442
150
35
0
3,583
<20 y
20-24 y
25-29 y
30-34 y
35-39 y
40-44 y
>45 y
Total
BIRTHS
Births
65
177
191
140
57
5
1
636
Unmarried
58
124
89
42
22
1
1
337
Births
2,675
5,007
3,259
1,731
738
165
8
13,583
%
90.9
52.5
22.2
13.5
15.6
14.3
0
26.3
Births
25
72
74
53
23
5
1
253
Asian
Other/Not listed
Age
%
89.2
70.1
46.6
30.0
38.6
20.0
100.0
53.0
Black, non-Hispanic
%
86.5
53.0
19.4
9.8
12.4
15.5
27.6
27.3
Unmarried
2,604
4,308
2,219
947
366
73
4
10,521
%t
97.3
86.0
68.1
54.7
49.6
45.1
50.0
77.5
Native American
Unmarried
25
46
27
18
10
1
0
127
%
100.0
63.9
36.5
34.0
43.5
20.0
0
50.2
Page 43 of 294
Table 4-18 Percent of live births to unmarried women by zip code, Kansas City, Mo, 2007
Zip code
Births
Unmarried
Percent
unmarried
Zip Code
Births
Unmarried
Percent
unmarried
64101
0
0
0.0
64134
429
281
65.5
64102
0
0
0.0
64136
37
24
64.9
64105
30
19
63.3
64137
204
72
35.3
64106
158
127
80.4
64138
231
135
58.4
64108
136
80
58.8
64139
20
5
25.0
64109
183
152
83.1
64145
40
13
32.5
64110
278
176
63.3
64146
9
3
33.3
64111
235
125
53.2
64147
32
26
81.3
64112
54
10
18.5
64149
1
1
100.0
64113
173
9
5.2
64151
253
86
34.0
64114
343
73
21.3
64152
120
40
33.3
64116
155
63
40.6
64153
62
6
9.7
64117
227
113
49.8
64154
124
21
16.9
64118
363
154
42.4
64155
341
84
24.6
64119
308
85
27.6
64156
69
15
21.7
64120
8
4
50.0
64157
319
27
8.5
64123
290
172
59.3
64158
79
5
6.3
64124
357
233
65.3
64160
0
0
0.0
64125
58
43
74.1
64161
2
0
0.0
64126
171
121
70.8
64163
4
3
75.0
64127
407
320
78.6
64164
0
0
0.0
64128
246
212
86.2
64165
0
0
0.0
64129
165
95
57.6
64166
1
0
0.0
64130
404
347
85.9
64167
0
0
0.0
64131
343
195
56.9
64192
0
0
0.0
64132
283
233
82.3
All Others*
8
5
62.5
64133
251
146
58.2
Total
8,011
4,159
51.9
* Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191, 64195, 64196, and 64199 are associated with post office box numbers; zip codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197,
64198, 64944, and 64999 are associated with unique entities, and zip codes 64012, 64030, 64079, and 64081 are associated
with Belton, Grandview, Platte City, and Lee’s Summit, respectively.
Birth spacing
Both short (<18 months) and long (>59
months) intervals between pregnancies are significantly associated with increased risk of preterm birth, low birthweight, and SGA infants.62
Thus, spacing pregnancies appropriately could
help prevent such adverse outcomes. Short intervals between pregnancies are for the most
part unintended63 and, among adolescents, may
be associated with depression.64 Long intervals
are most likely not chosen but may result from
the end of a partnership, infertility, reproductive
losses in the interval, health problems in the
mother/infant, or economic issues.65
In Kansas City, the percentage of women who have had a baby and then in <18
months delivered another baby has been in-
Figure 4-22 Rate of births with spacing
less than 18 months and more than 59
months from a prior live birth, Kansas
City, Mo
<18 months
25.8% 25.9% 26.8%
14.8%
2000
12.4%
2001
>59 months
24.3% 24.9% 24.4% 24.1% 24.0%
13.0% 13.9%
11.1% 12.1% 12.2%
2002
2003
2004
2005
2006
15.3%
2007
BIRTHS
Page 44 of 294
diate, adequate, and adequate plus. Women who received no prenatal care are
grouped in the inadequate
<18 m
>59 m
category.
29.0%
27.3%
27.1%
Based on this index,
24.6%
22.9%
the distributions of the levels
20.0%
15.9%
of prenatal care received by
13.6%
13.6%
12.1%
11.8%
11.5%
women who had live births in
2003 through 2007 are
shown in Tables 4-19 and 420. The Healthy People 2010
Asian
Native
Other/not
Hispanic
Hispanic
American
listed
objective is that 90% of
women receive an adequate
number of prenatal visits and
that 90% of pregnant women
creasing in recent years, while the percentage of
begin prenatal care early (first trimester).
women with birth intervals >59 months remained
In 2007, 61.3% of pregnant women in
relatively stable (Figure 4-22). In 2007, there
Kansas
City received an adequate or more than
were 638 births that occurred <18 months from a
adequate number of pre-natal visits; this was
previous birth and 998 that occurred >59 months
lowest percentage of women receiving adequate
from a previous birth. The highest rate of subseprenatal care in the past 5 years. In 2007, 83.1%
quent deliveries within <18 months occurred
of birth mothers initiated prenatal care in their
among non-Hispanic blacks, while Hispanics
first trimester (Figure 4-23, Tables 4-21 and 4had the highest rate for birth spacing >59
22), which was below the Healthy People 2010
months (Figure 4-23).
objective of 90%. The declining trend in initiation
of prenatal care during the first trimester observed in Kansas City is consistent with what
Prenatal care
has been reported nationally.
Determining the adequacy or inadequaResearch suggests that women who get
cy of prenatal care by pregnant women is based
early and adequate prenatal care have improved
on a set of varying parameters. Each woman’s
birth outcomes with fewer preterm or low birthpregnancy history must be evaluated against
weight infants, and that women who have effecthose parameters in order to determine the adetive prenatal education and motivation encourquacy of prenatal care received. There are sevaging healthy behavior may be less likely to deeral different methodologies for determining
adequacy of prenatal
care. For the purposes
Table 4-19 Distribution of levels of prenatal care among pregnant
of this document, the
women, Kansas City, Mo
Adequacy of Prenatal
Adequate
Care Utilization Index
Year
Pregnancies Inadequate Intermediate Adequate
Plus
2003
6,326
10.8%
18.4%
50.7%
20.1%
(APNCU) was used.66
2004
6,590
10.7%
19.0%
48.7%
21.6%
67
The APNCU classi2005
6,880
11.4%
18.6%
48.1%
22.0%
fies prenatal care as
2006
6,774
11.5%
17.2%
46.0%
25.2%
2007
7,316
13.5%
19.5%
46.6%
20.7%
inadequate, intermeFigure 4-23 Rate of births with spacing less than 18 months and
more than 59 months by race/ethnicity, Kansas City, Mo, 20032007
BIRTHS
Page 45 of 294
liver infants with
Table 4-20 Distribution of levels of prenatal care among pregnant women,
intrauterine
by race/ethnicity, Kansas City, Mo, 2003-2007
growth retardaAdequate
tion. Yet, early
Race/ethnicity Pregnancies Inadequate Intermediate Adequate
Plus
access to preWhite, non15,490
6.1%
14.3%
54.9%
24.7%
Hispanic
natal care has
Black, non11,314
17.6%
20.4%
40.2%
21.8%
not resulted in
Hispanic
elimination of
5,401
14.1%
27.0%
43.9%
15.0%
Hispanic
racial/ethnic dis933
13.6%
18.8%
50.2%
17.5%
Asian
Native
American
231
13.4%
18.2%
43.7%
24.7%
parities in periOther/Not listed
542
17.9%
19.0%
43.0%
20.1%
natal mortality.68
33,911
11.7%
18.6%
47.9%
21.9%
Total
Conversely, inadequate use of prenatal care has been associated with increases in
low birthweight infants, premature births, and
increases in neonatal, infant, and maternal morFigure 4-23 Percent of pregnant women
tality. In Kansas City, disparities in the degree of
starting prenatal care in the first trimesinadequate prenatal care exist between rater, Kansas City, Mo
cial/ethnic groups. In 2007, non-Hispanic blacks
Yr 2010 objective is 90% of pregnant women starting
were 2.9 times more likely to have received inprenatal care in the first trimester
adequate prenatal care when compared to the
87.9%
86.9%
85.9%
85.0%
83.1%
experience of non-Hispanic whites; Native
Americans, Hispanics, and Asians were between 2.2 and 2.3 times more likely.
Prenatal care includes 3 major components: risk assessment, treatment for medical
conditions or risk reduction, and education. Each
2003
2004
2005
2006
2007
component can contribute to reductions in perinatal illness, disability, and death by identifying
and mitigating potential risks and helping women
address behavioral factors, such as smoking
and drinking alcohol, that contribute to poor outcomes. Therefore,
prenatal care is
Table 4-21 Distribution of initiation of prenatal care among pregnant
more likely to be
women, by race/ethnicity, Kansas City, Mo, 2007
effective if women
Race/ethnicity
Pregnancies
First
Second
Third
No care
begin receiving care
White, non-Hispanic
3,273
90.2%
7.9%
1.0%
0.9%
early in pregnancy.
Black, non-Hispanic
2,662
76.4%
18.4%
2.4%
2.7%
Hispanic
Asian
Native American
Other/Not listed
Total
1,209
229
46
128
7,547
79.9%
82.1%
84.8%
71.1%
83.1%
16.2%
12.2%
8.7%
18.0%
13.2%
2.9%
2.2%
2.2%
3.9%
1.9%
1.0%
3.5%
4.3%
7.0%
1.7%
BIRTHS
Page 46 of 294
Table 4-22 Initiation and inadequacy of prenatal care, Kansas City, Mo, 2007
Trimester in which prenatal care was initiated
Inadequate care
st
nd
rd
Zip code
Live births
1
2
3
No care
Number
Percent
64101
0
0
0
0
0
0
0
64102
0
0
0
0
0
0
0
64105
30
23
2
1
1
3
10.0
64106
158
108
30
2
4
36
22.8
64108
136
107
10
5
2
19
14.0
64109
183
113
34
2
4
38
20.8
64110
278
198
39
9
6
51
18.3
64111
235
171
29
3
8
32
13.6
64112
54
51
1
1
0
2
3.7
64113
173
165
5
0
1
4
2.3
64114
343
309
18
6
2
22
6.4
64116
155
134
12
1
3
13
8.4
64117
227
180
30
4
3
31
13.7
64118
364
305
43
3
4
35
9.6
64119
308
277
17
4
5
22
7.1
64120
8
4
1
0
0
2
25.0
64123
290
194
49
13
7
58
20.0
64124
357
252
52
8
7
68
19.0
64125
58
44
9
0
4
15
25.9
64126
171
121
19
5
4
35
20.5
64127
407
282
72
12
10
92
22.6
64128
246
170
41
6
8
50
20.3
64129
165
121
26
6
3
31
18.8
64130
404
289
64
9
12
84
20.8
64131
343
264
52
1
3
49
14.3
64132
283
194
49
7
9
62
21.9
64133
251
197
34
5
2
37
14.7
64134
429
303
81
15
8
86
20.0
64136
37
27
9
1
0
6
16.2
64137
204
157
34
2
2
29
14.2
64138
231
178
40
1
1
32
13.9
64139
20
18
2
0
0
3
15.0
64145
40
38
2
0
0
1
2.5
64146
9
8
0
0
0
0
0.0
64147
32
16
14
1
0
10
31.2
64149
1
1
0
0
0
0
0.0
64151
253
219
18
4
3
20
7.9
64152
120
105
5
0
2
7
5.8
64153
62
59
1
0
0
1
1.6
64154
124
110
7
2
1
7
5.6
64155
341
312
23
3
0
16
4.7
64156
69
63
3
1
1
7
10.1
64157
319
305
11
1
2
11
3.4
64158
79
69
9
0
0
7
8.9
64160
0
0
0
0
0
0
0
64161
2
2
0
0
0
0
0.0
64163
4
3
0
0
0
0
0.0
64164
0
0
0
0
0
0
0.0
64165
0
0
0
0
0
0
0.0
64166
1
1
0
0
0
0
0.0
64167
0
0
0
0
0
0
0.0
64192
0
0
0
0
0
0
0.0
All Others*
7
6
1
0
0
1
14.2
Total
8,011
6,273
998
144
132
1,135
14.2
* Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191, 64195, 64196, and 64199 are associated with post office box numbers; zip codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197,
64198, 64944, and 64999 are associated with unique entities, and zip codes 64012, 64030, 64079, and 64081 are associated
with Belton, Grandview, Platte City, and Lee’s Summit, respectively.
BIRTHS
Page 47 of 294
runs counter to the achievement of the Healthy
People 2010 objective (number of C-sections for
Babies are born via vaginal delivery or
first time mothers not to exceed 15%).
cesarean section (C-section) (Table 4-23). Each
The national increase in singleton premethod of delivery can result in injury to the
term
births
occurred primarily among those delinewborn, the mother, or both. In 2006, accord71
resulting in the largest
vered
by
C-section,
ing to the national Healthcare Cost and Utilizapercentage increase for late preterm births. For
tion Project, there were nearly 157,000 potentialall maternal racial/ethnic groups, singleton Cly avoidable injuries to birth mothers and new69
section rates have increased for each gestationborns. Vaginal births with instrumentation were
al age group with rates for non-Hispanic black
associated with the highest obstetrical injury
women increasing at a faster pace among all
rates for mothers while C-sections had the lowpreterm gestational age groups compared to
est rate of maternal injury. Newborns covered by
non-Hispanic white and Hispanic women. The
Medicaid had higher injury rates than those covincrease is not explained by changes in the freered by private insurance. Obstetrical trauma for
quency of pregnancy complications, women’s
mothers was highest among women with private
age, insurance, or hospital characteristics;
insurance and those living in the wealthiest
changes in delivery practices regarding pregcommunities. In general, both blacks and Hisnancy complications may have a contributory
panics had lower childbirth-related injury rates
role.72 Women delaying childbirth reportedly
compared to whites, while Asians had higher
have contributed significantly to the rising rate of
rates.
primary C-sections.73
C-sections can be subdivided as primary
In Kansas City, the overall rate for Cor repeat, with and without labor. Of public
sections in 2007 was 27.5%, while that among
health concern is the increase in the overall C1st time mothers was 27.9%. The percentage of
section rate as well as the increase in primary Cprimary elective C-sections continued to insections without labor (primary elective Ccrease. First births to women >35 years of age
sections). Nationally, the C-section rate rose to
are nearly twice as likely to be delivered via C31.8% in 2007 (the highest rate on record) and
section as those to younger women (Figure 4the increasing rate of primary C-section cannot
24). Primary elective C-section rates by
be explained by an increase in maternal risk pro70
race/ethnicity are shown in Figure 4-25.
files. The increasing trend in the C-section rate
The literature suggests that
elective C-sections
Table 4-23 Method of live birth delivery, Kansas City, Mo
should not be perPrimary
Primary
Total
elective
emergency
Repeat
All
formed prior to 39
Births Year births Vaginal C-section
C-section
C-section others
weeks gestation as
2003
7,340
74.9%
6.6%
8.6%
8.6%
1.2%
those delivered ear2004
7,439
75.0%
7.0%
8.2%
8.9%
1.0%
All
2005
7,572
73.9%
9.4%
6.4%
9.4%
0.9%
lier had more com2006
7,853
73.5%
11.3%
6.3%
8.3%
0.7%
plications, including
2007
7,993
72.5%
12.1%
6.2%
8.5%
0.7%
breathing problems,
2003
2,972
74.9%
10.1%
12.9%
2.1%
even though they
2004
2,956
74.4%
11.3%
12.8%
1.5%
st
were full term.74
1
2005
2,971
73.7%
15.0%
9.8%
1.5%
2006
3,163
72.1%
17.4%
9.6%
0.9%
Table 4-24 shows
2007
3,279
72.2%
18.1%
8.7%
0.9%
births by delivery
Delivery method
BIRTHS
Page 48 of 294
Figure 4-24 Primary elective C-section for first time births by age of first time birth mothers,
Kansas City, Mo
2003
2004
2005
2006
2007
32.3%
8.6% 10.2%
5.1% 5.0% 6.7%
11.0% 12.6%
<20 y
16.2%
18.9% 19.5%
20-34 y
38.1% 36.2%
21.0% 23.2%
=>35 y
method and gestation
Figure 4-25 Primary elective C-section by race/ethnicity, Kansas City,
for Kansas City in 2007;
Mo, 2007
35.5% of the primary
elective and repeat C28.6%
No previous birth
Previous birth
sections were done
24.3%
21.9%
prior to 39 weeks ges14.6%
14.4%
tation.
13.6%
13.2%
8.4%
C-sections are
7.9%
7.2%
6.5%
2.9%
not without risk. In
2005, 1,301,770 CWhite, nonBlack, nonHispanic
Asian
Native
Other/Not listed
sections were perHispanic
Hispanic
American
formed in the US and
228 of the women
died.75 While cesarean
are additional risk factors, namely health comdelivery reduces overall risk in breech presentapromising behaviors (eg pregnancy-smoking)
tions and the risk of intrapartum fetal death in
and weight gain during pregnancy. For example,
cephalic presentations, it increases the risk of
the literature shows that daily alcohol consumpsevere maternal and neonatal morbidity and
76
tion during pregnancy is associated with inmortality in cephalic presentations. There is a
creased risk of having a child with low birthhigher risk of respiratory problems in term in77
weight79 or who is born preterm.80 Only a small
fants delivered by C-section. Rates of severe
proportion of women planning a pregnancy folobstetric complications have increased in the US
low recommendations for lifestyle and nutrition.81
and for many of these complications were assoImmigrant women are less likely to engage in
ciated with the increasing rate of cesarean delithese behaviors, however maternal health behavery.78
viors worsen with length of residency.82
Maternal risk factors
The birth certificate lists a number of
medical risk factors for any pregnancy. For
2007, a compilation of those factors and the frequency of their occurrence are provided in Table
4-25. Besides these medical risk factors, there
BIRTHS
Diabetes
Currently, Missouri’s certificate of birth
only captures information on diabetes as to
whether the mother had type 1 (insulin dependent) disease or as having other diabetes.
Therefore it is not possible to reliably determine
Page 49 of 294
how many women experienced gestational diand non-insulin dependent diabetes.
abetes.
According to the literature, the prevaIn Kansas City, in a comparison of sinlence of gestational diabetes has remained stagleton births for 1993-1997 and 2003-2007, the
ble and there has been an increase in preprevalence of
maternal insulin
Table 4-24 Births by gestation and delivery method, Kansas City, Mo, 2007
dependent diPrimary
Primary
Repeat
abetes rose
Gestation
elective Cemergency
CAll
33.7% (Figure 4(weeks)
Vaginal
section
C-section
section
others
Total
26), while that for
12
1
0
0
0
0
1
17
1
0
0
0
0
1
other diabetes
19
1
0
0
1
0
2
rose 59.7%. A
20
7
0
1
0
0
8
21
1
0
0
0
0
1
comparison of
22
5
0
0
0
0
5
maternal diabetes
23
5
0
2
0
0
7
24
5
0
7
0
0
12
rates per 1,000
25
8
4
5
1
1
19
live births is pre26
5
4
4
1
0
14
sented in Table 427
4
1
4
0
0
9
28
2
8
6
0
0
16
26. Asians, wom29
5
6
9
0
1
21
en >35 years of
30
7
5
2
1
0
15
31
10
9
12
2
0
33
age, parous
32
15
7
14
1
0
37
women, women
33
27
21
14
4
1
67
who were foreign34
51
11
20
11
0
93
35
96
30
15
2
1
144
born, and women
36
194
45
23
22
2
286
who had more
37
423
69
32
57
5
586
38
918
147
69
131
9
1,274
than a high
39
1,667
265
99
303
16
2,350
school education
40
1,686
232
109
115
16
2,158
had the highest
41
568
87
39
22
3
719
42
55
20
7
2
0
84
rates for both in44
1
0
0
0
0
0
sulin dependent
Total
5,768
971
493
676
55
7,962
Table 4-25 Frequency of medical risk factors among pregnant women, Kansas City, Mo, 2007
Frequency1
Medical risk factor
Women
Percent
Acute or chronic lung disease
324
4.0%
Anemia
182
2.3%
Cardiac disease
Diabetes, insulin dependent
49
54
0.6%
0.7%
Diabetes, other
318
Eclampsia
4
Genital herpes
131
Hemoglobinapathy
43
Hydramnios/Oligohydramnios
215
1
The denominator varies slightly for each item listed
4.0%
0.05%
1.6%
0.5%
2.7%
Frequency
Medical risk factor
Hypertension, chronic
Hypertension, pregnancy associated (preeclampsia)
Incompetent cervix
Previous infant >4,000 gm
Previous infant preterm or small
for gestational age
Renal disease
Rh sensitization
Uterine bleeding
Women
Percent
78
1.0%
314
3.9%
36
78
0.4%
1.0%
154
1.9%
29
40
0.4%
0.5%38
BIRTHS
Page 50 of 294
Table 4-26 Maternal diabetes rates per 1,000 live births, Kansas City, Mo, 2003-2007
Factor
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native Americans
Insulin
dependent
Noninsulin
dependent
6.6
6.6
7.5
13.1
7.9
32.1
32.6
44.8
64.8
39.5
<35 years old
6.4
30.8
>35 years old
12.1
73.6
existing diabetes, particularly among younger
women early in their reproductive years.83 This
requires that pre-existing diabetes being appropriately managed during pregnancy.84
Prepregnancy diabetes type 1 or type 2
accelerates maternal diabetes complications
and increases risk for spontaneous abortions
and birth defects. Gestational diabetes can lead
to pregnancy associated hypertension, fetal macrosomia, and cesarean delivery, particularly if
the woman gains more than the recommended
weight during the pregnancy.85 Glucose levels
can vary during pregnancy by the type of diabetes making it difficult to maintain treatment
target levels, particularly among those women
with type 1 diabetes.86 Treatment of mild gestational diabetes mellitus does not significantly
reduce the frequency of stillbirth or perinatal
death and several neonatal complications, but it
does reduce the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders.87
In 1995, 2 out of every 3 cases of prepregnancy diabetes in the US were type 2. This
proportion has likely increased because the prevalence of obesity and type 2 diabetes has
grown among women of childbearing age. There
are a variety of adverse outcomes associated
with maternal diabetes. One example is birth
defects. About 7% of all birth defects are associated with diabetes. Prepregnancy diabetes is
BIRTHS
Insulin
dependent
Noninsulin
dependent
Nulliparous
Parous
6.3
7.5
28.0
40.1
US -born
Foreign-born
6.7
7.7
32.5
48.3
< High school education
High school education
> High school education
6.1
31.7
7.4
33.4
7.3
38.1
Factor
Figure 4-26 Comparison of maternal diabetes rates per 1,000 live births, Kansas
City, Mo, 1993-1997 and 2003-2007
1993-1997
2003-2007
35.3
22.1
4.2
7.0
Insulin dependent
Other diabetes
significantly associated with nearly 40 types of
cardiac and non-cardiac birth defects, while gestational diabetes is associated with a more limited group of cardiac and non-cardiac birth
defects.88
Another example is infants with macrosomia which is defined as birthweights >4,000
grams (8 lb 13 oz). Diabetes that is poorly controlled in pregnancy is the greatest risk factor for
fetal macrosomia. This is believed to be partially
explained by excessive growth due to elevated
maternal plasma glucose levels and resulting
elevated insulin and insulin-like growth factor
levels, which stimulate glycogen synthesis, fat
deposition, and fetal growth. Between 1993 and
1997, 9.0% of all singleton births in Kansas City
were involved infants with macrosomia; this decreased to 8.0% between 2003 and 2007 (Fig-
Page 51 of 294
All
12.4%
17.4%
18.8%
15.0%
2003-2007
8.8%
1993-1997
7.8%
Smoking during pregnancy can cause
poor outcomes for both the pregnant woman
and her unborn child and also result in added
health-care expenditures. The Centers for Disease Control and Prevention (CDC) estimated
that in 1996 pregnancy-smoking cost the nation
$366 million for neonatal health care or $704 per
birth mother who smoked; for Missouri the estimate was $10 million.89
Pregnancy-smoking results in a reduction of blood flow to the fetus as a result of decreased endothelial nitric oxide synthase, a protein that helps blood vessels relax.90 This has
been suggested as a major risk factor for premature birth, low birthweight, small for gestational
age and spontaneous abortions as well as being
associated with childhood obesity.91 92 However,
women who stop pregnancy-smoking early have
no more adverse pregnancy outcomes than nonsmokers93 94 and there is no association with
SGA if the woman stops smoking before the
32nd week of gestation.95 Pregnancy-smoking
does not appear to affect a child’s cognitive abilities growing up or the subsequent development
of asthma.96 It is, however, associated with reduced growth in head circumference, abdominal
circumference, and femur length.97
Reports suggest infants of women who
quit pregnancy-smoking have “cheerier, more
adaptable babies”.98 Also, these women had
better general functioning, including more sustained relationships, more skillfulness in use of
community resources and less disrupted and
stressful life circumstances and were less likely
to have a history of social problems and antisocial behavior compared to pregnancy smokers.
In 2007, 11.8% of Kansas City birth
mothers smoked during their pregnancies (Figure 4-28). While pregnancy-smoking rates declined significantly from the levels of the late
9.0%
Pregnancy-smoking
Figure 4-27 Percent of infants with macrosomia by maternal diabetes status,
Kansas City, Mo, 1993-1997 and 20032007
8.0%
ure 4-27). Declines occurred across maternal
diabetes categories.
No diabetes
Insulin
dependent
Other
diabetes
1990s, the decline in the pregnancy-smoking
rate decelerated in recent years. The prevalence
of pregnancy-smoking was inversely associated
with increasing median family income with variation by race/ethnicity (Figure 4-29).
Monitoring the national trend in pregnancy-smoking has become more complicated
as states begin to adopt the 2003 revision of the
national birth certificate form. States using the
new form have higher pregnancy-smoking rates
than states that have not adopted it; Kansas, but
not Missouri, has adopted the revised birth certificate. In addition, there are data that suggest
Figure 4-28 Prevalence of pregnancysmoking, Kansas City, Mo
20.9%
17.1%17.3%
14.1%
12.3%12.7%12.1%13.1%12.6%11.8%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
BIRTHS
Page 52 of 294
Figure 4-29 Prevalence of pregnancy-smoking by zip code median family income, Kansas
City, Mo, 2007
Total
White, non-Hispanic
Black, non-Hispanic
Hispanic
29.0%
19.0%
12.0%
11.5%
10.5%
7.8% 7.8%
3.9%
3.0%
$20-39,999
18.7%
15.8%
15.4%
$40-59,999
3.7%
$60-79,999
2.9% 1.9%
0.0%
$80-99,999
the number of infants exposed to tobacco in utecode in Table 4-29.
ro may be 31% higher than is currently reported
The effects of pregnancy-smoking are
on the birth certificates.99
increased when a woman engages in either or
There is variation in pregnancy-smoking
both alcohol consumption and illicit drug use.101
CDC reports that approximately 12% of women
by racial/ethnic groups (Table 4-27) and over the
use alcohol while pregnant and approximately
past 5 years the average pregnancy-smoking
2% engaged in binge drinking or frequent use of
rate was highest among women 20-29 years of
alcohol.102 Unfortunately, studies have shown
age (Table 4-28). The pregnancy-smoking rate
that nearly 75% pregnant women who drink alis influenced by the number of prior live births a
cohol during pregnancy do not admit to doing
woman has had and increases with subsequent
so.103 Table 4-30 shows the additive effects of
pregnancies (Figure 4-30). Although about 25%
these health compromising behaviors on preof Kansas City women who smoked during their
term births to non- Hispanic whites and nonfirst pregnancy do not smoke during their
second pregnancy and only
about 5% of women who
Table 4-27 Pregnancy-smoking by race/ethnicity, Kansas City, Mo
did not smoke during their
Race/ethnicity
2003
2004
2005
2006
2007 Average
first pregnancy initiate
White, non-Hispanic
15.6%
15.2%
15.8%
15.3%
14.2%
15.2%
smoking in their second
Black, non-Hispanic
12.9%
12.4%
14.8%
14.0%
13.4%
13.5%
Hispanic
3.8%
3.9%
4.0%
2.9%
3.3%
3.6%
pregnancy, there is a net
Asian
8.2%
5.9%
2.6%
5.6%
3.2%
5.1%
increase in smokers during
Native American
26.6%
35.4%
32.0%
26.2%
21.3%
28.3%
Other/Not listed
3.4%
6.6%
11.8%
16.1%
13.5%
10.3%
the second pregnancy resulting in a higher pregnancy-smoking
rate.100 The disTable 4-28 Pregnancy-smoking by age group, Kansas City, Mo
tribution of
Year
Total births
10-14 y
15-19 y
20-29 y
30-39 y
>40 y
Average
women who
2003
7,340
12.0%
15.2%
14.0%
8.6%
13.3%
12.5%
engaged in
2004
7,395
0.0%
15.3%
14.2%
7.1%
10.7%
12.1%
pregnancy2005
7,551
0.0%
13.6%
15.1%
8.8%
16.4%
13.1%
2006
7,823
0.0%
11.4%
15.1%
8.2%
12.1%
12.6%
smoking is
2007
7,979
5.9%
12.1%
13.7%
8.1%
9.8%
11.8%
shown by zip
Average rate of smoking
3.6%
13.5%
14.4%
8.2%
12.5%
12.4%
BIRTHS
Page 53 of 294
Hispanic blacks in Kansas City.
Figure 4-30 Pregnancy-smoking rates by number of preAmong pregnant women in Kansas
vious live births, Kansas City, Mo
City who were heavy smokers, men0 PLB
1 PLB
2 or more PLB
tal illness was associated with addi23.4%
tional risk for illicit drug abuse.104
20.8%
19.6%
19.1%
Changes in smoking rates
18.6%
18.4%
18.1%
17.3%
17.0%
16.7%
have been attributed to greater
15.1%
awareness by pregnant women of
12.3% 13.1% 11.8%
11.9% 12.4% 12.5% 11.5%
11.0%
10.4%
the health consequences of smoking especially as it pertains to fetal
11.5%
10.6% 9.9% 10.5%
9.8%
9.6% 10.0%
health.105 Inherent in these state8.5% 8.9%
8.4%
ments are the assumptions that
fewer women are starting to smoke
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
cigarettes and that more smokers
stopped smoking specifically during
pregnancy. Approximately 70% of
mended gestational weight gains.114 Women
women who stop pregnancy-smoking resume
who believe that external factors primarily desmoking once the infant is delivered.106 107 108
termine fetal health appear to be more vulneraNationally, women who stop smoking do
ble to non-adherence to gestational weight gain
so in the first trimester or prior to their first preguidelines.115 In contrast, underweight women
natal care visit. And, of those who continue to
with a history of restrained eating behaviors gain
smoke, whether nationally109 or in Kansas
less weight compared to underweight women
110
City, up to 90% report decreasing the number
without those behaviors. In 2006, approximately
of cigarettes smoked per day. National monitor33% of all birth mothers nationally had weight
ing data report small but significant declines in
gains outside the national guidelines, regardless
the number of women who smoke during and
of their height, while in Kansas City only a third
after pregnancy.111 Smoking cessation programs
of pregnant women had appropriate weight
for pregnant women need to consider the smokgains (Figure 4-31).
ing behaviors of others in the household as well
The National Academy of Sciences has
112
as those of grandparents.
established guidelines based on the mother’s
body weight. Underweight women are expected
Weight gain
to gain 28-40 pounds, normal weight women 25The amount of weight a woman should
35 pounds, overweight women 15-25 pounds,
gain during pregnancy depends upon her preand obese women 11-20 pounds.116 Of concern
pregnancy weight and height. Excessive gestaare women who gain too little or lose weight and
tional weight gains are common, especially
those who gain too much weight. Various stuamong the youngest women and those who are
dies have reexamined the current recommendanulliparous.113 It has been reported that with the
tions and showed their benefit for non-obese
exception of underweight women, all other
women,117 118 but suggest lower weight gains for
women with a history of prepregnancy dieting or
that group.119 A systematic review of select
restrained eating are more likely to gain more
pregnancy outcomes based on those guidelines
weight during pregnancy and exceed recomhas been published.120
BIRTHS
Page 54 of 294
Table 4-29 Distribution of pregnancy-smoking by zip code, Kansas City, Mo, 2007
Zip code
Births
Smokers
Percent
smokers
Zip code
Births
Smokers
Percent
smokers
64101
0
0
64134
425
51
12.0
64102
0
0
64136
37
2
5.4
64105
30
3
10.0
64137
203
15
7.4
64106
157
14
8.9
64138
230
23
10.0
64108
136
5
3.7
64139
20
2
10.0
64109
183
33
18.0
64145
40
5
12.5
64110
275
29
10.5
64146
9
0
0.0
64111
233
22
9.4
64147
32
6
18.8
64112
54
3
5.6
64149
1
0
0.0
64113
173
5
2.9
64151
253
35
13.8
64114
342
27
7.9
64152
120
12
10.0
64116
152
28
18.4
64153
62
2
3.2
64117
227
51
22.5
64154
123
6
4.9
64118
362
46
12.7
64155
341
28
8.2
64119
307
36
11.7
64156
69
6
8.7
64120
7
1
85.7
64157
319
10
3.1
64123
289
39
13.5
64158
79
4
5.1
64124
357
33
9.2
64160
0
64125
58
16
27.6
64161
2
0
0.0
64126
170
18
10.6
64163
4
2
50.0
64127
406
62
15.3
64164
0
64128
246
39
15.9
64165
0
64129
163
24
14.7
64166
1
0
0.0
64130
403
79
19.6
64167
0
64131
340
39
11.5
64192
0
64132
283
46
16.3
All Others*
7
0
0.0
64133
250
35
14.0
Total
7,980
942
11.8
* Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191, 64195, 64196, and 64199
are associated with post office box numbers; zip codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193,
64194, 64197, 64198, 64944, and 64999 are associated with unique entities, and zip codes 64012, 64030, 64079,
and 64081 are associated with Belton, Grandview, Platte City, and Lee’s Summit, respectively.
ternal weight gain
is associated with
increased risk of
Preterm
% preterm
spontaneous
births
births
term birth.123
10,123
9.3
Among non2,127
11.8
82
7.8
Hispanic blacks
209
19.0
with a previous
186
18.4
401
23.3
preterm birth, both
12
20.3
low and high
160
34.0
13,300
10.1
weight gains are
associated with
increased risk of
preterm birth. For women of other racial/ethnic
groups who had a previous preterm birth high
weight gain is not associated with subsequent
preterm birth. Among Asians there also is no
association with low weight gains.
Table 4-30 Percent of non-Hispanic white and non-Hispanic black preterm
births according to health compromising behaviors, Kansas City, Mo,
1990-2007
Behavior
Total
births
Full-term
births
None
Smoking alone
Alcohol alone
Drugs alone
Smoking and alcohol
Smoking and drugs
Alcohol and drugs
Smoking, alcohol and drugs
Total
108,361
17,977
1,052
1,102
1,009
1,724
59
470
131,754
98,238
15,850
970
893
823
1,323
47
310
118,454
Both the mother’s prepregnancy weight
and the amount of weight gained during pregnancy are linked to the birthweight of the infant.121 122 In addition, weight gain during pregnancy impacts the risk for preterm birth; low
BIRTHS
Page 55 of 294
Obesity
A major public health concern is the rising rate of obesity in the population in general
and among pregnant women in particular. Obesity (prepregnant weight status) in pregnant
women may lead to pregnancies exceeding 40
weeks124 as well as poor pregnancy outcomes,
such as stillbirth, infant death, maternal death,
gestational diabetes, labor complication, and
increased risk of babies born with birth defects.
The obesity rate among pregnant women in Missouri tripled from 7.1% in 1983 to
13.8% in 1993 to 21.3% in 2003.125 During the
same 20 year period, the number of women who
were underweight decreased by 46% and there
was a 27.4% decrease in women who were of
normal weight. Obese women had higher rates
of medical risk factors, complications of labor/delivery, C-sections, fetal and infant deaths,
early preterm births, congenital anomalies, very
low birthweight infants, higher birthweight babies, and babies with macrosomia.
A study of Kansas City women who
were overweight prior to their first pregnancy,
found that 55% were overweight prior to their
second pregnancy, 33% were obese and 12%
were normal or underweight. The increase in
prepregnancy weight to obese was associated
with being unmarried and have a birth interval
>18 months, while the decrease was associated
with low or normal gestational weight gain.126
Figure 4-31 Weight gains by pregnant
women, Kansas City, Mo
1993-1997
2003-2007
48.9%
43.3%
35.4%
31.6%
21.3%19.5%
Low
Normal
Over
Complications of labor
& delivery
Table 4-31 shows the recorded complications of labor and delivery for births in Kansas
City during 2007. Nationally, in 2006, the prevalence of meconium was 4.4%, breech presentation 5.4%, and precipitous labor 2.1%. The
presence of meconium during labor and delivery
can directly alter the amniotic fluid, reduce antibacterial activity, and damage the infant’s lungs
if inhaled. Fetal distress from meconium aspiration often leads to delivery by cesarean section.
Table 4-31 Frequency of complications of labor and/or delivery among pregnant women,
Complication
o
Frequency1
Women Percent
Febrile, >100 F
100
1.2
Meconium, moderate/heavy
499
6.2
Premature rupture of membrane,
245
3.1
>12 hours
Abrupto placenta
39
0.5
Placenta previa
17
0.2
Other excessive bleeding
50
0.6
Seizures during labor
4
0.05
Precipitous labor, <3 hours
230
2.9
1
Complication
Frequency
Women Percent
Prolonged labor, >20 hours
Dysfunctional labor
53
232
0.7
2.9
Breech
236
2.9
Other malpresentation
Cephalopelvic disproportion
Cord prolapse
Anesthetic complications
Fetal distress
128
68
9
701
541
1.6
0.8
0.1
8.8
6.8
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Page 56 of 294
Table 4-32 Frequency of newborn abnormalities, Kansas City, Mo, 2007
Frequency1
Infants Percent
Abnormality
Anemia, Hct <39/Hgb <13
31
Birth injury
11
Fetal alcohol syndrome
0
Hyaline membrane disease/RDS
52
1
0.4
0.1
0.0
0.6
Abnormal conditions of the
newborn
For 2007, the distribution of abnormal
conditions in newborns is shown in Table 4-32.
Frequency
Infants Percent
Abnormality
Meconium aspiration syndrome
Assisted ventilation <30 min
Assisted ventilation >30 min
Seizures
8
225
133
9
0.1
2.8
1.7
0.1
Figure 4-32 Births to women who lacked a
high school education, Kansas City, Mo
23.4%
23.3% 23.2%
22.7%
22.6%
Maternal education
Women without a high school education
are more likely to have poorer birth outcomes
and engage in health compromising behaviors,
compared to women with more education. Births
to women without a high school education have
remained relatively constant in recent years
(Figure 4-32) and have been highest among
Hispanics (Figure 4-33).
22.0%
21.9%
21.8%
2000
2001
2002
2003
2004
2005
2006
2007
Figure 4-33 Births by educational attainment level of mother and race/ethnicity, Kansas City,
Mo, 2007
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
49.4%
45.9%
43.9%
24.8%
9.9%
21.3%
19.7%
12.9%
<High school
BIRTHS
31.9%
26.6%25.5%
36.2%
24.5%23.6%
23.2%
12.1%
High school
37.3%
Some college
17.0%
7.7% 6.6%
College
Page 57 of 294
ernment funds the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food
Stamps) and the Women, Infants, and Children
Nutrition plays an important role during
(WIC) food assistance program. In 2007, 30.3%
pregnancy and post-partum. Dietary or suppleof pregnant Kansas City women used food
mental intake of 0.4-0.8 mg of folic acid daily
stamps, while 48.8% received WIC assistance
protect against neural tube defects.127 Yet, there
(Figure 4-34).
are reports that disparities persist in serum foThe American Academy of Pediatrics
late values by race/ethnicity, age, and body
recommends breastfeeding for at least the first
mass among pregnant women.128 Women who
year of life, and beyond as mutually desired by
are less likely to take folic acid on a daily basis
mother and child.133 Breastfeeding is associated
are young, non-whites who have less education,
with decreased risk for many early-life diseases
less income and no health insurance than
and conditions, including otitis media, respiratory
whites.129 In 2005-2006, the prevalence of low
tract infections, atopic dermatitis, gastroenteritis,
red blood cell folate (<140 ng/mL) among womtype 2 diabetes, sudden infant death syndrome,
en of childbearing age was 4.5%, while the preand obesity.134 For maternal outcomes, a history
valence of low serum folate (<3 ng/mL) was
of lactation was associated with a reduced risk
0.5%.130 Women’s knowledge concerning the
of type 2 diabetes, breast, and ovarian cancer.
importance of folic acid supplements may be
Early cessation of breastfeeding or not breastdeclining.131
feeding was associated with an increased risk of
Preconceptional folate supplementation
maternal postpartum depression. It has been
is associated with a 50-70% reduction in the inreported that children who were ever breastfed
cidence of early spontaneous preterm birth.132
have a lower risk of dying in the postnatal period
The risk of early spontaneous preterm birth dealthough the situation is unclear in developed
creases as the duration of preconceptional folate
countries.
supplementation increases. Preconceptional
According to CDC, the percentage of infolate supplementation has no demonstrable
fants who were ever breastfed increased from
effect on other complications of pregnancy.
60% among infants who were born in 1993-1994
To improve nutrition, the federal govto 77% among those born in 2005-2006.135
Breastfeeding
rates increased
Figure 4-34 Pregnant women who received supplemental food assistance,
significantly
among nonWhite, non-Hispanic
Black, non-Hispanic
Hispanic
Hispanic black
Asian
Native American
Other/not listed
women to 65% in
2005-2006. Rates
70.9% 68.5%
62.2%
were significantly
56.3%
53.9%
higher among
43.2%
35.4%
31.7%
those with higher
25.5%
16.6%
16.6% 18.3%
income (74%)
compared with
those who had
WIC
SNAP
lower income
(57%). And,
Maternal nutrition and breastfeeding
BIRTHS
Page 58 of 294
breastfeeding rates among mothers >30 years
old were significantly higher than those of
younger mothers.
Prior studies demonstrated that younger
women and those with limited socioeconomic
resources are more likely to stop breastfeeding
within the 1st month usually citing sore nipples,
inadequate milk supply, infant having difficulties,
and the perception that the infant was not satiated.136 Newer data showed no significant
change in the rate of breastfeeding at 6 months
of age for infants born between 1993 and 2004.
Exclusive breastfeeding is defined as an
infant receiving only breast milk and no other
liquids or solids except for drops or syrups containing vitamins, minerals, or medicines. In
2007, Healthy People 2010 objectives for
breastfeeding were updated to include two new
objectives (objectives 16-19d and 16-19e) on
exclusive breastfeeding; to increase the proportion of mothers who exclusively breastfeed their
infants through age 3 months to 60% and
though age 6 months to 25%. Rates for breastfeeding initiation and duration have increased
nationally in recent years, but in 2004 the rates
for exclusive breastfeeding through 3 months
and 6 months were 30.5% and 11.3%, respectively, well below the new 2010 objectives.137
Only five states meet all the Healthy People
2010 breast feeding objectives and Missouri is
not one of the five.138
Maternal deaths
The World Health Organization defines a
maternal death as the death of a woman while
pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and the
site of the pregnancy, from any cause related to
or aggravated by the pregnancy or its management but not from accidental or incidental causes. This is the definition used by the National
Center for Health Statistics and followed here.
Nationally, the risks of dying from comBIRTHS
plications of pregnancy declined from approximately 850 maternal deaths per 100,000 live
births in 1900 to 7.5 in 1982. However, since
1982, no further decrease has occurred. In
2003, the rate was 12.1 (non-Hispanic blacks
had a rate of 30.5 and non-Hispanic whites 8.7
and both rates were increased from those in
2002).139 Women who have multifetal pregnancies are at a greater risk of dying than women
who have only a single fetus irrespective of age,
race, marital status, and educational level.140 It is
estimated that approximately 40% of deaths
(those due to hemorrhage and complications of
chronic diseases) are preventable.141
The Healthy People 2010 objective for
pregnancy-related mortality is no more than 3.3
maternal deaths per 100,000 live births. Pregnancy-related deaths are uncommon in Kansas
City, yet the maternal mortality rate currently is
4.0 times higher than the Healthy People 2010
objective. There were 5 deaths and 37,247 total
live births between 2003 and 2007, for a maternal mortality rate of 13.1 per 100,000 births.
Four of the deaths were among non-Hispanic
black women and one was a non-Hispanic white
woman. The maternal mortality rate for nonHispanic black women in Kansas City was 29.5
compared to 6.1 for non-Hispanic white women.
The disparity ratio was 4.8 and reflects what has
been observed nationally, namely non-Hispanic
black women are more likely to die from pregnancy-related causes than women of other racial/ethnic groups. It is believed that among
women with pregnancy complications there are
racial differences in severity of disease, comorbidities, and care status that place non-Hispanic
black women are at greater risk of pregnancyrelated death.142 143
The maternal mortality rate is probably
an underestimate based on a report from Maryland that found 38% of pregnancy-related
deaths were not indicated as a maternal death
on the death certificates.144 At least half of the
unreported deaths were among women who
were undelivered at the time of death, expe-
Page 59 of 294
rienced a fetal death or therapeutic abortion,
died more than a week after delivery, or died as
a result of a cardiovascular disorder.
16
Galson SK. Preterm birth as a public health initiative. Public Health Rep 2008;123:548-550.
17
Engle WA et al. “Late-preterm” infants: a population at risk.
Pediatrics 2007;120:1390-1401.
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Task Force Recommendation Statement. Ann Intern Med
2009;150:626-631.
128
Lawrence JM et al. 2006. Do racial and ethnic differences
in serum folate values exist after food fortification with folic
acid? Am J Obstet Gynecol 194:520-526.
129
Sharp GF et al. Assessing awareness, knowledge and
use of folic acid in Kansas women between the ages of 18
rd
and 44 years. Matern Child Health J 2008;12:Sept 23 epub
ahead of print.
130
139
Hoyert DL. Maternal mortality and related concepts. Vital
Health Stat 2007;3(33). www.cdc.org/nchs
140
MacKay A et al. Pregnancy-related mortality among
women with multifetal pregnancies. Obstet Gynecol
2006;107:563-568.
141
Berg CJ et al. Preventability of pregnancy-related deaths:
results of a state-wide review. Obstet Gynecol
2005;106:1228-1234.
142
Harper M et al. Why African-American women are at
greater risk for pregnancy-related death. Ann Epidemiol
2007;17:180-185.
143
Tucker MJ et al. The black-white disparity in pregnancyrelated mortality from 5 conditions: differences in prevalence
and case-fatality rates. Am J Public Health 2007;97:247-251.
144
Horon IL. Underreporting of maternal deaths on death
certificates and the magnitude of the problem of maternal
mortality. Am J Public Health 2005;95:478-482.
McDowell MA et al. Blood folate levels: the latest
NHANES results. NCHS Data Brief 2008;6.
www.cdc.gov/nchs
131
Lindsey LLM et al. 2005. Use of dietary supplements
containing folic acid among women of childbearing age –
United States, 2005. MMWR Morb Mortal Wkly Rep 54:955958.
132
Bukowski R et al. Preconceptional folate supplementation
and the risk of spontaneous preterm birth: a cohort study.
PLoS Med 2009;6:e1000061.
133
American Academy of Pediatrics. Breastfeeding and the
use of human milk. Pediatrics 2005;115:496-506.
134
Ip S et al. Breastfeeding and maternal and infant health
outcomes in developed countries. US Department of Health
and Human Services, 2007.
www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
135
McDowell MM et al. Breastfeeding in the United States:
findings from the National Health and Nutrition Examination
Surveys, 1999-2006. NCHS Data Brief 2008;5.
www.cdc.gov/nchs
136
Ahluwalia IB, Morrow B, Hsia J. 2005. Why do women
stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics 116:14081412.
137
Scanlon KS et al. Breastfeeding trends and updated national health objectives for exclusive breastfeeding – United
States, birth years 2000-2004. MMWR Morb Mortal Wkly
Rep 2007;56:760-763.
138
DiGirolamo AM et al. Breastfeeding-related maternity
practices at hospitals and birth centers – United States,
BIRTHS
Page 65 of 294
5. Fetal and Infant Mortality – Kansas City Health Commission Priority
national fetal mortality rate (FMR) in 2005 was
6.2 per 1,000 fetal deaths and live births, and
holding steady since 2003.6
In 2007, pregnant Kansas City residents
experienced 37 registered fetal deaths and
2,190 abortions (Figure 5-2). Women <20 years
old experienced 18.9% of the fetal deaths, those
20-34 years old accounted for 64.9%, and women >35 years old for 16.2% (Figure 5-3 and Table 5-1). The rates of fetal death per 1,000 live
births were 7.2 for women of other/not listed
race/ethnicity, 6.2 for non-Hispanic blacks, 4.5
Fetal mortality
for non-Hispanic whites, 3.9 for Asians, and 0.8
Fetal death or stillbirth is one of the most
for Hispanics. For the period 2003-2007, there
common adverse pregnancy outcomes, compliwere 212 fetal deaths to Kansas City women for
cating 1 in 160 deliveries in the United States.1
an average of 42 each year and the distribution
Fetal deaths can occur for many reasons (Figure
of those deaths by race/ethnicity and gestational
5-1).2 3 In the US, only fetal deaths at >20 weeks
age are presented in Figure 5-4. Male fetuses
gestation or a birthweight >350 grams are rerepresented 53.5% of the fetal deaths for a sex
quired to be registered and approximately
ratio of 1.15:1 (Table 5-2).
25,000 are reported annually. These deaths
Since 1970 rates of stillbirth at >20
nearly equal the number of infant deaths that
weeks of gestation have declined by more than
occur each year, accounting for 49% of all fetal
50% in the US,7 yet non-Hispanic blacks have
th
and infant deaths that occur between the 20
an increased risk of stillbirth compared to nonweek of pregnancy and the 1st year of life.4 5 The
Hispanic whites.8 Nationally, the risk of stillbirth
is highest among
mothers <20 years
old and those >35
Figure 5-1 Causes of fetal deaths (from: Fretts RC, Usher, RH. Obstet Gynecol
1997;89:40-45)
years of age.9 There
are data that sugUnexplained
25.0%
gest women, who
Other
17.0%
give birth to small
Intrauterine growth restriction
15.0%
babies, whether
Abruption
15.0%
prematurely or not,
Anomalies
10.0%
are more likely to
Infection
9.0%
have stillborns durDiabetes
4.0%
ing their next pregHypertension
3.0%
nancy10 and that
women who wait at
Labor
2.0%
FETAL & INFANT DEATHS
Page 66 of 294
Although the risk for fetal death
has declined nationally since the 1950s,
disparities in the risk for fetal death by
race/ethnicity persist.13 14 15 Therefore,
8,011
7,858
7,574
7,442
7,252
2,414
2,252
2,204
2,190
2,074
one of the Healthy People 2010 health
objectives is to reduce deaths among
46
45
43
41
37
fetuses >20 weeks gestation to a FMR
of 4.1 for all racial/ethnic populations.
Nationally, non-Hispanic black
women have a FMR approximately
2003
2004
2005
2006
2007
Live births
Fetal deaths
Abortions
double that for any other group. The
reason for this disparity is multifactorial
and the subject of ongoing research.
Higher rates persist among non-Hispanic black
Figure 5-3 Distribution of fetal deaths by
age of mother, Kansas City, Mo, 2007
women with adequate prenatal care.16
In Kansas City the Healthy People 2010
9
9
target has not been achieved by non-Hispanic
6
6
blacks and Asians (Table 5-3). Compared to
5
non-Hispanic whites, non-Hispanic blacks were
1
1
2.0 times more likely to experience a fetal death
0
and Asians were 1.3 times more likely. Hispan10-14 15-17 18-19 20-24 25-29 30-34 35-39 =>40
ics, on the other hand had a 31% lower risk of
fetal death.
Table 5-4 shows the FMRs for nonHispanic whites and non-Hispanic blacks by
Table 5-1 Ratio of live births to fetal
gestational age. Although non-Hispanic blacks,
deaths by age of mother, Kansas City,
overall, had a significantly higher FMR than nonMo, 2007
Ratio
Hispanic whites, that disparity does not manifest
live
itself until later in gestation. An analysis of FMR
Live
Fetal
births:fetal
for the counties of Clay, Jackson, and Platte,
Age
births
deaths1
deaths
and using 10 years worth of data, found that
10-14 y
17
0
15-17 y
349
1
349.0:1
non-Hispanic blacks were not disadvantaged
18-19 y
652
6
108.7:1
until about the 32nd week of gestation; prior to
20-29 y
4,508
18
251.0:1
that time, non-Hispanic whites were either dis30-39 y
2,350
11
213.6:1
advantaged or the rates are not significantly dif>40 y
134
1
134:1
ferent.17
Total
8,010
37
216.5:1
1
There are reports in the literature that
Mother’s age not recorded on one birth certificate
women who have late fetal deaths die earlier in
life than women who do not have fetal deaths.18
least 6 years after giving birth to another baby
This could not be assessed for Kansas City
may be at higher risk of having a stillborn child.11
women. Also, the literature reports a small inThe risk of miscarriage (spontaneous abortion)
creased risk for stillbirth following a previous
increases significantly when both parents are
small-for-gestational age (SGA) birth, particularsmokers.12
ly if that birth was preterm.19
Figure 5-2 Live births, fetal deaths, and abortions,
Kansas City, Mo
Page 67 of 294
Table 5-2 Sex ratios by race/ethnicity for fetal deaths, Kansas City, Mo1
Year
White, nonHispanic
M
F
Black, nonHispanic
M
F
Hispanic
M
F
M
2
1
1
3
0
7
2
0
1
1
1
5
2003
6
4
18
9
2004
8
4
12
9
2005
10
4
16
11
2006
7
8
8
11
2007
7
9
5
13
Total
38
29
59
53
Sex ratio
1.31:1
1.11:1
1
Three fetuses did not have sex recorded
F
Native
American
M
F
Other/Not
listed
M
F
0
0
1
0
0
1
0
0
0
0
0
0
0
1
1
0
1
3
Asian
1
4
1
4
1
11
0.63:1
5.00:1
0
0
0
0
0
0
0:0
0
2
0
1
0
3
1.00:1
Table 5-3 Race/ethnicity specific fetal mortality rates (FMR) per 1,000 fetal
deaths and live births, Kansas City, Mo, 2003-2007
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/Not listed
Total
Fetal deaths
Live births
Fetal deaths
+
live births
69
113
18
6
0
6
212
16,438
13,584
6,291
1,066
253
641
38,273
16,507
13,697
6,309
1,072
253
647
38,485
FMR
4.2
8.2
2.9
5.6
0.0
9.3
5.5
Table 5-4 Gestational age specific fetal death rates (FMR) per 1,000 fetal deaths and live births
for non-Hispanic whites and non-Hispanic blacks, Kansas City, Mo, 2003-2007
Gestational age
20-23 weeks
24-32 weeks
33-36 weeks
>37 weeks
Not listed
All ages
Race
Fetal deaths
Live births
Fetal deaths
+
live births
White, non-Hispanic
Black, non-Hispanic
White, non-Hispanic
Black, non-Hispanic
White, non-Hispanic
Black, non-Hispanic
White, non-Hispanic
Black, non-Hispanic
White, non-Hispanic
Black, non-Hispanic
White, non-Hispanic
Black, non-Hispanic
20
38
21
33
10
16
15
16
3
10
69
113
17
74
257
441
1,145
1,205
14,751
11,796
263
68
16,438
13,584
37
112
278
474
1,155
1,221
14,766
11,812
266
78
16,507
13,697
FMR
540.5
339.3
75.5
69.6
8.7
13.1
1.0
1.4
11.3
128.2
4.2
8.2
Page 68 of 294
Infant mortality
Table 5-5 Infant mortality rates (IMR) by
Infant mortality is a complex and multifactorial problem that has proved resistant to
intervention efforts.20 The national infant mortality rate (IMR) has not changed significantly since
2000.21 The rate was 6.89 in 2000 and 6.77 in
2007.22 While the rate of fetal mortality in the US
is similar to that in Canada, the US has a significantly higher infant mortality rate.23 And, for infants born <24 weeks gestation there has been
no change in the mortality rate despite improvements in medical care.24
Race/ethnicity
Births
Deaths
IMR
3,336
15
4.5
Black, non-Hispanic
2,916
43
14.7
Hispanic
1,322
6
4.5
Asian
251
0
0.0
Native American
48
0
0.0
Other/Not listed
138
8,011
1
65
7.2
8.1
White, non-Hispanic
Total
for both non-Hispanic whites and Hispanics
were 4.5 while for non-Hispanic blacks it was
14.7 (Table 5-5). There was one death with no
race/ethnicity listed and there were no infant
deaths among Asians or Native Americans.
The Healthy People 2010 objective is an
IMR of 5.0; Kansas City’s 2007 IMR was 62%
higher than the national objective. However, the
rates for non-Hispanic whites over the last 10
years have fluctuated around the Healthy
People 2010 objective, dipping below 5.0 on
four different occasions (1998, 2001, 2005,
2007) (Figure 5-6). The non-Hispanic black IMR,
on the other hand, remained consistently 2-3
times higher than the Healthy People 2010 objective. The annual disparity ratio in IMR between non-Hispanic whites and non-Hispanic
blacks averaged 2.7 over the past 10 years. This
disparity ratio is highest among women who
were college graduates even though this group
Trends and 2007
Less than 1% of infants born in Kansas
City die within their first year of life. Despite this
low percentage, the IMR is considered one of
the basic measures of the community’s health.
The rate ignores the fact that not all infants who
die during a calendar year were born in that calendar year and assumes that deaths balance
out over time. The IMR is calculated by dividing
the number of deaths among infants <1 year of
age by the number of live births for the year and
then multiplying by 1,000 live births.
In 2007, the overall IMR in Kansas City
declined to 8.1 from 9.4 in 2006, but the decrease was not statistically significant (Figure 55). There were 65 infant deaths recorded in
2007 compared to 74 the prior year. The IMRs
Figure 5-5 Infant mortality rates per 1,000 live births for Missouri and Kansas City, 1998-2007
MO
KC
10.2
9.4
8.6
8.3
8.2
7.9
7.5
7.6
7.2
1998
1999
8.5
2000
7.4
2001
2002
8.1
7.3
7.8
7.7
8.2
2003
7.5
7.5
7.4
2004
2005
2006
2007
Page 69 of 294
Figure 5-6 Infant mortality rates per 1,000 live births for non-Hispanic whites and non-Hispanic
blacks, Kansas City, Mo, 1998-2007
White, non-Hispanic
14.5
15.6
Black, non-Hispanic
14.7
13.0
12.9
10.6
4.2
1998
5.7
6.0
1999
2000
6.8
6.4
12.8
11.6
Births
Deaths
IMR
4.5
4.3
4.2
2001
2002
2003
Zip Code
Births
2004
Deaths
2005
IMR
64101
0
64134
429
4
9.3
64102
0
64136
37
0
0.0
64105
30
0
0.0
64137
204
1
4.9
64106
158
1
6.3
64138
231
2
8.7
64108
136
0
0.0
64139
20
0
0.0
64109
183
3
16.4
64145
40
0
0.0
64110
278
6
21.6
64146
9
0
0.0
64111
235
2
8.5
64147
32
1
31.3
64112
54
1
18.5
64149
1
0
0.0
64113
173
1
5.8
64151
253
1
4.0
64114
343
1
2.9
64152
120
1
8.3
64116
155
1
6.5
64153
62
0
0.0
64117
227
1
4.4
64154
124
0
0.0
64118
363
1
2.8
64155
341
1
2.9
64119
308
4
13.0
64156
69
1
14.5
64120
8
0
0.0
64157
319
1
3.1
64123
290
1
3.4
64158
79
0
0.0
64124
357
4
11.2
64160
0
64125
58
0
0.0
64161
2
0
0.0
64126
171
1
5.8
64163
4
0
0.0
64127
407
6
14.7
64164
0
64128
246
3
12.2
64165
0
64129
165
1
6.1
64166
1
0
0.0
64130
404
7
17.3
64167
0
64131
343
1
2.9
64192
0
64132
283
5
17.7
All Others*
8
0
0.0
64133
251
1
4.0
Total
8,011
65
8.1
* Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191,
64195, 64196, and 64199 are associated with post office box numbers; zip codes 64144,
64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197, 64198, 64944, and
64999 are associated with unique entities, and zip codes 64012, 64030, 64079, and 64081
are associated with Belton, Grandview, Platte City, and Lee’s Summit, respectively.
has the lowest IMR.
In recent years, despite improved gestational age-specific survival, the US black-white
14.7
7.6
6.1
Table 5-6 Distribution of infant deaths and infant mortality rates
(IMR) by zip code, Kansas City, Mo, 2007
Zip code
14.3
2006
2007
infant mortality gap has
widened. Yet, a recent
report suggests that this
disparity has been eliminated in Dane County,
Wi, and that this was
likely due to the convergence of two related but
independent trends:
greater survival of highrisk infants and fewer
high-risk infants being
born.25
The distribution
of infant deaths and IMR
by zip code is shown in
Table 5-6.
Infant mortality for
2003-2007
There are too
few infant deaths in any
given year to permit
meaningful epidemiological analyses of contributing factors. Consequently, the Kansas City Health Department utilizes five years of combined data.
For the years 2003 through 2007, KanFETAL & INFANT DEATHS
Page 70 of 294
sas City experienced 315 infant deaths and
38,273 live births, yielding an IMR of 8.2. Infants
born preterm were 20 times more likely to die
than those born full-term (Table 5-7). The IMR
for non-Hispanic blacks (13.2) was more than
twice that for non-Hispanic whites (5.7) and for
Hispanics (5.1). Male infants had an IMR (8.7)
that was 13% higher than that of female infants
(7.7) (Table 5-8). The distribution of infant
deaths by zip code is shown in Table 5-9.
Infant mortality in Kansas City was not
evenly distributed across the community. Infants
born in zip codes with lower median family income levels had higher mortality rates (Figure 57). And, of the seven Health Zones utilized by
the Kansas City Health Department, the Jackson02 and Jackson03 zones had the highest
IMRs (Figure 5-8). Given the distribution and
demographics of the various racial/ethnic groups
that comprise the population, this finding was
not surprising.
Timing of infant deaths
Infant deaths are categorized as occurring in the neonatal period (first 27 days of life)
or the postneonatal period (28th to the 365th day
of life). The neonatal period is further subdivided
into early (days 0-6) and late (days 7-27). Over
the five year period, 70% of the infant deaths in
Kansas City occurred during the neonatal period
(Table 5-10). The majority of the neonatal
deaths (83.4%) occurred in the early neonatal
period. Among very preterm and very low birthweight infants >72% of deaths occurred during
the first day of life as opposed to term and normal birthweight infants among whom >63% of
deaths occurred in the postneonatal period (Table 5-11).
Figure 5-9 shows the disparity ratios for
non-Hispanic blacks and Hispanics compared to
non-Hispanic whites for fetal, neonatal, and
postneonatal deaths. Nationally, the racial disparity in infant mortality has widened despite an
increasing rate of low birthweight non-Hispanic
white infants.26
Table 5-7 Infant mortality rates per 1,000 live births (total, preterm, and term) by race/ethnicity
for Kansas City, Mo, 2003-2007
Births
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/Not listed
Total
16,180
13,535
6,259
1,046
247
628
37,895
Total births
Deaths
IMR
92
178
32
2
0
4
308
5.7
13.2
5.1
1.9
0.0
6.4
8.1
Preterm births
Births Deaths
IMR
1,429
1,739
471
86
18
70
3,813
56
127
24
2
0
4
213
39.2
73.0
51.0
23.2
0.0
57.1
55.9
Table 5-8 Infant mortality rates (IMR) by race/ethnicity and sex, Kansas City, Mo, 2003-2007
Race/ethnicity
Births
Males
Deaths
IMR
Births
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/Not listed
Total
8,479
6,806
3,174
557
134
306
19,456
48
100
16
1
0
4
169
5.7
14.7
5.0
1.8
0.0
13.0
8.7
7,958
6,778
3,117
509
119
335
18,816
Females
Deaths
48
80
16
1
0
0
145
IMR
6.0
11.8
5.1
2.0
0.0
0.0
7.7
Full-term births
Births Deaths
IMR
14,751
11,796
5,788
960
229
558
34,082
36
51
8
0
0
0
95
2.4
4.3
1.4
0.0
0.0
0.0
2.8
Causes of infant
death
Since 2000, the
national, Missouri, and
Kansas City IMRs have
been leveling off and
this, in part, has been
attributed to an increase
Page 71 of 294
all infant deaths in
this country occur
among the 2% of
Zip code
Births
Deaths
IMR
Zip Code
Births
Deaths
IMR
64101
1
0
0.0
64134
1,995
17
8.5
infants born at <32
64102
1
0
0.0
64136
126
1
7.9
weeks gestation.29
64105
121
0
0.0
64137
829
9
10.9
64106
734
7
9.5
64138
1,066
8
7.5
Still, infant mortality
64108
663
4
6.0
64139
69
0
0.0
rates for moderately
64109
931
12
12.9
64145
198
1
5.0
64110
1,303
15
11.5
64146
58
0
0.0
preterm infants (3264111
1,169
11
9.4
64147
117
4
34.2
36 weeks gestation)
64112
320
2
6.2
64149
13
0
0.0
were three times
64113
936
2
2.1
64151
1,338
11
8.2
64114
1,515
7
4.6
64152
592
2
3.4
those for term; 3.9
64116
772
4
5.2
64153
316
2
6.3
times higher in
64117
1,187
9
7.6
64154
479
3
6.3
64118
1,779
8
4.5
64155
1,565
10
6.4
Kansas City during
64119
1,382
12
8.7
64156
190
1
5.3
2003-2007. Nation64120
35
0
0.0
64157
1,253
3
2.4
64123
1,420
9
6.3
64158
455
0
0.0
al data show that
64124
1,842
18
9.8
64160
0
moderately preterm
64125
301
2
6.6
64161
12
0
0.0
infants have higher
64126
864
4
4.6
64163
18
0
0.0
64127
2,082
18
8.6
64164
8
0
0.0
mortality rates than
64128
1,128
17
15.1
64165
2
0
0.0
term infants
64129
863
4
4.6
64166
4
0
0.0
64130
1,929
26
13.5
64167
1
0
0.0
throughout infan64131
1,721
10
5.8
64192
1
0
0.0
cy.30 31 Applying the
64132
1,372
26
19.0
All Others*
77
7
90.9
64133
1,120
9
8.0
Total
38,273
315
8.2
same criteria to in* Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191, 64195,
fant deaths in Kan64196, and 64199 are associated with post office box numbers; zip codes 64144, 64170, 64180,
sas City resulted in
64183, 64184, 64185, 64187, 64193, 64194, 64197, 64198, 64944, and 64999 are associated
with unique entities, and zip codes 64012, 64030, 64079, and 64081 are associated with Belton,
a slightly higher
Grandview, Platte City, and Lee’s Summit, respectively.
overall percent of
deaths being attributed to preterm related causes; Hispanics had
Figure 5-7 Annualized infant mortality
the highest rate (Figure 5-10).
rates per 1,000 live births by zip code meThe etiology of preterm births is heterodian family income, Kansas City, Mo,
geneous,
resulting from spontaneous delivery,
2003-2007
maternal-fetal conditions necessitating medical
intervention, or elective cesarean deliveries.
Preeclampsia, fetal distress, small-for2.1
1.4
gestational age, and placental abruption are the
1.0
0.4
most common indications for a medical intervention resulting in a preterm birth.32 Preterm birth is
$20-39,999
$40-59,999
$60-79,999
$80-99,999
associated with lower birthweights, particularly
the more preterm the birth.33 To close the disparity in infant mortality between non-Hispanic
in preterm and low birthweight births.27 Accordblacks and non-Hispanic whites will require iming to the National Center for Health Statistics, in
proved prevention of extremely preterm birth
2005, 36.1% of all infant deaths in the US were
among black infants.34
preterm-related and prematurity was the most
Of the infants who died in Kansas City
frequent cause of infant death.28 About 55% of
between 2003 and 2007, 69.2% were born preTable 5-9 Distribution of infant deaths and infant mortality rates (IMR) by
zip code, Kansas City, Mo, 2003-2007
Page 72 of 294
1.9%, respectively, of births but 58.4% and
58.6%, respectively, of infant deaths. Consequently, infants who were very preterm
or who had very low birthweights had
IMRs 82.3 and 98.9 times higher, respectively, than term or normal weight infants.
Nationally, there is concern that infants
with extremely low birthweights are more
likely not have their death registered because of the often short life spans of these
infants and the potential for their deaths to
be misclassified as fetal deaths.35
Table 5-13 shows the causes of
death for the 325 infants, while Table 5-14
shows those causes by birth gestational
period. Disorders related to short gestation
and low birthweight were the single leading cause of death, accounting for 30.5%
of deaths. Congenital malformation, deformations, and chromosomal abnormalities were the 2nd leading cause accounting
for 19.4% of the deaths. And, sudden infant death syndrome (SIDS) was the 3rd
leading cause accounting for 9.5% of the
deaths. These three causes contributed to
nearly 60% of all infant deaths in Kansas
City over the 5-year period.
Nationally, birth defects are the
leading
cause of infant deaths based on
term and 72.0% had low birthweights (Table 5death certificate submissions,36 and the afore12). Very preterm infants as well as infants with
mentioned preterm birth-low birthweight combivery low birthweight accounted for 2.1%, and
nation is second. A reexamination of the data
led to the ascendancy of
prematurity to the number
Table 5-10 Neonatal and postneonatal infant mortality rates per
one cause.
1,000 live births, Kansas City, Mo, 2003-2007
Among infants in the
Neonatal
Postneonatal
US with birth defects, anen(<28 days)
(28-365 days)
cephaly, trisomy 13, and
Race/ethnicity
Births
Deaths
Rate
Deaths
Rate
trisomy 18 were the three
White, non-Hispanic
16,438
72
4.4
24
1.5
leading conditions related to
Black, non-Hispanic
13,584
118
8.7
62
4.6
Hispanic
6,291
25
4.0
8
1.3
in-hospital mortality.37 The
Asian
1,066
2
1.9
0
0.0
abnormalities associated
Native American
253
0
0.0
0
0.0
with these conditions genOther/not listed
641
4
6.2
0
0.0
erally are not compatible
Total
38,273
221
5.8
94
2.5
Figure 5-8 Infant mortality rates per 1,000 live births
by the Kansas City Health Department’s Health
Zones, 2003-2007
Page 73 of 294
with more than a few months of life and generally life sustaining measures are not recommended. In Kansas City, approximately 1.3% of infants each year are born with a congenital malformation, deformation, or chromosomal abnormality and this does not vary significantly between racial/ethnic groups. A listing of the affected body systems in fatal cases for 20032007 is provided in Table 5-15. Maternal obesity
is associated with an increased risk of congenital anomalies.38
Sudden infant death syndrome (SIDS),
the third leading cause of death for Kansas City
infants, accounted for 9.5% of deaths; 83% of
the SIDS deaths occurred among term gestation
infants. The trend in SIDS deaths per 1,000 live
births is shown in Figure 5-11. However, there
were no deaths from SIDS in 2007. This appears to be related to the change in medical examiners and the application of CDC’s the Sudden Unexpected Infant Death Investigation
(SUIDI) criteria.39 Thus, for the first time, Kansas
City’s rate was below the Healthy People 2010
objective of 0.25. During 2007, the Missouri
Child Fatality Review Program reviewed 127
sudden, unexpected deaths of infants and determined that 15 were as SIDS, 59 unintentional
suffocation, 25 illness/natural causes, and 23
could not be determined.40
The fourth leading cause of death was a
constellation of causes related to the pregnancy
itself, including maternal complications of preg-
Figure 5-9 Disparity ratios for nonHispanic black and Hispanic fetal deaths,
neonatal infant deaths, and post-neonatal
infant deaths compared to non-Hispanic
whites, Kansas City, Mo, 2003-2007
Non-Hispanic blacks
Hispanics
3.07
2.00
1.95
0.91
0.69
Fetal
Neonatal
0.87
Post-neonatal
Figure 5-10 Percent of infant deaths in
Kansas City, Mo, for the years 2003-2007,
attributed to preterm related causes as
defined by the National Center for Health
Statistics
42.9%
48.9%
51.5%
Black, nonHispanic
Hispanic
29.2%
Total
White, nonHispanic
nancy, complications of the placenta, cord, and
membranes,
Table 5-11 Timing of infant deaths by gestation and by birthweight, Kansas City,
intrauterine
Mo, 2003-2007
hypoxia
Days until death
and birth
Births
Deaths
IMR
<1
1-6
7-27
28-365
Survivors
asphyxia,
Gestation (weeks)
<32
781
180
230.5
133
17
10
20
76.9%
and birth
32-36
3,032
33
10.9
6
9
5
13
98.9%
trauma.
>37
34,082
95
2.8
9
11
15
60
99.7%
Total
Birthweight (grams)
<1,500
1,500-2,499
>2,500
Total
37,895
308
8.1
148
37
30
93
99.2%
720
2,637
34,894
38,251
178
59
67
304
247.2
22.4
1.9
7.9
129
12
4
145
19
7
10
36
11
10
9
30
19
30
44
93
75.3%
97.8%
99.8%
99.2%
Page 74 of 294
Maternal characteristics
Table 5-12 Infant mortality rates per 1,000 live births based on
gestation and birthweight, Kansas City, Mo, 2003-2007
Cumulative
The 2007 report,
percent of
Births
Deaths
IMR
deaths
Dying so Young: Infant MorGestational age
tality in Kansas City, Mo,
<20 weeks
32
23
718.8
7.5
documented that being a
20-27 weeks
338
132
390.5
17.4
28-31 weeks
411
25
60.8
58.4
teenager, having less than
32-36 weeks
3,032
33
10.9
69.2
a high school education,
>37 weeks
34,082
95
2.8
100.0
Total
37,895
308
8.1
being unmarried, having an
Birthweight
unintended pregnancy, be<500 grams
110
99
900.0
32.6
ing prepregnancy obese,
500-999 grams
283
56
197.9
51.0
1,000-1,499 grams
327
23
70.3
58.6
diabetic or a smoker, re1,500-1,999 grams
633
18
28.4
64.5
ceiving inadequate or in2,000-2,499 grams
2,004
23
11.5
72.0
2,500-2,999 grams
6,968
36
5.2
83.9
termediate amounts of pre3,000-3,499 grams
14,778
31
2.1
94.1
natal care, having a multi>3,500 grams
12,148
18
1.5
100.0
fetal pregnancy, having a
Total
37,251
304
8.2
primary elective cesarean
section, delivering a prespecific approaches may be necessary to reterm infant, or having a male infant all increased
duce IMR.43
the risk that the infant would die. Given that the
report examined 2001-2005 data for the community and that those findings also were prePerinatal Mortality
sented in the Community Health Assessment
The perinatal mortality rate encom2007 report, they will not be updated here.
passes both fetal deaths and early infant deaths.
It was recently reported that obese
There is no good consensus as to which deaths
women are at
increased risk of
having their inTable 5-13 Causes of infant death, Kansas City, Mo, 2003-2007
fant die soon
Percent
Cause of death listed on death certificate
Deaths
of total
after birth,41 esDisorders related to short gestation and low birth weight
96
30.5
pecially if premaCongenital malformation, deformations, and chromosomal abnormalities
61
19.4
ture rupture of
Sudden infant death syndrome
30
9.5
Newborn
affected
by
complications
of
placenta,
cord,
and
membranes
13
4.1
the membranes
Newborn affected by maternal complications of pregnancy
11
3.5
(PROM) ocUnintentional injuries.
10
3.2
Respiratory distress of newborn
8
2.5
curs.42 In addiDiseases of the circulatory system
6
1.9
tion, it has been
Homicide
5
1.6
Bacterial sepsis of the newborn
4
1.3
proposed that
Neonatal hemorrhage
4
1.3
since maternal
Intrauterine hypoxia and birth asphyxia
4
1.3
Chronic respiratory disease originating in the perinatal period
3
1.0
sociodemoAtelectasis
2
0.6
graphic risk facPneumonia/influenza
2
0.6
tors vary by inNecrotizing enterocolitis of newborn
2
0.6
Septicemia
2
0.6
fant cause of
Gastritis, duodenitis, and noninfective enteritis and colitis
1
0.3
death and ethAll others
51
16.2
Total
315
100.0
nicity, that raceFETAL & INFANT DEATHS
Page 75 of 294
Table 5-14 Causes of infant deaths by birth gestational age, Kansas City, Mo, 2003-2007
<32
Cause of death
%
95
99.0
0
-
0
-
1
1.0
96
12
19.7
19
31.1
30
49.2
0
-
61
2
6.7
3
10.0
25
83.3
0
-
30
92.3
1
7.7
0
-
0
-
13
11
100.1
0
-
0
-
0
-
11
2
8
1
1
3
0
4
20.0
100.0
16.7
20.0
75.0
100.0
0
0
0
1
0
1
0
20.0
25.0
-
8
0
4
3
0
1
0
80.0
66.7
60.0
25.0
-
0
0
1
0
1
2
0
16.7
25.0
50.0
-
10
8
6
5
4
4
4
3
100.0
0
-
0
-
0
-
3
1
2
0
50.0
100.0
-
1
0
0
50.0
-
0
0
2
100.0
0
0
0
-
2
2
2
0
-
0
-
2
100.0
0
-
2
1
100.0
0
-
0
-
0
-
1
22
180
43.1
57.1
7
33
13.7
10.5
20
95
39.2
30.2
2
7
3.9
2.2
51
315
Table 5-15 Causes of infant death from
congenital malformations, deformations,
and chromosomal abnormalities, Kansas
City, Mo, 2003-2007
Affected body system
Total
12
should be included; therefore the National Center for Health Statistics employs two different
definitions for calculation of the rate. Perinatal
definition 1 includes infant deaths of less than 7
days of age and fetal deaths of 28 weeks of gestation or more. Perinatal definition 2 is the more
inclusive definition, and includes infant deaths of
Chromosomal anomalies
Circulatory system
Nervous system
Musculoskeletal system
Respiratory system
Gastrointestinal system
Urinary system
Other congenital malformations
Total
Not listed
No.
%
No.
Disorders related to short gestation and
low birth weight
Congenital malformation, deformations,
and chromosomal abnormalities
Sudden infant death syndrome
Newborn affected by complications of placenta, cord, and membranes
Newborn affected by maternal complications of pregnancy
Unintentional injuries
Respiratory distress of newborn
Diseases of the circulatory system
Homicide
Neonatal hemorrhage
Intrauterine hypoxia and birth asphyxia
Bacterial sepsis of the newborn
Chronic respiratory disease originating in
the perinatal period
Atelectasis
Necrotizing enterocolitis of newborn
Septicemia
Pneumonia/influenza
Gastritis, duodenitis, and noninfective enteritis and colitis
All others
Total
Gestational age (weeks)
32-36
>37
No.
%
No.
%
Frequency
14
18
11
4
2
1
1
10
61
less than 28 days of age and fetal deaths of 20
weeks or more. Both rates are expressed as per
1,000 live births plus fetal deaths.
Perinatal definition 1 is preferred for international comparisons due to differences
among countries in completeness of reporting of
fetal deaths of 20–27 weeks of gestation. Perinatal definition 2 is useful for monitoring perinatal mortality throughout the gestational age spectrum, as the majority of fetal deaths occur before
28 weeks of gestation.
Figure 5-12 displays perinatal mortality
rates for Kansas City calculated by both methods and compares them to national rates for
2005 (the most recent year available). The Kansas City rates are very comparable to those reported nationally.
Page 76 of 294
Hispanic whites, the deaths were distributed differently between the two groups with low birthweight being the greatest contributing factor for
1.8
Hispanics. Additionally, over time, PPOR demonstrated improvements in excess fetal-infant
1.1
1.1
1.0
1.0
1.0
mortality for both non-Hispanic whites and non0.8
Hispanic blacks, but the rates of improvement
were disparate and the disparity ratio for non0.0
Hispanic blacks continued to widen. And, geographically, there were differences between
2000 2001 2002 2003 2004 2005 2006 2007
eastern and western Jackson County
in the distribution of excess fetalinfant mortality suggesting that difFigure 5-12 Perinatal mortality rates by definition 1 and
ferent types of intervention might be
definition 2, Kansas City, Mo
required in each portion of the counUS 05 KC 05 KC 06 KC 07
ty.
12.5
Figure 5-11 Sudden infant death syndrome (SIDS) rates per 1,000 live births,
Kansas City, Mo
10.7
10.7
9.1
6.6
7.2
10.0
6.9
Definition 1
Definition 2
Perinatal Periods of Risk
The Kansas City Health Department
employs a technique known as Perinatal Periods
of Risk (PPOR) to examine fetal-infant mortality
that provides more in-depth understanding about
the factors associated with fetal and infant mortality. PPOR has been applied to fetal-infant
deaths in Kansas City proper,44 45 the portion of
Kansas City within Jackson County compared to
the balance of Jackson County,46 and to the 5county area of Clay, Jackson, Platte, Johnson
and Wyandotte.47 Those analyses demonstrated
that the excess fetal-infant mortality experiences
of Hispanics and non-Hispanic whites are similar
and significantly different from that of nonHispanic blacks. Despite the similarities in
excess death rates between Hispanics and nonFETAL & INFANT DEATHS
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Silver RM. Fetal death. Obstet Gynecol 2007;109:153-167.
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Fretts RC, Usher RH. Causes of fetal death in women of
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MacDorman MF, Kirmeyer S. The challenge of fetal mortality. NCHS Data Brief 2009;16:April. www.cdc.gov/nchs
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Martin JA, Hoyert DL. The national fetal death file. Semin
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Donohue PK et al. Intervention at the border of viability.
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Alexander GR et al. The increasing racial disparity in infant
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MacDorman MF et al. Trends in preterm-related infant
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Matthews TJ, MacDorman MF. Infant mortality statistics
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Callaghan WM et al. The contribution of preterm birth to
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Allen CL et al. 2005. The influence of race on fetal outcome. Am J Perinatol 22:245-248.
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Paulson J et al. Unregistered deaths among extremely low
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Cai J et al. Perinatal periods of risk: analysis of fetal-infant
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45
Guillory VJ et al. Secular trends in excess fetal and infant
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46
Cai J et al. Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri. J Public Health Manage
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Page 79 of 294
6. Deaths
death rates declined significantly between 2006
and 2007 and life expectancy reached a record
high of 77.9 years.1 The 2007 age-adjusted
death rate was 760.3 deaths per 100,000 population, a record low. In addition, death rates for 8
of the 15 leading causes of death in the US
dropped significantly in 2007; only deaths from
chronic lower respiratory diseases increased in
2007.
In 2007, the number of Kansas City residents who died was 3,698 (Figure 6-1). The
majority of deaths occurred among non-Hispanic
whites and non-Hispanic blacks (Table 6-1) and
the percent of total deaths attributed to each
group continues to narrow (Figure 6-2). Of the
deaths, 77.4% occurred in the Jackson County
portion of the city (73% of the population lives in
the Jackson County portion of Kansas City)
(Tables 6-2 and 6-3). Forty-one percent of the
deaths occurred among hospitalized individuals,
25.5% occurred in nursing homes, and the balance occurred in other locations. Nine percent of
the decedents were autopsied.
Over the past 10 years, the annual ageadjusted death rate for Kansas City residents
fluctuated but declined 14.2% overall (Figure 63). The age-adjusted rate remained relatively
Death or mortality rates can be calculated
as crude rates (number of deaths/population
or subpopulation x 10,000 or 100,000) or
adjusted rates (using the year 2000 US
standard population). Both types of calculations are used in the current report. For
comparative purposes, the adjusted rates
are favored since they accommodate differences, for example, in age or race/ethnicity
composition.
Trends
In the United States, the age-adjusted
Figure 6-1 Resident deaths for Kansas City, Mo, 1990-2007
4422
4437
4429
4549
4377
4445
4273
4173
4250
4243
3992
90
91
92
93
94
95
96
97
98
99
00
3937
01
3847
02
3826
03
3745
3753
3784
04
05
06
3698
07
DEATHS
Page 80 of 294
period with the last 5
years, only nonHispanic whites and
White,
Black,
Age
nonnonNative
Other/not
non-Hispanic blacks
(years) Hispanic Hispanic Hispanic Asian American
listed
Total
experienced decreases
<1
15
43
6
1
0
1
66
1-4
3
7
2
0
0
0
12
in their age-adjusted
5-14
2
2
0
0
0
0
4
death rates, 10.3% and
15-24
17
41
6
0
2
0
66
25-34
35
45
6
0
0
1
87
2.2%, respectively (Fig35-44
78
59
7
3
1
1
149
ure 6-4). The age45-54
202
136
10
3
2
0
353
adjusted death rates for
55-64
296
199
15
2
0
1
513
65-74
327
221
24
3
4
0
579
Hispanics, Asians and
75-84
589
292
31
6
3
0
921
Native Americans in>85
711
204
20
4
3
2
944
Not
creased 8.5%. 51.8%,
4
0
0
0
0
0
4
listed
and 6.7%, respectively.
Total
2,279
1,249
127
22
15
6
3,698
The rates for Asians
and Native Americans
must be treated cautiously given the low number
Figure 6-2 Percent of total deaths by
of deaths in these groups. During 2003-2007,
race, Kansas City, Mo
non-Hispanic blacks were 52% more likely to die
White
Black
Hispanic
than non-Hispanic whites (disparity ratio for age77.7% 77.2% 75.4%
adjusted death rate of 1.52:1), while Hispanics
70.4% 67.8%
64.9% 62.5% 61.6%
were 4% more likely to die than non-Hispanic
whites (disparity ratio of 1.04).
Table 6-4 shows the age-adjusted death
31.6% 33.8% 33.8%
27.1% 29.5%
22.2% 22.5% 24.3%
rates for select causes of deaths over time. For
those causes of death for which a Healthy
1.7% 1.9% 3.0% 3.0% 3.4%
People 2010 objective exists, age-adjusted
deaths for coronary heart disease, stroke, breast
1975 1980 1985 1990 1995 2000 2005 2007
cancer and diabetes either are below or meet
the objective.
The National Association of County
Table 6-2 Deaths among Kansas City residents
and City Health Officials publish the Big Cities
by race/ethnicity and area of the City, 2007
Health Inventory reports. Those reports allow
Clay
Jackson
Platte
comparisons of selected mortality and morRace/ethnicity County County County Total
bidity data for communities of 350,000 populaWhite,
non575
1,475
229
2,279
Hispanic
tion or more, although for historical continuity
Black,
non21
1,221
7
1,249
some cities such St Louis are included despite
Hispanic
11
111
5
127
Hispanic
falling below this population threshold. The
1
18
3
22
Asian
report writers use federal and state data
4
11
0
15
Native American
sources and the numbers reported in the Big
Other/not listed
1
5
0
6
Total
613
2,841
244
3,698
Cities Health Inventory may differ from what is
reported by the local jurisdictions. Selected
age-adjusted mortality rates for 2004 (the last
constant between 2004 and 2007; approximately
year available) are presented in Table 6-5 for
15.6% higher than the national rate.
some comparable cities.
Comparing the first 5 years of this time
Table 6-1 Deaths in Kansas City, Mo, by race/ethnicity and age,
2007
DEATHS
Page 81 of 294
rates starting at birth. Tables 6-6 and 6-7 list the
number of deaths by sex, age, and race/ethnicity
Mortality patterns vary by both sex and
2
among Kansas City residents for the years 2007
race/ethnicity. Men have shorter life expectanand 2003-2007. It is not until the age of 75 years
cies than women and higher age-specific death
and older that more women die than men.
Tables 6-8 and 6-9 display the 2003-2007
age-specific death rates by sex and
Table 6-3 Age at death for Kansas City, Mo, resirace/ethnicity. The literature suggests that
dents, by area of city, 2007
Age at
Clay
Jackson
Platte
as much as 75% of the difference in
death
County
County
County
Total
ity between men and women can be attri9
55
2
66
<1 y
buted to just three causes: heart disease,
2
9
1
12
1-4 y
lung cancer, and traumatic deaths.3
1
3
0
4
5-14 y
Deaths by sex and age
15-24 y
25-34 y
35-44 y
45-54 y
55-64 y
65-74 y
75-84 y
>85 y
Not listed
Total
4
8
27
54
90
111
159
148
0
613
59
71
113
281
394
436
702
714
4
2,841
3
8
9
18
29
32
60
82
0
244
66
87
149
353
513
579
921
944
4
3,698
Figure 6-3 Age-adjusted death rates per
100,000 population, Kansas City, Mo
1024 1025 967
941
925
900
902
906
879
2003-2007
Hispanic
Asian
509
477
313
241
817
1,190
1998-2002
753
875
1,217
Figure 6-4 Age-adjusted overall death rates per
100,000 population, Kansas City, Mo
785
Of the Kansas City residents who
died during 2007, the average age at death
was 69.6 years with the median age of
death of 75.0 years (Table 6-10). The
erage and median ages of death varied by
cause of death being lowest for deaths
from homicide (33.9 years and 32.0 years,
respectively) and highest for Alzheimer’s deaths
(86.0 years and 86.0 years, respectively).
Premature deaths
901
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Hispanic
Average age of death
Native
American
Since most deaths occur among
sons in older age groups, crude and ageadjusted mortality data are dominated by the
underlying disease processes of the elderly.
One of public health’s concerns is preventable
deaths among younger age groups - deaths that
occur prior to age 65 years are termed
ture. Although many authors have emphasized the importance of the concept of premature mortality, there is no consensus on a
functional definition or the best means of
deriving a quantitative measure. Alternative
measures have been proposed to reflect the
mortality trends of younger age groups.
These measures provide a more accurate
picture of premature mortality by weighting
deaths occurring at younger ages more
heavily than those occurring in older populations, such as years of potential life lost
(YPLL). Here premature mortality will be disDEATHS
Page 82 of 294
Table 6-4 Age-adjusted rates1 for selected causes of deaths, Kansas City, Mo
Heart
disease
Year
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Yr 2010
All
deaths
1,050
1,052
1,053
1,082
1,044
1,064
1,024
1,003
1,024
1,025
967
943
928
905
900
902
906
897
All
332
320
327
332
289
303
300
299
278
279
272
243
237
227
218
201
196
185
Cancer
Coronary
257
257
251
245
248
212
224
226
218
206
198
182
161
152
152
134
134
126
166
Stroke
71
69
68
74
71
62
66
66
62
64
65
58
66
53
59
44
48
48
48
All
249
245
244
230
231
244
228
221
243
211
241
217
201
205
211
209
206
210
160
Lung
78
70
77
67
74
76
76
63
71
63
62
70
63
64
68
64
68
61
45
Motor
2
Year
CLRD
Homicide
Suicide
vehicle
Alcohol
Drug
1990
49
23
15
17
10
2
1991
44
28
18
17
11
7
1992
44
29
17
14
9
3
1993
55
29
14
17
10
2
1994
53
28
16
12
16
4
1995
54
22
14
16
13
5
1996
52
21
18
20
14
5
1997
51
19
13
16
16
7
1998
52
28
11
15
13
5
1999
56
25
18
12
16
8
2000
52
22
17
13
15
8
2001
43
22
14
14
15
8
2002
47
16
12
14
12
5
2003
42
18
10
14
11
9
2004
41
18
12
13
16
8
2005
51
24
10
15
14
7
2006
50
21
16
14
15
9
2007
49
17
15
11
11
9
Yr 2010
60
3
5
9
1
1
2
All rates rounded to nearest whole number; Chronic lower respiratory disease
cussed without any other quantitative measures.
YPLL information can be found in Section 8 of
this report.
For the period 2003-2007, 32.9% of
deaths among Kansas City residents were premature with males having a higher rate than females (41.3% and 24.6%, respectively). Non-
DEATHS
Breast
28
32
25
22
26
25
26
22
22
19
20
21
18
24
18
18
16
14
22
Diabetes
21
25
23
25
30
28
28
29
31
33
31
33
29
33
26
25
26
25
45
AIDS
18
19
27
28
26
24
17
9
9
7
8
7
4
5
9
9
5
6
1
Unintentional
injury
34
29
35
38
31
37
41
42
43
40
31
42
43
37
38
41
45
43
18
Hispanic whites had the lowest premature death
rate and Hispanics the highest (Figure 6-5). Table 6-11 provides projections for the number of
deaths and premature deaths, both with 95%
confidence intervals, for the years 2007 through
2011.
Page 83 of 294
5.4% of female deaths. The
five leading causes of death
and age-specific death rates
Cancer,
for 15-44 year old men and
breast
Diabetes
women and by race/ethnicity
27.2
25.9
are shown in Tables 6-12
30.3
25.8
23.5
21.5
and 6-13.
20.1
28.9
Improving a popula30.6
37.1
22.9
32.1
tion’s health does not guar28.8
35.6
antee that health inequities,
such as disparities in premature deaths, will improve as the magnitude of
health inequities can rise or can fall.5 Poverty
and premature mortality remain firmly linked.6
Table 6-5 Comparison of mortality rates based on Big Cities
Health Inventory 2004
Age-adjusted mortality rates for the year 2004
Kansas City
Charlotte
Denver
Indianapolis
Jacksonville
Nashville
St Louis
Overall
Heart
disease
Cancer,
overall
Cancer,
lung
912.6
973.0
841.9
1,009.1
1,061.2
899.7
1,013.2
224.8
210.1
175.4
238.6
262.3
239.7
248.7
212.0
214.9
185.8
233.4
240.7
199.7
234.4
68.7
65.5
44.3
77.6
73.6
66.5
75.5
Internationally, more men than women
<45 years of age die prematurely.4 The main
causes of death among persons 15-44 years old
are associated with lifestyle and risk taking. In
Kansas City, the annualized premature death
rate for men 15-44 years of age was 2.3 times
that for females (22.8 per 10,000 population vs
9.9). Of all deaths among men, those to men 1544 years old accounted for 12.2% compared to
Table 6-6
Mo, 2007
Males
Females
Avoidable Premature Deaths
Avoidable mortality (AM) analysis has
been used primarily in Europe as an indicator of
health system performance; it has not been
widely employed in the US, particularly in ex-
Deaths among males and females by age and race/ethnicity, Kansas City,
Age
(years)
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
White,
nonHispanic
9
1
1
11
22
50
126
185
186
286
243
4
1,124
6
2
1
6
13
28
76
111
141
303
468
0
1,155
Black,
nonHispanic
24
3
1
32
33
37
78
114
121
131
59
0
633
19
4
1
9
12
22
58
85
100
161
145
0
616
Hispanic
3
0
0
5
5
6
7
7
18
19
7
0
77
3
2
0
1
1
1
3
8
6
12
13
0
50
Asian
1
0
0
0
0
1
1
1
3
3
0
0
10
0
0
0
0
0
2
2
1
0
3
4
0
12
Native
American
0
0
0
1
0
0
1
0
3
1
0
0
6
0
0
0
1
0
1
1
0
1
2
3
0
9
Other/not
listed
1
0
0
0
1
0
0
1
0
0
0
0
3
0
0
0
0
0
1
0
0
0
0
2
0
3
Total
38
4
2
49
61
94
213
308
331
440
309
4
1,853
28
8
2
17
26
55
140
205
248
481
635
0
1,845
DEATHS
Page 84 of 294
Table 6-7 Deaths among males and females by age and race/ethnicity, Kansas City,
Mo, 2003-2007
Males
Females
Age
(years)
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
White,
nonHispanic
48
3
9
70
119
293
638
777
997
1,646
1,136
11
5,747
47
12
9
38
60
132
329
517
770
1,804
2,324
2
6,044
Black,
nonHispanic
104
17
21
184
158
226
465
508
609
646
304
2
3,244
83
14
6
48
65
141
312
381
499
796
682
0
3,027
Hispanic
16
3
4
28
32
31
31
44
50
79
29
1
348
16
4
1
6
2
8
20
29
41
62
62
0
251
amination of racial/ethnic disparities. AM is defined as causes of death that should not occur in
the presence of high-quality and timely medical
intervention and from causes that can be influenced at least partly by public health interventions and policies, (eg smoking, drunk driving,
excessive drinking, seat belt use, access to firearms).
Using established AM criteria based on
International Statistical Classification of Diseases and Related Health Problems (ICD) codes,
the Kansas City Health Department examined
avoidable premature mortality comparing 19851987 to 2005-2007. These premature deaths
were examined in terms of racial disparities between non-Hispanic whites and non-Hispanic
blacks. Hispanics and other groups were not
included due to low numbers of deaths during
1985-1987.
DEATHS
Asian
2
0
0
0
3
1
3
2
8
4
4
0
27
1
0
0
1
0
2
5
1
4
12
7
0
33
Native
American
0
0
0
1
1
1
4
5
10
3
1
0
26
0
0
1
1
0
1
5
4
3
11
8
0
34
Other/not
listed
4
0
0
2
3
1
6
11
4
4
3
0
38
1
1
1
0
2
3
2
4
8
3
6
0
31
Total
174
23
34
285
316
553
1,147
1,347
1,678
2,382
1,477
14
9,430
148
31
18
94
129
287
673
936
1,325
2,688
3,089
2
9,420
The analysis distinguished among causes that are amenable to medical care and sensitive to public health interventions and policies
directed at changing behavior. In addition,
ischemic heart disease and HIV were examined
separately because they are amenable to both
medical care and policy/behavior interventions.
Between 1985-1987 and 2005-2007, the
overall premature AM death rates, declined for
non-Hispanic white males (25.9%) and females
(23.0%) and for non-Hispanic black females
(2.4%); it rose 0.4% for non-Hispanic black
males. The overall non-Hispanic black:nonHispanic white disparity ratio for premature AM
rose from 1.2 to 1.6. This finding is consistent
with information present previously in the Health
Department’s Minority Health Indicators 2008
report (www.kcmo.org/health).
Page 85 of 294
Table 6-8 Annualized age-specific crude mortality rates for overall population, nonHispanic whites and non-Hispanic blacks per 10,000 population (Census 2000) by age
and sex, Kansas City, Mo, 2003-2007
Age
Population
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
3,283
12,822
32,026
29,862
36,079
35,498
27,154
16,185
11,671
6,933
1,628
Age
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Age
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
213,141
All males
Deaths
174
23
34
285
316
553
1,147
1,347
1,678
2,382
1,477
14
9,430
Male, white, non-Hispanic
Population
Deaths
1,498
6,744
15,382
16,454
23,568
23,083
18,722
12,817
8,347
5,272
1,254
133,141
48
3
9
70
119
293
638
777
997
1,646
1,136
11
5,747
Male, black, non-Hispanic
Population
Deaths
1,128
4,623
13,459
9,880
8,485
9,808
6,851
4,247
2,960
1,478
343
63,262
104
17
21
184
158
226
465
508
609
646
304
2
3,244
Rate
Age
106.0
3.5
2.1
19.1
17.5
31.2
84.5
166.4
287.6
687.1
1,814.5
88.5
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Rate
Age
64.1
0.9
1.2
8.5
10.1
25.4
68.2
121.2
238.9
624.4
1,811.8
86.3
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Rate
Age
184.4
7.4
3.1
37.2
37.2
46.1
135.7
239.2
411.5
874.2
1,772.6
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
102.6
The change in premature AM rates by
race and sex for the medical care and policy and
behavior categories are shown in Figure 6-6.
The rates declined for both races and sexes, but
with much less improvement in the non-Hispanic
black rates. Figures 6-7 and 6-8 more clearly
All females
Population
Deaths
3,256
12,394
30,573
30,781
36,314
35,811
29,338
18,477
15,492
11,330
4,638
228,404
148
31
18
94
129
287
673
936
1,325
2,688
3,089
2
9,420
Rate
90.9
5.0
1.2
6.1
7.1
16.0
45.9
101.3
171.0
474.5
1,332.0
82.5
Female, white, non-Hispanic
Population
Deaths
Rate
1,542
6,392
14,517
16,538
22,080
21,754
18,941
12,051
10,567
8,542
3,596
136,520
47
12
9
38
60
132
329
517
770
1,804
2,324
2
6,044
61.0
3.8
1.2
4.6
5.4
12.1
34.7
85.8
127.8
422.4
1,292.5
88.5
Female, black, non-Hispanic
Population
Deaths
Rate
1,057
4,553
13,012
11,146
10,930
11,813
8,715
5,570
4,363
2,515
943
74,617
83
14
6
48
65
141
312
381
499
796
682
0
3,027
157.0
6.1
0.9
8.6
11.9
23.9
71.6
136.8
228.7
633.0
1,446.4
81.1
show the differences in declines of premature
AM attributable to medical care and policy and
behavior. Overall, the non-Hispanic black:nonHispanic white premature AM disparity ratio rose
from 1.4 to 2.0 for medical care and from 1.4 to
3.7 for policy and behavior.
DEATHS
Page 86 of 294
Table 6-9 Annualized age-specific crude mortality rates for Hispanics, Asians, and
Native Americans per 10,000 population (Census 2000) by age and sex, Kansas City,
Mo, 2003-2007
Age
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Age
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Age
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Male, Hispanic
Population
Deaths
427
1,449
2,830
3,229
3,435
2,358
1,368
652
449
224
33
16,454
16
3
4
28
32
31
31
44
50
79
29
1
348
Male, Asian
Population
Deaths
59
223
506
778
1,110
544
412
280
106
46
5
133,141
2
0
0
0
3
1
3
2
8
4
4
0
5,747
Male, Native American
Population
Deaths
10
48
154
169
181
202
139
76
39
15
1
1,034
0
0
0
1
1
1
4
5
10
3
1
0
26
Rate
Age
74.9
4.1
2.8
17.3
18.6
26.3
45.3
135.0
222.7
705.4
1,757.6
42.3
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Rate
Age
67.8
0.0
0.0
0.0
5.4
3.7
14.6
14.3
150.9
173.9
1,600.0
86.3
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Rate
Age
0.0
0.0
0.0
11.8
11.0
9.9
57.6
131.6
512.8
400.0
2,000.0
<1
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
50.3
With ischemic heart disease, there was a
decline in premature AM rates for both whites
and blacks, but with a reversal in the non-
DEATHS
Female, Hispanic
Population
Deaths
401
1,338
2,632
2,473
2,657
1,868
1,181
674
552
287
87
14,150
16
4
1
6
2
8
20
29
41
62
62
0
251
Female, Asian
Population
Deaths
68
261
453
742
970
505
556
307
171
63
17
136,520
1
0
0
1
0
2
5
1
4
12
7
0
6,044
Female, Native American
Population
Deaths
13
45
127
184
182
214
173
64
46
26
14
1,088
0
0
1
1
0
1
5
4
3
11
8
0
34
Rate
79.8
6.0
0.8
4.9
1.5
8.6
33.9
88.7
148.6
432.1
1,425.3
35.5
Rate
29.4
0.0
0.0
2.7
0.0
7.9
17.8
6.5
46.8
381.0
823.5
88.5
Rate
0.0
0.0
15.7
10.9
0.0
9.3
57.8
131.1
130.4
846.2
1,142.9
62.5
Hispanic black:non-Hispanic white premature
AM disparity ratio (0.9 to 1.2) (Figure 6-9).
Page 87 of 294
Table 6-10 Average and median ages at time of death by selected causes of death, Kansas
City, Mo, 2007
Cause
Mean
Median
All causes
Heart disease
Stroke
Atherosclerosis
Hypertension
Other circulatory disease
Cancer, breast
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, lymphoma, non-Hodgkin
Cancer, pancreas
Cancer prostate
Cancer, stomach
Cancer, urinary tract
Cancer, all others
Diabetes
Endocrine, other
Nephritis
69.62
74.74
77.31
84.67
74.18
74.75
69.12
73.76
73.92
69.00
70.48
67.12
78.22
77.40
74.79
68.33
70.87
72.91
76.99
75.00
79.00
81.00
85.00
78.00
80.00
67.50
75.00
76.00
70.00
74.00
62.00
79.00
81.00
75.00
70.00
72.00
77.00
80.00
Cause
Mean
Median
Alzheimer’s
Mental/behavioral disorders
Narcotics poisoning
Chronic liver & cirrhosis
Suicide
Homicide
Motor vehicle crashes
Falls
All other unintentional injuries
AIDS
Pneumonia & influenza
Chronic lower respiratory disease
Other respiratory diseases
Septicemia
All other infectious diseases
Other digestive diseases
Other nervous system diseases
Musculoskeletal diseases
86.01
78.93
46.65
60.55
43.38
33.96
38.71
78.31
42.84
44.04
78.37
75.07
77.40
67.98
63.77
70.49
64.46
74.05
86.00
84.00
47.00
59.00
44.00
32.00
31.00
82.00
45.00
42.50
82.00
77.00
83.00
70.00
60.00
74.00
66.00
75.50
For HIV, the non-Hispanic black premature AM rate more than doubled between the
two time periods, while there was an 80% de-
cline in the non-Hispanic white rate (Figure 610). Note, there were no non-Hispanic black HIV
deaths in 1985-1986, consequently the initial
time frame was shifted. Interpretation of the HIV data must be
done with caution since early in
Figure 6-5 Percent of premature deaths among Kansas City,
the HIV epidemic in Kansas
Mo, residents by race/ethnicity, 2003-2007
City, illness and death among
non-Hispanic black males was
46.0%
43.6%
40.0%
often concealed from the Kan35.0%
32.9%
sas City Health Department.
26.3%
Thus, the shift in non-Hispanic
black:non-Hispanic white premature AM disparity ratio from 0.4
to 3.7 may not be an accurate
reflection of what has occurred.
Total
Asian
Native
Hispanic
Hispanic
American
In 2008, the non-Hispanic black
population in Kansas City had
more than twice the rate of newly
diagnosed
HIV among persons <65
Table 6-11 Five year projection of total and premayears old than non-Hispanic whites. 7
ture deaths with 95% confidence intervals, Kansas
Based on the analysis, there is
City, Mo, 2008-2012
Total deaths
Premature deaths
considerable potential for narrowing of
Year Projection Low High Projection Low High
the premature AM non-Hispanic black:
2008
3,663
3,453 3,873
1,232
1,147 1,317
non-Hispanic white disparity ratio, espe2009
3,623
3,363 3,883
1,232
1,112 1,352
2010
3,582
3,281 3,884
1,232
1,085 1,379
cially from causes amenable to medical
2011
3,542
3,204 3,880
1,232
1,062 1,402
care and policy behavior interventions
2012
3,502
3,130 3,873
1,232
1,042 1,422
DEATHS
Page 88 of 294
(Figure 6-11). These two categories accounted
for 34.5% of the overall premature AM—26.9%
among non-Hispanic whites and 41.8% among
non-Hispanic blacks. In addition, they accounted
for 67% of the premature AM non-Hispanic
black: non-Hispanic white disparity during 20052007. However, the contribution of these two
categories varied by sex. Among men, policy
and behavior were more important and constituted 42.2% of premature AM disparity; medical
care contributed 23.9%. Medical care accounted
for 51.8% of the disparity among women while
policy and behavior accounted for only 9.7%.
These observations are consistent with
national data that found that medical care and
policy and behavior accounted for nearly 70% of
premature AM non-Hispanic black: non-Hispanic
white disparity.8 The national data for sex, however, was different from that for Kansas City with
medical care being the largest contributor to
premature AM non-Hispanic black: non-Hispanic
white disparity (men 30%; women 42%), while
policy and behavior contributed 20% and 4%,
respectively.
Causes of death
The major causes of death among Kansas City residents vary throughout the life
course as illustrated in Figure 6-12 using mortality data from 2003 to 2007; more specific
causes of death are shown in the tables that
follow. The list of causes was
selected by the Office of Epidemiology & Community
Table 6-12 Annualized age-specific death rates per 10,000
population for the 5 leading causes of death among Kansas
Health Monitoring based on
City, Mo residents, 15-44 years of age, 2003-2007
community and public health
Men
Women
interests. These causes ac(N = 101,439)
(N = 102,906)
count for all the deaths,
Cause of death
Rate
Cause of death
Rate
Homicide
5.5
Cancer
1.7
however, many of the causHeart disease
2.4
Heart disease
1.1
es could be parsed further
2.4
Homicide
1.1
via the ICD codes used for
Suicide
2.4
1.1
Other, unintentional injuries
1.2
Suicide
0.5
classifying
deaths.
Table 6Table 6-13 Annualized age-specific death rates per 10,000 population for
14 lists the causthe leading causes of death among Kansas City, Mo residents, 15-44
years of age, by race/ethnicity, 2003-2007
es of death by
Total
White, non-Hispanic
Black, non-Hispanic
year for all Kan(N = 204,345)
(N = 123,477)
(N = 62,062)
sas City residents
Cause
Rate
Cause
Rate
Cause
Rate
while Table 6-15
Homicide
3.3
MVC
1.7
Homicide
8.6
Heart disease
1.8
Suicide
1.6
Heart disease
3.3
distributes the
1
MVC
1.7
Cancer
1.4
Cancer
2.1
deaths in 2006 by
Cancer
1.5
Heart disease
1.2
MVC
1.8
2
Suicide
1.5
Other UI
0.9
AIDS
1.5
whether the indiHispanic
Asian
Native American
vidual resided in
(N = 16,020)
(N = 4,659)
(N = 1,132)
the Clay, JackCause
Rate
Cause
Rate
Cause
Rate
son, or Platte
Homicide
4.2
Heart disease
0.9
Suicide
3.5
MVC
1.9
county portion of
Other UI
1.2
the community.
Drowning
0.7
Cancer
0.7
Tables 6-16 to 6Heart disease
0.7
21 present the
Suicide
0.7
1
2
MVC = motor vehicle crash; Other UI = Other unintentional injuries
causes of death
DEATHS
Page 89 of 294
Figure 6-6 Percentage change in premature avoidable mortality rates per 100,000
population due to medical care and to
policy and behavior, Kansas City, Mo,
1985-1987 and 2005-2007
Figure 6-9 Premature avoidable mortality
rates per 100,000 population due to
ischemic heart disease, Kansas City, Mo
57.0
51.9
White, nonHispanic
35.3
Medical care -4.0%
Policy & behavior
30.2
-36.0%
-40.7%
-39.0%
1985-1987
2005-2007
-63.5%
-74.4%
rates per 100,000 population due to HIV,
Kansas City, Mo
rates per 100,000 population due to medical care, Kansas City, Mo
17.7
14.1
6.3
White, nonHispanic
1987-1989
rates per 100,000 population, Kansas City,
Mo, 2005-2007
18.7
1985-1987
White, nonHispanic
Black, nonHispanic
Medical Policy & Ischemic
care behavior heart
disease
HIV
164.8
201.6
55.0
110.5
88.7
Black, non-Hispanic
3.8
14.1
White, non-Hispanic
rates per 100,000 population due to policy
and behavior, Kansas City, Mo
30.2
36.3
2005-2007
69.2
2005-2007
Black, nonHispanic
18.7
69.2
55.0
63.8
Black, nonHispanic
3.8
110.5
89.1
1985-1987
White, nonHispanic
All
others
272.4
430.6
NHW males
NHW females
NHB males
NHB females
124.4
Black, nonHispanic
-16.3%
-17.1%
Total
2005-2007
by year by race/ethnicity, while tables 6-22 to 625 break the information down by sex and
race/ethnicity.
Leading causes of death are presented
in the next section.
Leading causes of death
There are several different ways in
which leading causes of death information can
be summarized depending upon on how the
deaths are grouped. Table 6-26 shows the ten
leading causes of death among Kansas City residents for the period 2003-2007 and for 2007.
DEATHS
Page 90 of 294
Figure 6-12 Major causes of death among Kansas City, Mo, residents by age, 2003-2007
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
<1 y
1-4 y
5-14 y
15-24 y 25-34 y 35-44 y 45-54 y 55-64 y 65-74 y 75-84 y
>=85 y
Other
External causes of injury & poisoning
Cancer
Diseases of digestive system
Diseases of respiratory system
Disease of circulatory system
The number of deaths from Alzheimer’s disease
continues to rise as the population ages. In Missouri, approximately 110,000 persons currently
are living with the disease; average survival is
approximately 4.5 years.9 10
For the period 2003-2007, the three
leading causes of death were heart disease,
cancer, and stroke for all residents and for
women (Table 6-27). Among men, the leading
causes were cancer, heart disease and unintentional injury. However, in 2007, cancer, heart
disease, and chronic lower respiratory disease
were the top three causes of death overall.
Among men, the causes were cancer, heart disease, and unintentional injuries, while among
women they were cancer, heart disease, and
stroke.
Besides varying between time periods
and by sex, the leading causes of death differ by
race/ethnicity. Table 6-28 shows the ranking of
the leading causes of death for non-Hispanic
whites, non-Hispanic blacks and Hispanics for
2007. Cancer and heart disease were the top
two causes of death for each group. However,
single year data for Asians and Native Americans have too few deaths for a meaningful interpretation of leading mortality causes.
DEATHS
Total
In Table 6-29 deaths from 2003 to 2007
are combined and rankings assigned. While this
approach still results in very low numbers of
deaths among Asians and Native Americans, it
does show that, even in these groups, cancer
and heart disease are the major causes of
death. The reader should note that the rankings
and even the cause of the major contributors to
mortality among non-Hispanic whites, nonHispanic blacks, and Hispanics are different
starting with the 3rd leading cause through the
10th leading cause. For example, homicide was
the 4th leading cause of death among Hispanics
and 5th leading causes among non-Hispanic
blacks, yet was not a top 10 cause of mortality
among non-Hispanic whites. And, infant mortality resulting from conditions related to the perinatal period was the 9th leading cause of death
among Hispanics. Tables 6-30 to 6-36 provide
information on leading causes of death by age
and sex among non-Hispanic whites, nonHispanic blacks, and Hispanics.
Page 91 of 294
Table 6-14 Causes of death among Kansas City, Mo, residents by year
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, non-Hodgkin lymphoma
Cancer, ovary
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Cancer, uterus
Chronic liver and cirrhosis
Circulatory diseases, other
Congenital anomalies
Diabetes
Digestive, other
Diseases of the blood, other
Diseases of the skin & subcutaneous tissue
Drowning
Endocrine, other
Excessive natural heat
Falls
Fire
Genitourinary, other
Heart disease
Homicide
Hypertension
Infectious diseases, other
Injuries, all other intentional
Injuries, all other unintentional
Mental & behavioral disorders
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Nervous system diseases, other
Peptic ulcer
Perinatal, conditions
Pregnancy complication
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
Symptoms & signs of illness involving the circulatory &
respiratory systems
Syphilis
Tuberculosis
Total
2003
24
88
83
219
14
82
2
73
24
267
26
20
44
40
10
49
12
29
175
48
22
133
93
20
6
8
45
4
44
2
15
945
83
47
36
2
51
112
63
18
25
81
91
4
32
92
2
62
67
7
218
45
23
2004
41
95
74
191
23
64
5
89
42
279
18
15
48
42
18
45
9
35
169
35
17
108
82
21
7
7
34
0
52
9
20
895
82
42
37
2
42
128
56
17
26
89
85
6
33
61
0
80
54
7
239
52
24
2005
38
119
66
205
16
75
5
83
33
266
22
25
46
47
21
46
8
31
211
30
17
103
93
27
8
5
45
3
64
7
21
841
107
49
32
3
37
148
67
24
19
91
91
1
34
69
1
71
61
9
180
48
11
2006
23
107
79
193
13
68
6
74
35
278
26
16
46
39
13
46
9
35
206
43
26
106
85
13
8
11
38
6
58
6
18
814
97
39
49
4
59
149
60
22
29
90
103
6
39
81
1
76
49
10
197
68
17
2007
26
128
69
228
15
58
9
100
37
252
27
13
49
41
15
34
11
38
206
32
21
103
89
22
9
7
45
6
71
4
20
769
80
28
39
12
56
140
51
20
31
94
83
1
34
51
1
81
46
0
199
64
28
Total
152
537
371
1,036
81
347
27
419
171
1,342
119
89
233
209
77
220
49
168
967
188
103
553
442
103
38
38
207
19
289
28
94
4,264
449
205
193
23
245
677
297
101
130
445
453
18
172
354
5
370
277
33
1,033
277
103
0
0
3,827
0
0
3,751
0
2
3,782
0
3
3,792
1
4
3,698
1
9
18,850
DEATHS
Page 92 of 294
Table 6-15 Number of deaths among Kansas City, Mo, residents by area of the city,
2007
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, ovary
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Cancer, uterus
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Peptic ulcer
Respiratory, other
Septicemia
Stroke
Suicide
respiratory systems
Syphilis
Tuberculosis
Total
DEATHS
Clay
County
0
19
3
44
4
15
2
19
7
54
7
3
9
4
2
9
3
12
45
4
1
10
13
2
3
1
4
0
10
0
3
121
1
4
6
1
13
28
13
4
4
17
9
0
5
7
0
15
7
29
14
Jackson
County
26
99
60
163
11
41
7
73
27
183
16
9
37
34
11
21
8
23
149
24
19
86
71
20
6
6
39
6
58
4
16
598
79
23
29
9
41
107
32
16
25
71
66
1
28
36
1
59
37
155
46
Platte
County
0
10
6
21
0
2
0
8
3
15
4
1
3
3
2
4
0
3
12
4
1
7
5
0
0
0
2
0
3
0
1
50
0
1
4
2
2
5
6
0
2
6
8
0
1
8
0
7
2
15
4
Total
26
128
69
228
15
58
9
100
37
252
27
13
49
41
15
34
11
38
206
32
21
103
89
22
9
7
45
6
71
4
20
769
80
28
39
12
56
140
51
20
31
94
83
1
34
51
1
81
46
199
64
3
24
1
28
0
0
613
1
4
2,841
0
0
244
1
4
3,698
Page 93 of 294
Table 6-16 Causes of death among non-Hispanic white residents, Kansas City, Mo, by
year
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, ovary
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Cancer, uterus
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Peptic ulcer
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
respiratory systems
Tuberculosis
Total
2003
13
63
51
132
11
51
1
44
22
178
22
11
28
23
5
37
5
14
133
36
10
59
64
7
6
1
33
2
34
1
8
613
12
23
24
1
27
80
40
8
11
40
55
3
8
69
1
41
33
4
139
32
2004
16
68
37
129
11
44
4
56
29
178
13
10
34
22
9
27
6
25
134
25
10
47
51
11
2
5
20
0
44
6
14
588
15
14
25
1
26
94
34
12
15
42
59
5
10
47
0
62
24
0
142
38
2005
16
93
42
124
9
46
4
51
24
180
17
18
24
28
7
34
7
19
175
20
9
46
62
14
5
3
28
1
58
4
14
530
19
19
15
1
23
97
38
13
14
49
68
0
7
50
0
42
38
2
112
36
2006
6
86
50
124
10
45
4
49
21
199
22
12
33
19
6
34
6
25
166
22
15
50
56
5
6
8
25
4
50
2
12
527
9
19
35
0
40
106
31
17
15
45
68
4
9
61
0
52
25
3
108
52
2007
5
100
33
142
9
30
4
61
24
161
20
9
33
18
6
24
7
32
166
16
5
47
59
6
7
4
28
2
54
1
12
498
11
12
28
5
33
96
31
12
20
51
49
1
6
35
0
54
27
0
123
50
Total
56
410
213
651
50
216
17
261
120
896
94
60
152
110
33
156
31
115
774
119
49
249
292
43
26
21
134
9
240
14
60
2,756
66
87
127
8
149
473
174
62
75
227
299
13
40
262
1
251
147
9
624
208
14
16
7
9
11
57
0
2,383
0
2,356
1
2,363
2
2,409
1
2,279
4
11,790
DEATHS
Page 94 of 294
Table 6-17 Causes of death among non-Hispanic black residents, Kansas City, Mo, by
year
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, ovary
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Cancer, uterus
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Peptic ulcer
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
respiratory systems
Syphilis
Tuberculosis
Total
DEATHS
2003
10
23
32
79
1
30
1
28
2
83
4
6
15
14
4
10
7
12
39
11
9
65
25
12
0
2
10
2
7
1
7
296
66
23
8
0
19
28
20
9
14
36
31
1
21
17
1
16
29
3
72
11
2004
23
23
36
54
9
19
0
30
11
94
4
5
10
18
8
14
3
8
30
10
5
56
21
10
5
0
13
0
6
3
5
284
60
27
11
1
13
30
14
5
10
43
22
1
18
13
0
16
29
6
83
12
2005
22
24
24
67
6
27
1
28
8
82
4
6
20
17
13
12
1
9
33
10
7
50
21
12
3
2
16
2
5
3
6
294
74
27
15
2
11
47
22
10
5
38
21
1
22
17
1
26
21
6
61
10
2006
13
18
27
63
3
21
2
23
11
75
4
3
12
18
5
10
3
8
34
20
7
50
21
8
2
3
13
2
6
2
5
260
82
20
14
2
15
36
25
5
13
41
29
2
25
18
1
18
21
6
80
13
2007
19
24
33
76
5
27
5
34
12
81
7
4
15
22
6
10
3
6
37
16
10
49
28
16
2
1
16
4
12
3
6
237
55
13
10
7
17
39
16
7
11
40
32
0
25
12
1
26
17
0
70
8
Total
87
112
152
339
24
124
9
143
44
415
23
24
72
89
36
56
17
43
173
67
38
270
116
58
12
8
68
10
36
12
29
1,371
337
110
58
12
75
180
97
36
53
198
135
5
111
77
4
102
117
21
366
54
8
7
4
8
15
42
0
0
1,280
0
0
1,238
0
1
1,277
0
1
1,227
1
1
1,249
1
3
6,271
Page 95 of 294
Table 6-18 Causes of death among Hispanic residents, Kansas City, Mo, by year
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, ovary
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Cancer, uterus
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
respiratory systems
Tuberculosis
Total
2003
1
2
0
5
1
1
0
0
0
5
0
2
0
3
1
2
0
2
0
1
3
6
4
1
4
2
2
0
0
28
5
1
3
1
5
2
1
0
0
3
3
3
4
5
4
0
4
1
2004
2
2
1
6
1
1
1
3
2
4
1
0
4
2
0
2
0
2
4
0
2
4
7
0
2
1
1
0
1
14
7
0
1
0
2
4
8
0
1
3
3
3
1
2
1
1
14
1
2005
0
1
0
11
0
1
0
3
1
2
0
1
2
2
1
0
0
1
1
0
1
5
9
0
0
1
1
0
0
15
13
3
2
0
2
4
7
1
0
4
2
5
1
3
2
1
5
1
2006
3
1
1
3
0
2
0
2
2
4
0
1
1
1
2
2
0
2
3
1
2
6
8
0
0
0
1
1
0
16
6
0
0
2
3
6
3
0
1
3
4
4
2
4
2
1
5
2
2007
1
4
3
9
1
0
0
4
1
5
0
0
1
1
1
0
1
0
2
0
6
5
2
0
2
1
2
0
1
25
12
3
0
0
5
4
1
1
0
3
1
2
3
0
2
0
5
4
Total
7
10
5
34
3
5
1
12
6
20
1
4
8
9
5
6
1
7
10
2
14
26
30
1
8
5
7
1
2
98
43
7
6
3
17
20
20
2
2
16
13
17
11
14
11
3
33
9
1
1
0
0
2
4
0
122
0
123
0
115
0
113
1
127
1
600
DEATHS
Page 96 of 294
Table 6-19 Causes of death among Asian residents, Kansas City, Mo, by year
Cause of death
Alzheimer’s
Cancer, all other
Cancer, benign
Cancer, colon
Cancer, lung
Cancer, prostate
Cancer, stomach
Diabetes
Digestive, other
Falls
Heart disease
Homicide
Motor vehicle crash
Nephritis
Respiratory, other
Septicemia
Stroke
Suicide
Total
2003
0
3
0
0
0
0
0
0
0
0
1
0
1
0
0
4
0
0
0
1
0
0
0
0
0
1
0
11
2004
1
1
1
0
0
0
0
0
1
0
0
0
0
1
1
2
0
0
0
0
0
0
0
0
0
0
0
8
2005
0
0
0
0
0
1
0
0
0
1
0
0
1
0
0
0
0
1
0
0
0
0
0
0
0
0
0
4
2006
0
1
0
0
0
0
1
0
0
0
0
1
0
0
0
4
0
0
0
0
1
1
1
1
1
2
1
15
2007
0
0
0
1
3
0
0
2
0
0
1
0
2
0
2
3
1
1
1
2
0
1
0
1
0
1
0
22
Total
1
5
1
1
3
1
1
2
1
1
2
1
4
1
3
13
1
2
1
3
1
2
1
2
1
4
1
60
Table 6-20 Causes of death among Native American residents, Kansas City, Mo, by
year
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, leukemia
Cancer, lung
Digestive, other
Falls
Heart disease
Homicide
Hypertension
Nephritis
Respiratory, other
Stroke
Suicide
Total
DEATHS
2003
0
0
0
0
0
1
0
1
1
0
0
0
0
2
0
0
0
0
2
2
0
1
0
0
0
10
2004
0
0
0
0
0
1
1
0
1
0
0
0
0
3
0
1
0
0
0
0
0
0
0
0
1
8
2005
0
0
0
0
0
1
0
1
1
1
1
0
1
0
0
0
0
0
0
0
0
0
0
1
0
7
2006
0
2
1
1
1
0
0
0
2
0
0
1
1
5
0
0
0
1
1
0
1
0
1
2
0
20
2007
1
0
0
1
0
2
0
0
0
0
0
1
0
5
1
0
1
0
0
0
0
1
0
0
2
15
Total
1
2
1
2
1
5
1
2
5
1
1
2
2
15
1
1
1
1
3
2
1
2
1
3
3
60
Page 97 of 294
Table 6-21 Causes of death among residents of other race/ethnicity or for whom
race/ethnicity was not listed, Kansas City, Mo, by year
Cause of death
AIDS
Alzheimer’s
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, colon
Cancer, lung
Cancer, pancreas
Cancer, stomach
Diabetes
Digestive, other
Drowning
Falls
Fire
Heart disease
Homicide
Motor vehicle crash
Musculoskeletal
Nephritis
Septicemia
Stroke
Suicide
Tuberculosis
Total
2003
0
0
1
1
0
1
0
1
0
1
0
2
0
1
1
0
0
2
0
1
0
1
1
0
2
0
1
1
2
1
0
21
2004
0
1
1
1
0
0
2
0
1
0
0
1
2
0
0
0
0
4
0
0
1
0
0
1
1
2
0
0
0
0
0
18
2005
0
1
3
1
1
1
1
0
0
1
0
1
0
0
0
0
0
2
1
0
0
0
0
0
0
0
1
0
1
1
0
16
2006
1
0
1
0
0
0
0
0
0
1
0
0
0
0
0
1
0
2
0
0
0
1
0
0
0
0
0
0
0
0
0
7
2007
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
1
0
0
0
1
0
0
0
0
1
6
Total
1
2
6
3
2
2
3
1
1
3
1
4
2
1
1
1
1
11
1
1
1
3
1
1
3
3
2
1
3
2
1
69
DEATHS
Page 98 of 294
Table 6-22 Causes of death among men by year, Kansas City, Mo
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, pancreas
Cancer, prostate
Cancer, stomach
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Peptic ulcer
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
respiratory systems
Syphilis
Tuberculosis
Total
DEATHS
2003
16
27
35
125
9
1
36
18
144
13
25
40
10
33
19
82
26
9
61
28
11
0
7
20
1
23
0
5
437
74
13
15
2
36
53
48
5
19
35
41
2
17
45
35
37
7
92
36
2004
37
28
33
103
10
1
42
26
154
9
20
42
12
26
20
69
16
8
52
45
9
3
5
16
0
26
6
8
463
58
17
17
1
26
68
37
4
17
41
40
3
19
24
42
25
2
79
46
2005
31
34
25
121
8
0
43
17
154
11
27
47
14
33
17
113
12
8
43
36
5
3
3
12
2
31
5
7
416
91
16
18
1
28
72
49
5
13
51
52
1
22
32
40
25
5
69
39
2006
20
26
27
107
6
0
33
20
172
16
26
39
8
26
19
95
20
14
51
37
5
1
10
14
5
34
3
6
408
76
18
19
3
38
68
36
4
23
50
55
5
17
38
34
27
6
79
57
2007
22
38
16
133
9
0
52
16
139
14
27
41
9
24
21
100
14
8
53
40
13
3
6
23
3
32
2
9
419
63
11
22
9
34
55
30
4
21
41
38
1
19
29
24
25
0
72
48
Total
126
153
136
589
42
2
206
97
763
63
125
209
53
142
96
459
88
47
260
186
43
10
31
85
11
146
16
35
2,143
362
75
91
16
162
316
200
22
93
218
226
12
94
168
175
139
20
391
226
10
12
5
9
17
53
0
0
1,883
0
0
1,867
0
1
1,913
0
3
1,913
1
3
1,853
1
7
9,429
Page 99 of 294
Table 6-23 Causes of death among male residents by race/ethnicity, Kansas City, Mo,
2003-2007
White,
1
NH
53
113
74
376
31
2
124
67
494
51
85
110
28
104
66
359
62
22
122
121
16
7
16
59
6
118
7
19
1,364
38
29
61
4
97
213
112
14
53
115
156
8
24
119
121
76
5
230
165
Black,
NH
64
32
62
191
8
0
71
27
253
12
38
89
20
33
23
91
26
13
120
48
25
3
6
24
5
21
8
14
707
285
45
26
9
49
91
67
8
38
90
63
4
62
41
44
55
13
145
48
Hispanic
7
5
0
17
2
0
8
3
10
0
2
9
3
4
5
6
0
11
12
14
1
0
8
2
0
5
1
0
56
39
1
2
3
15
10
16
0
2
9
5
0
4
6
10
8
2
14
8
Native
American
1
0
0
0
0
0
0
0
3
0
0
0
0
1
1
0
0
0
0
0
1
0
0
0
0
1
0
2
6
0
0
1
0
1
2
0
0
0
2
0
0
0
1
0
0
0
1
2
Cause of death
Asian
AIDS
0
Alzheimer’s
1
Atherosclerosis
0
Cancer, all other
2
Cancer, benign
0
Cancer, breast
0
Cancer, colon
1
Cancer, leukemia
0
Cancer, lung
1
0
Cancer, pancreas
0
Cancer, prostate
1
Cancer, stomach
2
0
1
0
0
0
Diabetes
3
Digestive, other
1
0
0
Drowning
0
Endocrine, other
0
0
Falls
1
Fire
0
0
Heart disease
8
Homicide
0
Hypertension
0
0
0
0
0
Motor vehicle crash
2
Musculoskeletal
0
Narcotics poisoning
0
Nephritis
1
0
Peptic ulcer
0
1
0
Respiratory, other
0
Septicemia
0
SIDS
0
Stroke
0
Suicide
1
Symptoms & signs of illness involving the
28
23
2
0
0
circulatory & respiratory systems
Syphilis
0
1
0
0
0
Tuberculosis
3
2
1
0
0
Total
5,747
3,243
348
27
26
1
2
NH = non-Hispanic; Total also includes persons for whom race/ethnicity was other or not listed
Other/not
listed
1
2
0
3
1
0
2
0
2
0
0
0
0
0
0
3
0
1
3
2
0
0
1
0
0
0
0
0
2
0
0
1
0
0
0
3
0
0
1
2
0
3
1
0
0
0
1
2
Total
126
153
136
589
42
2
206
97
763
63
125
209
53
142
96
459
88
47
260
186
43
10
31
85
11
146
16
35
2,143
362
75
91
16
162
316
200
22
93
218
226
12
94
168
175
139
20
391
226
0
53
0
1
38
1
7
9,429
2
DEATHS
Page 100 of 294
Table 6-24 Causes of death among women by year, Kansas City, Mo
Cause of death
AIDS
Alzheimer’s
Atherosclerosis
Cancer, all other
Cancer, benign
Cancer, breast
Cancer, cervix
Cancer, colon
Cancer, leukemia
Cancer, lung
Cancer, ovary
Cancer, pancreas
Cancer, stomach
Cancer, uterus
Diabetes
Digestive, other
Drowning
Endocrine, other
Falls
Fire
Heart disease
Homicide
Hypertension
Motor vehicle crash
Musculoskeletal
Narcotics poisoning
Nephritis
Peptic ulcer
Respiratory, other
Septicemia
SIDS
Stroke
Suicide
respiratory systems
Tuberculosis
Total
DEATHS
2003
8
61
48
94
5
81
2
37
6
123
13
20
19
0
16
12
10
93
22
13
72
65
9
6
1
25
3
21
2
10
508
9
34
21
0
15
59
15
13
6
46
50
2
15
47
2
27
30
0
126
9
2004
4
67
41
88
13
63
5
47
16
125
9
15
28
6
19
9
15
100
19
9
56
37
12
4
2
18
0
26
3
12
432
24
25
20
1
16
60
19
13
9
48
45
3
14
37
0
38
29
5
160
6
2005
7
85
41
84
8
75
5
40
16
112
11
25
19
7
13
8
14
98
18
9
60
57
22
5
2
33
1
33
2
14
425
16
33
14
2
9
76
18
19
6
40
39
0
12
37
1
31
36
4
111
9
2006
3
81
52
86
7
68
6
41
15
106
10
16
20
5
20
9
16
111
23
12
55
48
8
7
1
24
1
24
3
12
406
21
21
30
1
21
81
24
18
6
40
48
1
20
43
1
42
22
4
118
11
2007
4
90
53
95
6
58
9
48
21
113
13
13
22
6
10
11
17
106
18
13
50
49
9
6
1
22
3
39
2
11
350
17
17
17
3
22
85
21
16
10
53
45
0
15
22
1
57
21
0
127
16
Total
26
384
235
447
39
345
27
213
74
579
56
89
108
24
78
49
72
508
100
56
293
256
60
28
7
122
8
143
12
59
2,121
87
130
102
7
83
361
97
79
37
227
227
6
76
186
5
195
138
13
642
51
13
12
6
8
11
50
0
1,944
0
1,884
1
1,869
0
1,877
1
1,845
2
9,419
Page 101 of 294
Table 6-25 Causes of death among women residents by race/ethnicity, Kansas City,
Mo, 2003-2007
White,
1
NH
3
297
139
275
19
214
17
137
53
402
43
60
67
5
52
31
49
415
57
27
127
171
27
19
5
75
3
122
7
41
1,392
28
58
66
4
52
260
62
48
22
112
143
5
16
143
1
130
71
4
394
43
Black,
NH
23
80
90
148
16
124
9
72
17
162
11
24
34
16
23
17
20
82
41
25
150
68
33
9
2
44
5
15
4
15
664
52
65
32
3
26
89
30
28
15
108
72
1
48
36
4
58
62
8
221
6
Hispanic
0
5
5
17
1
5
1
4
3
10
1
4
6
2
2
1
2
4
2
3
14
16
0
0
0
3
0
2
0
2
42
4
6
4
0
2
10
4
2
0
7
8
0
12
5
0
4
3
1
19
1
Native
American
0
2
1
2
0
0
0
0
1
2
0
0
0
0
0
0
1
5
0
0
0
1
0
0
0
0
0
1
0
0
9
1
1
0
0
0
1
0
0
0
0
1
0
0
1
0
1
0
0
2
1
Cause of death
Asian
AIDS
0
Alzheimer’s
0
Atherosclerosis
0
Cancer, all other
3
Cancer, benign
1
Cancer, breast
0
Cancer, cervix
0
Cancer, colon
0
Cancer, leukemia
0
Cancer, lung
2
1
Cancer, ovary
0
Cancer, pancreas
0
Cancer, stomach
0
1
Cancer, uterus
0
0
2
0
1
Diabetes
1
Digestive, other
0
0
0
Drowning
0
Endocrine, other
0
0
Falls
2
Fire
0
0
Heart disease
5
Homicide
1
Hypertension
0
0
0
2
1
Motor vehicle crash
1
Musculoskeletal
0
Narcotics poisoning
0
Nephritis
0
2
Peptic ulcer
0
0
0
0
Respiratory, other
2
Septicemia
1
SIDS
0
Stroke
4
Suicide
0
29
19
2
0
0
Tuberculosis
1
1
0
0
0
Total
6,043
3,027
251
33
34
1
2
NH = non-Hispanic; Total also includes persons for whom race/ethnicity was other or not listed
Other/not
listed
0
0
0
3
2
2
0
0
0
1
0
0
1
1
0
0
0
0
0
0
1
0
0
0
0
0
0
1
1
1
9
1
0
0
0
1
0
0
1
0
0
1
0
0
1
0
0
1
0
2
0
Total
26
384
235
448
39
345
27
213
74
579
56
88
108
24
78
49
72
508
100
56
293
256
60
28
7
122
8
143
12
59
2,121
87
130
102
7
83
361
97
79
37
227
227
6
76
186
5
195
138
13
642
51
0
50
0
31
2
9,419
2
DEATHS
Page 102 of 294
Table 6-26 Ten leading grouped causes of death, Kansas City, Mo
2003-2007
2007
Cause of Death
Deaths
Rank
4,419
4,264
1,033
986
967
897
677
553
537
449
14,782
18,852
1
2
3
4
5
6
7
8
9
10
Cancer
Heart disease
Stroke
Infectious diseases
Diabetes
Alzheimer’s
Homicide
Total
All deaths
Cause of Death
Deaths
Cancer
Heart disease
Stroke
Infectious diseases
Alzheimer’s
Diabetes
Nephritis
Total
All deaths
889
769
206
199
189
167
140
128
103
94
2,884
3,698
Table 6-27 Leading causes of death among males and females, Kansas City, Mo
2003-2007
All
Males
Females
(18,848 deaths)
(9,429 deaths)
(9,419 deaths)
Cause
1
2
3
4
5
6
7
Deaths
Cancer
Heart disease
Stroke
Infectious diseases
1
CLRD
Mental/behavioral
disorders
4,419
4,264
1,033
986
967
897
677
8
Diabetes
553
9
10
Alzheimer’s
Homicide
537
449
2007
Cause
Deaths
Cancer
Heart disease
Infectious diseases
CLRD
Stroke
2,291
2,143
555
532
459
391
Mental/behavioral
disorders
Diabetes
Suicide
316
342
260
226
Diabetes
Atherosclerosis
293
235
All
Males
Females
(3,698 deaths)
(1,853 deaths)
(1,845 deaths)
Cause
Deaths
Cause
Deaths
889
769
206
199
189
Cancer
Heart disease
Infectious diseases
CLRD
464
419
104
102
100
6
Infectious diseases
167
Stroke
72
7
Mental/behavioral
disorders
140
Homicide
Alzheimer’s
128
9
Diabetes
103
10
Nephritis
94
1
CLRD = chronic lower respiratory disease
2,128
2,121
642
508
454
384
362
Cancer
Heart disease
CLRD
Stroke
DEATHS
Deaths
Homicide
1
2
3
4
5
8
Cause
Cancer
Heart disease
Stroke
CLRD
Infectious diseases
Alzheimer’s
Mental/behavioral
disorders
Mental/behavioral
disorders
Diabetes
Suicide
Cause
361
Deaths
Cancer
Heart disease
Stroke
CLRD
Alzheimer’s
Mental/behavioral
disorders
425
350
127
106
90
63
85
55
Infectious diseases
65
53
48
Atherosclerosis
Nephritis
53
53
85
Page 103 of 294
Table 6-28 Leading causes of death by race/ethnicity, Kansas City, Mo, 2007
White, non-Hispanic
Black, non-Hispanic
Hispanic
2,279 deaths
1,249 deaths
127 deaths
Cause
1
2
3
4
5
6
7
Cancer
Heart disease
1
CLRD
Stroke
Alzheimer’s
Mental/behavioral
disorders
Deaths
548
498
166
123
123
100
96
Cause
Deaths
Cause
Deaths
Cancer
Heart disease
Stroke
Infectious diseases
Homicide
307
237
70
60
55
49
Heart disease
Cancer
Homicide
Infectious diseases
25
24
12
10
6
6
Diabetes
49
Diabetes
5
39
Stroke
5
37
Suicide
Mental/behavioral
disorders
Alzheimer’s
4
8
Infectious diseases
96
9
Nephritis
51
Mental/behavioral
disorders
CLRD
10
Suicide
50
Atherosclerosis
33
4
4
DEATHS
Page 104 of 294
Table 6-29 Leading causes of death by race/ethnicity, Kansas City, Mo, 2003-2007
All
White, non-Hispanic
(18,850 deaths)
(11,790 deaths)
Cause
Deaths
8
Cancer
Heart disease
1
CLRD
Stroke
Alzheimer’s
Mental/behavioral
disorders
Infectious diseases
9
10
1
2
3
4
5
6
7
4,419
4,264
1,033
986
967
897
553
Nephritis
537
Diabetes
249
Suicide
449
Nephritis
227
677
Hispanic
Asian
(600 deaths)
(60 deaths)
Deaths
1
2
3
4
5
Cancer
Heart disease
Homicide
Stroke
115
98
53
43
33
6
Diabetes
26
7
Infectious diseases
Mental/behavioral
disorders
Conditions perinatal
Nephritis
25
9
10
20
17
16
Other/not listed
69 deaths
Cause
Deaths
Cancer
Heart disease
Diabetes
Infectious diseases
Stroke
Conditions perinatal
CLRD
1
CLRD = chronic lower respiratory disease
1
2
3
4
5
DEATHS
(6,271 deaths)
Deaths
Cancer
Heart disease
CLRD
Stroke
Infectious diseases
Mental/behavioral
disorders
Alzheimer’s
Cause
8
Cause
18
11
7
4
3
3
3
3
Cause
Cancer
Heart disease
Stroke
Diabetes
Black, non-Hispanic
2,847
2,756
774
624
598
596
Cause
Deaths
Cancer
Heart disease
Stroke
Infectious diseases
Homicide
Diabetes
1,415
1,371
366
343
337
270
473
228
410
Nephritis
Mental/behavioral
disorders
CLRD
198
180
173
Native American
(60 deaths)
Deaths
15
13
8
4
4
Cause
Heart disease
Cancer
CLRD
Stroke
Mental/behavioral
disorders
Deaths
15
9
5
3
3
3
Page 105 of 294
Table 6-30 Leading causes of death1 by age group, Kansas City, Mo, 2007
Deaths
by age
group
Ranking
1
2
3
4
Congenital
anomalies
13
Unintended
injury
8
Homicide
4
15-24 y
66
Conditions
perinatal
34
Not applicable
Unintended
injury
20
Homicide
19
Suicide
11
25-34 y
87
Homicide
24
Unintended
injury
17
Suicide
9
0-4 y
68
5-14 y
4
35-44 y
149
Unintended
injury
22
45-54 y
353
Cancer
77
55-64 y
513
Cancer
179
65-74 y
579
Cancer
221
75-84 y
921
Cancer
242
>85 y
944
Heart
disease
251
1
Heart disease
Cancer
18
5
6
7
8
9
10
Infectious diseases
Heart disease
3 each
Heart disease
Infectious disease
Cancer
Narcotic poisoning
7 each
Infectious
diseases
17
Suicide
13
Heart
disease
68
Heart
disease
104
Heart
disease
117
Heart
disease
199
Infectious
diseases
21
Infectious
diseases
272
Unintended
injuries
18
Suicide
16
CLRD
25
Unintended
injuries
19
CLRD
41
Diabetes
29
Stroke
27
CLRD
69
Stroke
70
Alzheimer’s
49
Cancer
132
Alzheimer’s
73
Mental & behavioral Stroke
69 each
Homicide
12
Mental &
behavioral
6
CLRD
Narcotics poisoning
13 each
Diabetes
Stroke
15 each
Infectious
Nephritis
diseases
16
21
Infectious diseases
Nephritis
36 each
Infectious
CLRD
diseases
55
39
Symptoms
& signs of
illness
Chronic liver &
involving
Narcotics
cirrhosis
the circupoisoning
5
latory &
3
respiratory
systems
4
Mental & behavioral
Stroke
Homicide
Diabetes
11 each
9 each
Chronic liver &
Mental &
Suicide
cirrhosis
behavioral
10
12
11
Chronic liver &
Mental & behavioral
cirrhosis
Unintended injuries
10
8 each
Unintended injuries
Diabetes
Mental & behavioral
27
34 each
Atherosclerosis
37
Nephritis
36
Unintended
injuries
34
If there are less than 3 persons for a specific cause of death, none of the cases are shown; 2 CLRD = Chronic lower respiratory disease
DEATHS
Page 106 of 294
Table 6-31 Leading causes of death1 among non-Hispanic white males by age group, Kansas City, Mo, 2003-2007
Deaths
by age
group
0-4 y
N=51
5-14 y
N=9
15-24 y
N=70
Ranking
1
2
3
4
Conditions
perinatal
24
Unintended
injury
3
Unintended
injury
35
Congenital
anomalies
10
SIDS
5
Heart
disease
3
Suicide
14
Homicide
7
Narcotics
poisoning
4
5
7
Heart
disease
6
Symptoms
& signs of
illness
involving
the circulatory &
respiratory
systems
4
8
9
Unintended
injury
26
Suicide
25
Homicide
12
Cancer
9
Narcotics
poisoning
7
35-44 y
N=293
Unintended
injury
51
Suicide
43
Heart
disease
41
Infectious
diseases
33
Cancer
24
45-54 y
N=638
Cancer
139
Heart
disease
136
55-64 y
N=777
Cancer
260
Heart
disease
189
Infectious
diseases
42
65-74 y
N=997
Cancer
359
Heart
disease
210
75-84 y
N=1,646
Cancer
473
>85 y
N=1,136
Heart
disease
344
Narcotics Poisoning
Mental & behavioral
21 each
Infectious disease
Mental & behavioral
3 each
Chronic
liver &
cirrhosis
9
Diabetes
8
Stroke
7
Stroke
10
Unintended
injuries
51
Suicide
36
Chronic
liver &
cirrhosis
22
Narcotics
poisoning
15
Homicide
13
Mental &
behavioral
40
Unintended
injuries
38
CLRD2
32
Stroke
21
Diabetes
20
Suicide
19
CLRD
99
Infectious
diseases
47
Stroke
36
Diabetes
27
Unintended
injuries
26
Nephritis
16
Mental &
behavioral
17
Heart
disease
430
CLRD
144
Stoke
95
Alzheimer’s
45
Nephritis
42
Cancer
203
Stroke
61
CLRD
69
Alzheimer’s
56
Unintended
injuries
54
Infectious diseases
Mental & behavioral
56 each
10
Cancer
3
25-34 y
N=119
1
6
Infectious
diseases
66
Infectious
diseases
63
Unintended
injuries
40
Atherosclerosis
46
Diabetes
35
Mental &
behavioral
42
Chronic
liver &
cirrhosis
16
Chronic
liver &
cirrhosis
14
Mental &
behavioral
34
Nephritis
29
DEATHS
Page 107 of 294
Table 6-32 Leading causes of death1 among non-Hispanic black males by age group, Kansas City, Mo, 2003-2007
Deaths
by age
group
1
0-4 y
N=121
Conditions
perinatal
62
5-14 y
N=21
Homicide
7
15-24 y
N=184
Homicide
117
25-34 y
N=158
Homicide
72
35-44 y
N=226
Heart
disease
45
45-54 y
N=465
Ranking
2
3
SIDS
13
Congenital
anomalies
11
5
Homicide
9
Unintended
injuries
7
6
7
Heart
disease
15
Homicide
40
Infectious
diseases
34
Unintended
injury
22
Cancer
14
Suicide
12
Heart
disease
101
Cancer
97
Infectious
diseases
48
Unintended
injury
32
Homicide
29
Stroke
16
55-64 y
N=508
Cancer
157
Heart
disease
138
Diabetes
36
Stroke
24
Infectious
diseases
22
Unintended
injuries
17
65-74 y
N=609
Cancer
211
Heart
disease
136
Stroke
44
Diabetes
25
Infectious
diseases
24
Stroke
44
CLRD
36
Diabetes
25
Atherosclerosis
20
Infectious
diseases
17
Stroke
16
>85 y
N=304
1
Heart disease
Cancer
179 each
Heart
Cancer
disease
71
82
Suicide
14
8
9
10
Heart disease
Infectious diseases
3 each
Heart
disease
7
Infectious
disease
10
75-84 y
N=646
Unintended
injury
27
Unintended
injury
30
4
Infectious
diseases
5
Cancer
4
Suicide
9
Narcotics
poisoning
8
Cancer
5
Diabetes
6
Mental &
behavioral
19
Mental &
behavioral
16
CLRD
Nephritis
22 each
Atherosclerosis
23
Mental & behavioral
Nephritis
14 each
Nephritis
24
Diabetes
4
Narcotics poisoning
Stroke
5 each
Narcotics poisoning
Diabetes
Nephritis
15
12 each
Narcotics
Nephritis
CLRD2
poisoning
12
9
11
Hypertension
15
Atherosclerosis
14
Alzheimer’s
10
Infectious
diseases
22
Mental &
behavioral
18
Alzheimer’s
13
CLRD
11
Alzheimer’s
9
Hypertension
7
DEATHS
Page 108 of 294
Table 6-33 Leading causes of death1 among Hispanic males by age group, Kansas City, Mo,
2003-2007
Deaths
by age
group
1
2
0-4 y
N=19
Congenital
anomalies
7
Conditions
perinatal
4
Homicide
13
Unintended
injury
8
Ranking
3
4
5
6
7
8
9
10
5-14 y
N=4
15-24 y
N=28
45-54 y
N=31
Unintended
injury
13
Unintended
injury
10
Unintended
injury
10
55-64 y
N=44
Cancer
11
Heart
disease
8
Infectious
diseases
5
Chronic
liver &
cirrhosis
3
65-74 y
N=50
Cancer
16
Heart
disease
10
Stroke
5
Diabetes
4
75-84 y
N=79
Heart
disease
21
Cancer
17
Stroke
5
>85 y
N=29
Cancer
7
Heart
disease
6
25-34 y
N=32
35-44 y
N=31
1
Homicide
10
Infectious
disease
3
Homicide
8
Homicide
Heart disease
5 each
Cancer
3
Infectious diseases
Diabetes
Nephritis
4 each
Alzheimer’s
Infectious diseases
Diabetes
3 each
Mental & behavioral
2
CLRD
3 each
DEATHS
Page 109 of 294
Table 6-34 Leading causes of death1 among non-Hispanic white females by age group, Kansas City, Mo, 2003-2007
Deaths
by age
group
Ranking
1
2
Conditions
perinatal
16
25-34 y
N=60
Congenital
anomalies
20
Unintended
injury
3
Unintended
injury
23
Unintended
injury
14
35-44 y
N=132
Cancer
31
45-54 y
N=329
Cancer
119
55-64 y
N=517
Cancer
239
65-74 y
N=770
Cancer
275
75-84 y
N=1,804
Cancer
450
>85 y
2,324
Heart
disease
672
0-4 y
N=59
5-14 y
N=9
15-24 y
N=38
1
3
4
5
6
7
Narcotics
poisoning
5
Suicide
4
Infectious
diseases
3
8
9
10
SIDS
Unintended injury
3 each
Homicide
4
Suicide
3
Cancer
9
Heart
disease
7
Homicide
6
Unintended
injury
23
Heart
disease
16
Suicide
10
Heart
disease
40
Heart
disease
83
Heart
disease
144
Heart
disease
426
Unintended
injury
25
CLRD2
17
Mental &
behavioral
16
CLRD
36
Unintended
injury
18
Diabetes
14
CLRD
91
Stoke
37
Diabetes
28
CLRD
160
Stoke
134
Alzheimer’s
90
Cancer
450
Stroke
198
Alzheimer’s
193
Infectious
diseases
182
Infectious diseases
Diabetes
Mental & behavioral
4
5 each
Infectious diseases
Chronic liver &
Diabetes
Stroke
Suicide
cirrhosis
8
7
14 each
10
Stroke
Infectious
Mental & behavioral
diseases
Suicide
13 each
14
7 each
Infectious
Unintended
Atherosclerosis
Alzheimer’s
diseases
injury Nephritis
Hypertension
13
16
12 each
9 each
Infectious
Mental &
Unintended
Diabetes
Nephritis
diseases
behavioral
injury
43
38
77
58
47
Mental &
Unintended
CLRD
Atherosclerosis
Nephritis
behavioral
injury
110
100
52
162
80
Homicide
Narcotics poisoning
7 each
DEATHS
Page 110 of 294
Table 6-35 Leading causes of death1 among non-Hispanic black females by age group, Kansas City, Mo, 2003-2007
Deaths
by age
group
1
2
3
4
5
0-4 y
N=97
Conditions
perinatal
48
Congenital
anomalies
15
Unintended
injury
10
SIDS
8
Infectious
diseases
3
15-24 y
N=48
Homicide
17
Unintended
injury
8
Cancer
5
Suicide
4
25-34 y
N=65
Homicide
11
Cancer
9
35-44 y
N=141
Cancer
30
Heart
disease
25
Heart
disease
8
Infectious
diseases
17
45-54 y
N=312
Cancer
96
Heart
disease
61
Infectious
diseases
21
Stroke
20
Diabetes
15
55-64 y
N=381
Cancer
120
Heart
disease
75
Stroke
32
Diabetes
27
Infectious
diseases
20
Nephritis
10
Hypertension
7
Unintended
injury
5
65-74 y
N=499
Cancer
150
Heart
disease
118
Stoke
31
CLRD2
21
Infectious
diseases
19
Hypertension
9
Ranking
6
7
8
9
10
Stoke
5
Narcotics
poisoning
4
Diabetes
3
Nephritis
8
Homicide
7
5-14 y
N=6
75-84 y
N=796
>85 y
N=682
1
Heart
disease
204
Heart
disease
172
Infectious diseases
Unintended injury
7 each
Unintended
Homicide
injury
10
8
Nephritis
Diabetes
33 each
Diabetes
Nephritis
3 each
Musculoskeletal
Mental & behavioral
6 each
Narcotics poisoning
Unintended injury
10 each
Cancer
169
Stoke
65
Diabetes
43
Alzheimer’s
35
CLRD
33
Cancer
94
Stroke
67
Atherosclerosis
53
Mental &
behavioral
51
Alzheimer’s
42
Infectious
diseases
32
Infectious
diseases
32
Nephritis
30
Diabetes
26
Chronic
liver &
cirrhosis
Mental &
behavioral
5 each
Homicide
4 each
Chronic
Atheroliver &
sclerosis
cirrhosis
7
5
AtheroHypersclerosis
tension
26
23
HyperNephritis
tension
24
21
DEATHS
Page 111 of 294
Table 6-36 Leading causes of death1 among Hispanic females by age group, Kansas City,
Mo, 2003-2007
Deaths
by age
group
1
2
0-4 y
N=20
Conditions
perinatal
12
Congenital
anomalies
3
5-14 y
N=1
15-24 y
N=6
25-34 y
N=2
35-44 y
N=8
45-54 y
N=20
Cancer
8
55-64 y
N=29
65-74 y
N=41
75-84 y
N=62
>85 y
N=62
1
Ranking
Infectious
diseases
5
Heart
Cancer
disease
14
9
Cancer
Heart disease
15 each
Heart
Stroke
disease
7
14
3
4
5
6
7
8
9
10
Diabetes
Nephritis
3 each
Cancer
8
Diabetes
4
Stroke
3
Stroke
6
Hypertension
4
Cancer
Mental & behavioral
8 each
Diabetes
3
Alzheimer’s
3
DEATHS
Page 112 of 294
Literature cited
1
Xu J et al. Deaths: preliminary data for 2007. Natl Vital Stat
Rep 2009;58(1). www.cdc.gov/nchs
2
Ezzati M et al. The reversal of fortunes: trends in county
mortality and cross-county mortality disparities in the United
States. PloS Med 2008;5:e66.
3
Wong MD et al. The contribution of specific causes of
death to sex differences in mortality. Public Health Rep
2006;121:746-754.
4
White A, Holmes M. 2006. Patterns of mortality across 44
countries among men and women aged 15-44 years. J
Men’s Health Gender 3:139-151.
5
Krieger N et al. The fall and rise of US inequities in premature mortality: 1960-2002. PLoS Med 2008;e46.
6
Gregory IN. Comparisons between geographies of mortality
and deprivation from the 1900s and 2001: spatial analysis of
census and mortality statistics. Brit Med J 2009;339:b3454.
7
Kansas City Health Department. Annual Report 2008.
www.kcmo.org/health).
8
Macinko J, Elo IT. Black-white differences in avoidable
mortality in the United States, 1980-2005. J Epidemiol
Community Health 2009;12 April [epub ahead of print]
9
Alzheimer’s Association. 2008 Alzheimer’s disease facts
and figures. Alzheimer’s Dementia 2008;4:110-133.
10
Xei J et al. Survival times in people with dementia: analysis from population based cohort study with 14 year followup. Brit Med J 2008;336:258-262.
DEATHS
Page 113 of 294
7. Emergency Department Visits and Hospitalizations
In 2007, Kansas Citians made 205,057
different age groups are shown in Figure 7-2.
visits to hospital emergency departments and
Emergency department utilization was lowest for
72,866 residents were admitted to hospitals;
children and adolescents 5-14 years old. Hos15.3% of hospitalized patients were admitted
from emergency rooms (Figure 7-1). This
Figure 7-1 Percent of hospitalized Kansas
represented a 14.9% increase in emergency
City, Mo, residents who were admitted
department visits and a 22.8% increase in adfrom an emergency department
missions from the levels reported in 2006, but
were similar to those reported for 2005. The rate
19.1%
19.0%
18.6%
per 100 residents for emergency department
15.9%
15.3%
visits was 46.4 while for hospitalizations it was
16.5.
Nationally, 6.8% of persons discharged
from a hospital are seen in an emergency de2003
2004
2005
2006
2007
partment within 7 days of discharge.1
About 10% of those patients presented
with medical or surgical complications that
Table 7-1 Top 10 leading reasons for emergency
may have been related to their recent
department visits and hospitalizations of Kansas
hospitalization. Uninsured persons were
City, Mo, residents, 2007
Emergency Departnearly three times as likely as those priRank
Hospitalizations
ment Visits
vately insured to have an emergency de1
Injury
Pregnancy/birth
partment visit following hospital discharge.
2
Respiratory diseases
Cardiovascular diseases
The rate amongst Medicare enrollees is
3
Genitourinary diseases
nearly 20%.2
4
Mental disorders
Injury
5
Pregnancy/birth
Mental disorders
The top 10 reasons for the emer6
Dental complaints
Digestive system diseases
gency department visits and hospital ad7
Digestive system diseases
Genitourinary diseases
missions are shown in Table 7-1, while
8
Infectious diseases
Cancer
the utilization rates per 100 persons in
9
Inguinal hernia
Infectious diseases
10
Diabetes
Figure 7-2 Utilization rates by age group for emergency department visits and hospitalizations,
Kansas City, Mo 2007
158.3
52.0
16.5
39.6
24.4
25.0
27.7
28.8
41.9
35-44 y
45-54 y
55-64 y
65-74 y
75-84 y
41.4
67.1
45.2
10.4
54.5
12.1
5-14 y
63.9
1-4 y
11.5
53.4
26.5
2.9
50
4.0
150
100
Hospitalized
107.8
200
46.4
16.5
Rate per 100 Population
Emergency Department
0
Total
<1 y
15-24 y
25-34 y
>=85 y
EMERGENCY DEPARTMENT VISITS & HOSPITALIZATIONS
Page 114 of 294
Figure 7-3 Rates per 100 persons by race/ethnicity for emergency department visits and hospitalizations, Kansas City, Mo, 2007
Hospitalized
76.5
68.9
46.4
36.0
16.5
Total
34.5
9.4
White, nonHispanic
17.5
Black, nonHispanic
pital utilization rates exhibited a U-shaped curve
across the age groups.
Non-Hispanic blacks had the highest
emergency department visit utilization rate; it
was more than 1.9 times that for any other group
(Figure 7-3). Asians and Native Americans had
the lowest utilization rates for both emergency
departments and hospitals.
Emergency department visits
Overall, the emergency department utilization rate was 46.4 per 100 persons, higher
than the 2005 national rate of 39.6.3 Approximately 24% of the visits were for injury, the
leading reason for emergency department visits
across all age groups and for all racial/ethnic
groups (Tables 7-2 to 7-4). Acute respiratory
disease was the 2nd leading reason for emergency department visits across racial/ethnic
groups and for persons <65 years of age. The
rate of self-pay emergency department visits per
100 persons by Kansas City Health Zones is
shown in Figure 7-4; the central city zones Jackson01 and Jackson02 had the highest rates,
reflecting higher numbers of persons lacking
health insurance. The overall rate for the city
was 10.0. Nationally, 41.8% of emergency department visits are billed nearly equally to Medicaid/Medicare, 34.6% to private insurance, and
17.7% to the uninsured.4
33.3
11.5
16.0
Hispanic
7.9
Asian
10.9
4.4
Native American Other/unspecified
Hospitalizations
The overall hospital utilization rate was
16.5 per 100 persons. Overall, pregnancyrelated issues and birth was the leading reason
for hospitalization, followed by heart disease and
injury (Tables 7-5 to 7-7). Pregnancy/birth was
the 9th leading cause of hospitalization among
persons 5-14 years of age, and the leading
cause for those 15-44 years old. Among persons
>45 years of age, either heart disease or injury
was the leading reason for hospitalization.
Figure 7-4 Annualized rate of self-pay per
100 population for emergency department
visits by Health Zone, Kansas City, Mo,
2003-2007
Page 115 of 294
Table 7-2
Reasons for 205,057 emergency department visits, Kansas City, Mo, 2007
Reason
AIDS
Alcoholism
Alcoholic cirrhosis
Appendicitis
Arteriosclerosis
Asthma
Calculus of kidney/urinary
tract
Cancer, breast
Cancer, cervical
Cancer, colorectal
Cancer, lung
Cancer, other
Chickenpox
Cholelithiasis
Cystitis
Diabetes
Disease, cervix/vagina inflammatory
Disease, circulatory other
Disease, chronic lower respiratory
Visits
40
604
36
73
6
4,042
676
3
2
5
22
38
50
368
53
144
1,291
767
Reason
Disease, chronic, tonsils &
adenoids
Disease, esophagus
Disease, genitourinary other
Disease, oral cavity
Disease, other
Disease, pancreas
Visits
Reason
Visits
9
Infection, respiratory acute
10,295
651
2,669
4,308
86,076
29
Infection, viral unspecified
Infection & parasitic, other
Influenza
Inguinal hernia
Intestine, diverticulitis
1,236
1,148
214
1,929
227
Disease, respiratory other
2,175
Intestine, obstruction
Disorder, breast
Disorder, digestive functional
Disorder, digestive other
Disorder, menstruation
Disorder, mental
Disorder, vagina noninflammatory
Endometriosis
Gastritis & duodenitis
Gastrointestinal hemorrhage
277
779
810
617
4,918
Injury
Nutritional deficiency
Orchitis & epididymitis
Pain & symptoms, genital
Pneumonia
Pregnancy & birth, complications
Septicemia
Streptococcal sore throat
Stroke
Ulcers, stomach/small intestine
48,303
15
179
874
1,727
Other/not specified
13,045
Heart disease
1,058
11
597
358
1,189
Herpes simplex
181
2,221
Herpes zoster
286
2,101
Hyperplasia of prostate
95
4,753
13
1,132
272
40
20
Page 116 of 294
Table 7-3 Leading causes of emergency department visits by age group, Kansas City, Mo, 2007
Age
group
Ranking
1
2
3
4
5
6
7
8
9
10
Diseases of
oral cavity
4,308
Asthma
4,042
Other
genitourinary diseases
2,669
Other
circulatory
diseases
2,221
Other
respiratory
diseases
2,175
CLRDa
2,101
Total
192,013
Injury
48,303
Acute
respiratory
infection
10,295
Mental
disorders
4,918
Complications of
birth/
pregnancy
4,753
0-4 y
19,390
Injury
3,808
Acute
respiratory
infection
2,293
Asthma
595
Pneumonia
548
Other
respiratory
diseases
479
Unspecified
viral infection
354
Inguinal
hernia
329
5-14 y
15,918
Injury
6,231
Asthma
882
Strep throat
369
Pneumonia
182
Mental
disorders
165
Disease
oral cavity
164
15-24 y
35,222
Injury
9,377
Acute
respiratory
infection
2,146
Mental
disorders
1,045
Diseases of
oral cavity
909
25-34 y
36,614
Injury
8,588
Acute
respiratory
infection
2,014
Complications of
birth/
pregnancy
1,796
Diseases of
oral cavity
1,325
Mental
disorders
1,157
35-44 y
30,344
Injury
7,228
Acute
respiratory
infection
1,261
Mental
disorders
1,094
Diseases of
oral cavity
924
Asthma
519
45-54 y
27,696
Injury
6,393
Acute
respiratory
infection
931
Mental
disorders
879
Diseases of
oral cavity
640
55-64 y
13,057
Injury
3,037
65-74 y
6,406
Injury
1,614
Acute
respiratory
infection
392
Other
circulatory
diseases
184
Other
circulatory
diseases
354
Acute
respiratory
infection
180
75-84 y
4,963
Injury
1,311
>85 y
2,403
Injury
716
a
Other
infectious
& parasitic
diseases
316
Unspecified
viral infection
140
Noninflammatory disorders
vagina
499
CLRD
177
Functional
digestive
disorder
165
Other
respiratory
diseases
133
Inguinal
hernia
119
Pain &
genital
symptoms
408
Inguinal
hernia
341
Asthma
666
Inguinal
hernia
387
Other
respiratory
diseases
360
CLRD
348
Other
circulatory
diseases
450
Other
386
CLRD
325
Other
circulatory
diseases
588
Asthma
446
CLRD
385
Diabetes
317
Mental
disorder
293
CLRD
288
Heart
disease
251
Diabetes
195
Heart
disease
151
CLRD
130
Diabetes
112
Mental
disorders
104
Heart disease
158
Other circulatory diseases
158
Mental
disorders
111
Diabetes
101
CLRD
99
Acute
respiratory
infection
96
Other
circulatory
diseases
75
Mental
disorders
65
Acute
respiratory
infection
47
Stoke
35
CLRD
33
Acute
respiratory
infection
935
Complications of
birth/
pregnancy
2,567
Heart
disease
81
Other
831
Other
676
CLDR = chronic lower respiratory disease
Asthma
677
Other
respiratory
diseases
171
Other
respiratory
diseases
95
Complications of
birth/
pregnancy
280
Other
308
Other
respiratory
diseases
275
Other
respiratory
diseases
259
Asthma
155
Diseases of
oral cavity
144
Inguinal
hernia
68
Asthma
67
Other
respiratory
diseases
67
Functional
digestive
disorder
56
Other
52
Functional
digestive
disorder
29
Other
respiratory
diseases
26
Diabetes
23
Page 117 of 294
Table 7-4 Leading causes of emergency department visits by race/ethnicity, Kansas City, Mo,
2007a
Total
visits by
race/ ethnicity
Ranking
1
2
3
4
5
All
192,013
Injury
48,303
Acute
respiratory
infection
10,295
Mental
disorders
4,918
Complications of
birth/
pregnancy
4,753
Diseases
of oral
cavity
4,308
White,
nonHispanic
86,856
Injury
26,144
Acute
respiratory
disease
4,125
Mental
disorders
2,637
Diseases
of oral
cavity
1,999
Complications
pregnancy
& birth
1,875
Black,
nonHispanic
87,303
Injury
18,025
Acute
respiratory
disease
4,972
Asthma
2,737
Complications
pregnancy
& birth
2,331
Mental
disorders
2,021
Hispanic
9,868
Injury
2,322
Acute
respiratory
disease
631
Asthma
165
Diseases
of oral
cavity
148
Asian
1,227
Injury
285
Acute
respiratory
disease
78
Pneumonia
31
Other
genitourinary
diseases
20
Native
American
207
Injury
59
Acute
respiratory
disease
10
Other/not
specified
6,552
Injury
1,468
Acute
respiratory
disease
479
Diseases
of oral
cavity
152
Mental
disorders
123
a
Complications
pregnancy
& birth
303
Complications
pregnancy
& birth
52
Complications
pregnancy
& birth
187
6
7
Other
genitourinary
diseases
2,669
Other
genitouriCLRD
nary
1,278
diseases
1,084
Other
Diseases
genitouriof oral
nary
cavity
diseases
1,987
1,330
Other genitourinary
diseases
130
Pneumonia
130
Diseases of oral
cavity
18
Mental disorders
18
Asthma
4,042
Other
genitourinary
diseases
104
Other
respiratory
diseases
103
8
9
10
Other
circulatory
diseases
2,221
Other
respiratory
diseases
2,175
CLRDa
2,101
Asthma
1,033
Inguinal
hernia
991
Other
respiratory
diseases
915
Other
circulatory
diseases
1,229
Other
respiratory
diseases
1,026
Diabetes
794
Other
respiratory
diseases
126
Mental
disorders
115
Streptococcal
sore throat
111
CLRD
16
Asthma
91
Other respiratory diseases
15
Other circulatory diseases
15
Inguinal
hernia
79
Pneumonia
75
If there were 5 or fewer cases, the data was not included; b CLRD = chronic lower respiratory disease
Page 118 of 294
Table 7-5 Reasons for 72,866 hospitalizations, Kansas City, Mo, 2007
Reason
Visits
AIDS
154
Alcoholism
Alcoholic cirrhosis
Appendicitis
Arteriosclerosis
Asthma
Calculus of kidney/urinary
tract
Cancer, breast
Cancer, cervical
Cancer, colorectal
Cancer, lung
Cancer, other
413
261
306
256
986
Chickenpox
209
68
33
217
265
1,094
3
Cholelithiasis
Cystitis
Diabetes
Disease, cervix/vagina inflammatory
501
223
21
1,254
Disease, circulatory other
Disease, chronic lower respiratory
28
Reason
Disease, chronic, tonsils &
adenoids
Disease, esophagus
Disease, genitourinary other
Disease, oral cavity
Disease, other
Disease, pancreas
Visits
Reason
12
Infection, respiratory acute
572
327
1,566
81
13,058
96
Infection, viral unspecified
Infection & parasitic, other
Influenza
Inguinal hernia
Intestine, diverticulitis
79
541
28
809
553
Disease, respiratory other
1,548
Intestine, obstruction
Disorder, breast
Disorder, digestive functional
Disorder, digestive other
Disorder, menstruation
Disorder, mental
Disorder, vagina noninflammatory
Endometriosis
Gastritis & duodenitis
Gastrointestinal hemorrhage
Heart disease
27
205
914
179
5,087
Injury
Nutritional deficiency
Orchitis & epididymitis
Pain & symptoms, genital
Pneumonia
Pregnancy & birth, complications
Prematurity
Septicemia
Streptococcal sore throat
Stroke
6
36
170
271
5,764
Herpes simplex
17
Tuberculosis
1,313
Herpes zoster
35
Ulcers, stomach/small intestine
1,049
Hyperplasia of prostate
60
Not specified
Visits
536
5,514
102
10
87
1,769
9,303
46
681
21
1,486
19
294
12,303
Page 119 of 294
Table 7-6 Leading causes of hospitalizations by age group, Kansas City, Mo, 2007
Age
group
Ranking
1
Total
60,563
Complications of
pregnancy/
birth
9,303
2
3
4
5
7
8
9
10
Pneumonia
1,769
Cancer
1,677
Other
1,566
Other
respiratory
diseases
1,548
Stroke
1,486
Other
circulatory
diseases
1,313
Pneumonia
116
Other
infectious
& parasitic
diseases
103
Other
genitorurinary tract
disease
51
Other
respiratory
diseases
50
Prematurity
46
Pneumonia
37
Other
disease
33
Congenital
anomalies
28
Complications of
pregnancy/
birth
20
Appendicitis
64
Asthma
52
Other
digestive
disorders
43
Cholelithiasis
42
Inguinal
hernia
41
Inguinal
hernia
92
Other
digestive
disorders
88
Cholelithiasis
87
Pneumonia
82
Other
circulatory
diseases
175
Other
digestive
disorders
153
Asthma
151
Pneumonia
124
Heart
disease
5,764
Injury
5,514
0-4 y
2,267
Acute
respiratory
disease
418
Asthma
168
Congenital
anomalies
136
5-14 y
1,713
Mental
disorders
729
Injury
163
Asthma
154
Mental
disorders
1,172
Injury
538
Other
genitourinary tract
disease
97
Diabetes
86
Mental
disorders
825
Injury
617
Heart
disease
186
Diabetes
144
Mental
disorders
931
Injury
722
Heart
disease
322
Diabetes
204
15-24 y
6,831
25-34 y
8,480
35-44 y
6,960
Complications of
pregnancy/
birth
3,719
Complications of
pregnancy/
birth
4,560
Complications of
pregnancy/
birth
994
Mental
disorders
5,087
6
Injury
127
Appendicitis
50
Diabetes
50
Other
disease
114
Other
disease
191
Diseases of
esophagus
37
Inguinal
hernia
37
Other
respiratory
diseases
17
Functional
digestive
disorders
17
45-54 y
8,547
Injury
888
Heart
disease
868
Mental
disorders
785
Cancer
290
Pneumonia
258
Diabetes
249
Other
disease
234
Other
circulatory
diseases
216
Other
respiratory
diseases
194
CLRDa
193
55-64 y
7,873
Heart
disease
1,219
Injury
697
Cancer
379
Mental
disorders
323
Stroke
301
Other
respiratory
diseases
292
Other
circulatory
diseases
274
Pneumonia
252
CLRD
248
Other
disease
244
65-74 y
7,001
Heart
disease
1,184
Injury
559
Cancer
395
Stroke
332
CLRD
289
Other
respiratory
diseases
282
Pneumonia
271
Other
circulatory
diseases
232
Diabetes
157
75-84 y
7,051
Heart
disease
1,269
Injury
674
Stroke
392
Pneumonia
367
Other
respiratory
diseases
341
Cancer
337
Other
circulatory
diseases
229
>85 y
3,840
Heart
disease
668
Injury
529
Pneumonia
225
Other
respiratory
diseases
208
Stroke
214
Other
disease
137
Other
circulatory
diseases
112
a
Other
disease
246
Other
genitourinary tract
disease
219
Septicemia
115
CLRD
217
Cancer
98
Septicemia
153
Intestinal
obstruction
65
CLDR = chronic lower respiratory disease
Page 120 of 294
Table 7-7 Leading causes of hospitalizations by race/ethnicity, Kansas City, Mo, 2007a
Total
visits by
race/ ethnicity
All
60,563
White,
nonHispanic
35,227
Black,
nonHispanic
20,037
Ranking
1
Complications of
pregnancy/
birth
9,303
Complications of
pregnancy/
birth
4,305
Complications of
pregnancy/
birth
3,112
2
3
4
5
6
7
8
9
10
Heart
disease
5,764
Injury
5,514
Mental
disorders
5,087
Pneumonia
1,769
Cancer
1,677
Other
genitourinary
diseases
1,566
Other
respiratory
diseases
1,548
Stroke
1,486
Other
circulatory
diseases
1,313
Heart
disease
3,673
Injury
3,433
Mental
disorders
3,047
Pneumonia
1,195
Cancer
1,095
Other
respiratory
diseases
970
Stroke
923
CLRDb
792
Heart
disease
1,812
Mental
disorders
1,731
Injury
1,701
Diabetes
708
Asthma
587
Other
circulatory
diseases
548
Other
respiratory
diseases
500
Stroke
486
Pneumonia
43
Acute
respiratory
disease
54
Diabetes
39
Cancer
36
Other
genitourinary
diseases
934
Other
genitourinary
diseases
534
Hispanic
2,431
Complications of
pregnancy/
birth
1,029
Injury
175
Heart
disease
85
Mental
disorders
80
Other
genitourinary
diseases
49
Asian
464
Complications of
pregnancy/
birth
169
Heart
disease
33
Mental
disorders
20
Cancer
19
Pneumonia
13
Stroke
12
Other
genitourinary
diseases
11
Other
respiratory
diseases
10
Other
digestive
disorders
7
Native
American
71
Mental
disorders
10
Complications of
pregnancy/
birth
9
Other/not
specified
2,233
Complications of
pregnancy/
birth
679
Mental
disorders
199
Injury
178
Heart
disease
156
Cancer
49
Acute
respiratory
disease
42
Pneumonia
39
Other
genitourinary
diseases
36
Other
circulatory
diseases
35
a
If there were 5 or fewer cases, the data was not included; b CLRD = chronic lower respiratory disease
Literature cited
1
Burt CW et al. Emergency department visits by persons
recently discharged from US hospitals. Natl Health Stat Rep
2008;6. www.cdc.gov/nchs
2
Jencks SF et al. Rehospitalizations amongst patients in the
Medicare fee-for-service program. N Engl J Med
2009;360:1418-1428.
3
Naraw EC et al. National hospital ambulatory medical care
survey: 2005 emergency department summary. NCHS Adv
Data Vital Health Stat 2007;386. www.cdc.gov/nchs.
4
Owens PL, Mutter R. Payers of emergency department
care, 2006. www.hcupus.ahrq.gov/reports/statbriefs/sb77.jsp
Other
respiratory
diseases
32
Cholelithiasis
32
Acute
respiratory
disease
6
Other
circulatory
diseases
6
Diabetes
34
Page 121 of 294
8. Health Zones
The Health Zone mapping project divides
the city into seven (7) zones, split along zip code
lines. To assist the reader, Figure 8-1 is a map
of the zip codes that constitute Kansas City and
Figure 8-2 shows the Health Zones. The Health
Zone profile reports list the zip codes included in
the respective zones. Tables 8-1 to 8-7 show the
health indicator data for each respective zone
compared to the citywide values while Table 8-8
provides a comparison summary for the city and
all seven zones.
Figure 8-1 Zip codes for Kansas City, Mo
HEALTH ZONES
Page 122 of 294
Figure 2 Kansas City Health Zones
HEALTH ZONES
Page 123 of 294
Platte Zone (includes zip codes 64079, 64151, 64152, 64153, 64154, 64163, 64164)
Table 8-1 Select health indicators for Platte Health Zone
Demographic Measures (2000 census)
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
Health Indicators (Year 2007)
Birth rate per 1,000 population
Infant mortality rate per 1,000 live births
Percent of babies with low birthweight
st
Percent of mothers with no 1 trimester prenatal care
Birth rate to teenagers per 1,000 live births
Percent of women smoking during pregnancy
Number of children screened for lead poisoning [2008 data]
Percent of children with elevated blood lead levels [2008 data]
Mortality Indicators (Year 2007)
Percent of premature deaths (prior to 65 y)
Years of potential life lost (YPLL) prior to 65 y per 100 total deaths
Death rate per 10,000 population for persons <20 years old
Death rate per 10,000 population due to heart disease
Death rate per 10,000 population due to all cancers
Death rate per 10,000 population due to lung cancer
Death rate per 10,000 population due to diabetes
Death rate per 10,000 population due to stroke
Death rate per 10,000 population due to homicide
Death rate per 10,000 population due to HIV infection
Death rate per 10,000 population due to Alzheimer’s disease
Other Measures (Year 2008)
Rate of sexually transmitted infections per 1,000 population among persons
15-24 years old
Rate of assault/rape per 1,000 population (emergency medical services
data)
Rate of stabbing/gunshot injuries per 1,000 population (emergency medical
services data)
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Platte
34,559
7.3%
14.1%
12.7%
57.7%
8.3%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
89.3%
10.7%
Platte
16.3
3.5
7.8
7.9
5.8
10.1
447
0.0
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
28.7
1,338
1.2
14.5
19.1
4.3
2.0
4.3
0.0
0.0
2.9
74.6
37.7
78.3
31.8
29.5
4.6
HEALTH ZONES
Page 124 of 294
Clay01 Zone (includes zip codes 64155, 64156, 64157, 64165, 64166, and 64167)
Table 8-2 Select health indicators for Clay01 Health Zone
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
HEALTH ZONES
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Clay01
21,277
8.9%
16.4%
11.3%
57.8%
5.6%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
93.5%
6.5%
Clay01
34.3
4.1
5.8
6.2
3.8
6.0
558
0.4
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
31.8
1,368
2.3
13.6
16.4
4.2
0.9
5.2
0.5
0.0
3.3
74.6
26.3
78.3
14.1
29.5
3.8
Page 125 of 294
Clay02 Zone (includes zip codes 64116, 64117, 64118, 64119, 64158, 64160, and 64161)
Table 8-3 Select health indicators for Clay02 Health Zone
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Clay02
62,661
7.7%
13.8%
12.8%
55.3%
10.3%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
89.6%
10.4%
Clay02
18.1
5.3
6.5
12.5
8.4
14.6
1121
0.0
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
31.9
1,599
1.1
14.5
22.8
7.2
1.3
2.9
0.0
0.0
1.9
74.6
32.3
78.3
29.4
29.5
7.8
HEALTH ZONES
Page 126 of 294
Jackson01 Zone (includes zip codes 64101, 64102, 64105, 64106, and 64108)
Table 8-4 Select health indicators for Jackson01 Health Zone
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
HEALTH ZONES
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Jackson01
15,906
6.8%
11.6%
16.5%
55.6%
9.6%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
44.0%
56.0%
Jackson01
20.4
9.3
10.2
19.3
14.2
6.8
614
0.2
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
41.5
1,817
2.5
17.0
17.0
1.9
1.9
1.9
3.1
2.5
3.1
74.6
77.5
78.3
288.6
29.5
62.9
Page 127 of 294
Jackson02 Zone (includes zip codes 64109, 64120, 64123, 64124, 64125, 64126, 64127, and
64128)
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Jackson02
81,065
8.2%
17.1%
14.7%
48.3%
11.7%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
34.6%
65.4%
Jackson02
21.2
9.9
9.8
23.7
20.0
14.0
3,200
1.4
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
44.1
2,012
3.5
19.6
17.8
5.8
3.0
5.2
3.7
1.4
1.9
74.6
108.1
78.3
155.7
29.5
65.9
.
HEALTH ZONES
Page 128 of 294
Jackson03 Zone (includes zip codes 64110, 64111, 64112, 64113, 64129, 64130, 64132, 64133,
and 64136)
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
HEALTH ZONES
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Jackson03
123,993
6.4%
13.3%
14.9%
53.7%
11.7%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
48.7%
51.3%
Jackson03
15.2
13.3
9.3
19.3
16.4
13.1
2,306
0.6
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
35.7
1,645
3.1
17.3
19.8
5.6
2.4
4.3
2.7
0.4
2.5
74.6
88.0
78.3
85.2
29.5
39.2
Page 129 of 294
Jackson04 Zone (includes zip codes 64012, 64030, 64081, 64114, 64131, 64134, 64137, 64138,
64139, 64145, 64146, 64147, 64149, and 64192)
Total population
<5 years
5-14 years
15-24 years
25-64 years
65 years and older
Race
White
Non-white
st
15-24 years old
data)
services data)
City
441,515
7.2%
14.2%
13.7%
53.2%
11.7%
Jackson04
101,850
6.7%
13.0%
12.6%
52.3%
15.4%
60.7%
39.3%
City
18.1
8.2
8.5
16.9
12.7
11.8
9,650
0.7
64.1%
35.9%
Jackson04
16.2
6.0
8.9
18.1
9.8
10.2
1,404
0.4
33.8
1,571
2.4
17.4
19.8
5.7
2.3
4.5
1.8
0.6
2.9
25.3
1,198
1.9
19.2
20.8
6.3
2.8
5.6
1.0
0.6
4.7
74.6
71.8
78.3
35.0
29.5
10.1
HEALTH ZONES
Page 131 of 294
Table 8-8 Comparison of select health indicators for Kansas City Health Zones
Citywide
Platte
Total population
441,515
34,559
<5 years
7.2%
7.3%
5-14 years
14.2%
14.1%
15-24 years
13.7%
12.7%
25-64 years
53.2%
57.7%
>65 years
11.7%
8.3%
Race
White
60.7%
89.3%
Non-white
39.3%
10.7%
Health Measures (Year 2007)
Birth rate per 1,000
18.1
16.3
population
Infant mortality rate
8.2
3.5
per 1,000 live births
Percent of babies with
8.5
7.8
low birthweight
Percent of mothers
with no 1st trimester
16.9
7.9
prenatal care
Birth rate to teenagers per 1,000 live
12.7
5.8
births
Percent of women
smoking during preg11.8
10.1
nancy
Number of children
9,650
447
screened for lead
poisoning [2008 data]
Percent of children
with elevated blood
0.7
0.0
lead levels [2008
data]
Mortality Measures (Year 2007)
Percent of premature
33.8
28.7
deaths (prior to 65 y)
Years of potential life
lost (YPLL) prior to 65
1,571
1,338
y per 100 total
deaths
Death rates per 10,000 population
Persons <20 years
2.4
1.2
Heart disease
17.4
14.5
All cancers
19.8
19.1
Lung cancer
5.7
4.3
Diabetes
2.3
2.0
Stroke
4.5
4.3
Homicide
1.8
0.0
HIV infection
0.6
0.0
Alzheimer’s disease
2.9
2.9
Rates per 1,000 population for
Sexually transmitted
74.6
37.7
infections n among
persons 15-24 y
Assault/rape (emergency medical servic78.3
31.8
es data)
Stabbing/gunshot
injuries (emergency
29.5
4.6
medical services
data)
Clay01
Clay02
Jackson01
Jackson02
Jackson03
Jackson04
21,277
8.9%
16.4%
11.3%
57.8%
5.6%
62,661
7.7%
13.8%
12.8%
55.3%
10.3%
15,906
6.8%
11.6%
16.5%
55.6%
9.6%
81,065
8.2%
17.1%
14.7%
48.3%
11.7%
123,993
6.4%
13.3%
14.9%
53.7%
11.7%
101,850
6.7%
13.0%
12.6%
52.3%
15.4%
93.5%
6.5%
89.6%
10.4%
44.0%
56.0%
34.6%
65.4%
48.7%
51.3%
64.1%
35.9%
34.3
18.1
20.4
21.2
15.2
16.2
4.1
5.3
9.3
9.9
13.3
6.0
5.8
6.5
10.2
9.8
9.3
8.9
6.2
12.5
19.3
23.7
19.3
18.1
3.8
8.4
14.2
20.0
16.4
9.8
6.0
14.6
6.8
14.0
13.1
10.2
558
1121
614
3,200
2,306
1,404
0.4
0.0
0.2
1.4
0.6
0.4
31.8
31.9
41.5
44.1
35.7
25.3
1,368
1,599
1,817
2,012
1,645
1,198
2.3
13.6
16.4
4.2
0.9
5.2
0.5
0.0
3.3
1.1
14.5
22.8
7.2
1.3
2.9
0.0
0.0
1.9
2.5
17.0
17.0
1.9
1.9
1.9
3.1
2.5
3.1
3.5
19.6
17.8
5.8
3.0
5.2
3.7
1.4
1.9
3.1
17.3
19.8
5.6
2.4
4.3
2.7
0.4
2.5
1.9
19.2
20.8
6.3
2.8
5.6
1.0
0.6
4.7
14.1
29.4
77.5
108.1
88.0
71.8
3.8
7.8
288.6
155.7
85.2
35.0
2.5
4.3
62.9
65.9
39.2
10.1
HEALTH ZONES
Page 133 of 294
9. Cancer
tion is being overweight, and particularly being
obese, which has been associated with increased risk of common and less common malignant cancers.1 2 Being obese currently is associated with about 14% of cancer deaths in
men and 20% in women.
In 2008, 8% of United States adults >18
years of age had been diagnosed with cancer at
some point in their life and as age increased so
did the percent of adults diagnosed with cancer.3
In Missouri, the 2007 Behavioral Risk Factor
Surveillance System (BRFSS) found that 7.7%
of residents had been diagnosed with cancer
(5.7% of men; 9.5% of women).4
Non-Hispanic whites, particularly women, were more likely to be diagnosed with cancer than other racial/ethnic groups. The lifetime
risk for a man developing cancer is higher than for a woman;
Figure 9-1 Age-adjusted cancer death rates, Mo, 2003-2007
a little less than 1 in 2 for men
(source: Missouri Department of Health and Senior Services)
and a little more than 1 in 3 for
women. The risk of being diagnosed with cancer increases
as individuals age with about
76% of all cancers being diagnosed in persons >55 years
old. Cancer becomes 100
times more common in men
and 30 times more common in
women as age increases from
25 to 75 years. Nationally,
since 1999, cancer has been
the leading cause of death
(ahead of heart disease) for
persons <85 years of age.5
Age-specific cancer mortality
rates for all age groups have
been steadily declining in the
US since the early 1950s.6
Figure 9-1 displays
age-adjusted cancer death
Cancer is a diverse group of diseases
characterized by uncontrolled growth and
spread of abnormal cells. Tumors, or abnormal
enlargements of tissue, may be benign or malignant. The principal danger of a cancer is its tendency to metastasize, or invade neighboring
tissues or organs, and to grow in other areas of
the body.
The causes of cancer are diverse with
some being external to the body (carcinogens)
while others are internal (inherited, hormones,
immune conditions, mutations). In 2005, the Department of Health and Human Services’ 11th
edition of the Report on Carcinogens listed 246
known (58 substances and viruses) and reasonably suspected (188 substances) carcinogens.
One cause of cancer that is gaining in recogni-
CANCER
Page 134 of 294
rates for Missouri counties. The Kansas City
area had rates in the 2nd and 3rd quintiles. In
2004, the Kansas City Health Department commissioned a telephone health assessment of
residents.7 Of the respondents, 3.7% reported
they had cancer.
Both the incidence rates of new cancer
diagnoses and deaths in the US have been declining, but it was not until 2003 that the actual
number of cancer deaths declined. The incidence of the three most common cancers
among men (lung, colorectal, and prostate), and
the two most common types among women
(breast and colorectal) are declining for the first
time.8 Lung cancer deaths among women appear to be leveling off. Despite these trends,
death rates for certain types of cancer, such as
esophageal in men and pancreatic in women,
and liver in both sexes are rising.
Worldwide, it is estimated that 35% of
the 7 million cancer deaths were due to 9 potentially modifiable risk factors.9 Increased body
mass index has been associated with increased
risk of common and less common malignancies.10 Smoking, alcohol use, and low fruit and
vegetable intake are the leading risk factors for
death from cancer worldwide and in low and
middle income countries. In high income countries, smoking, alcohol use, and overweight/obesity were the most important causes
of cancer. Yet, nearly half of US adults believe
they have little or no control in reducing their risk
of cancer according to a December 2005 survey
commissioned by the American Cancer Society
(ACS). This may contribute to the fact that many
people with cancer continue to smoke after their
diagnosis, even though smoking can significantly compromise the outcome of treatment.11
Because of advances in early detection
and treatment, cancer has become a curable
disease for some and a chronic illness for others. The National Cancer Institute estimated that
approximately 10.8 million Americans with a history of cancer were alive in 2004. Some were
cancer free, while others still had evidence of
CANCER
cancer and may have been undergoing treatments. Underscoring this change, persons with
diagnoses of cancer increasingly are described
as “cancer survivors” rather than “cancer victims.”
Cancer survivors include all living persons who ever received a diagnosis of cancer.12
For all cancers combined, the number of survivors has increased steadily during the last 3
decades. In 2004, an estimated 6% of cancer
survivors had received their cancer diagnosis at
least 29 years earlier. More females than males
are survivors, although more males than females received cancer diagnoses. The 5-year
relative survival rates have improved for all cancers combined and for most, but not all, specific
types of cancer.13 In most minority populations,
cancer-specific survival rates are lower and,
once diagnosed the risk of dying from cancer is
higher compared to the white population.14 15 For
example, blacks tend to die earlier from breast,
ovarian and prostate cancer than patients of
other races due to biological and genetic factors,
not socioeconomic ones, despite having uniform
stage, treatment, and follow-up.16
The continued measurable declines for
overall cancer death rates, along with improved
survival rates, reflect progress in earlier diagnoses through increased screening, more effective treatment, prevention of secondary disease
and cancer recurrence, and decreases in mortality from other causes. In Missouri, racial disparities between blacks and white in overall cancer
mortality narrowed during 1990-2005, yet blacks
still were 28.2% more likely to die than whites; it
is expected that it will take decades to eliminate
the disparities at the current rate of decline.17 A
similar pattern occurs nationally.18
The National Institutes of Health estimated the overall cost for cancer in 2005 at
$209.9 billion with $74.0 billion for direct medical
costs (total of all health care expenditures),
$17.5 billion for indirect morbidity costs (cost of
lost productivity due to illness), and $118.4 billion for indirect mortality costs (cost of lost prod-
Page 135 of 294
uctivity due to premature death).
Racial and ethnic groups are not affected equally by cancer. In Kansas City, the
age-adjusted death rates for non-Hispanic
blacks and non-Hispanic whites are declining
while the rate for Hispanics is increasing (Figure
9-2). Non-Hispanic blacks are 38% more likely
to die from cancer than non-Hispanic whites and
78% more likely to die than Hispanics while nonHispanic whites were 29% more likely to die
than Hispanics. The age-adjusted hospitalization
rates and age-adjusted death rates due to cancer are shown in Figure 9-3.
For the purposes of this document, only
lung, breast, cancers of the female reproductive
Figure 9-2 Age-adjusted death rates from
cancer, Kansas City, Mo
1998-2002
216 201
2003-2007
273 269
197 189
123
All
White, nonHispanic
Black, nonHispanic
169
Hispanic
Figure 9-3 Age-adjusted rates for hospitalizations and deaths due to cancer, Kansas City, Mo
Hospitalizations
Deaths
515.5 500.5 507.6 499.4 492.8
428.0
241
392.8 401.9
217
201
205
211
209
206
210
2000 2001 2002 2003 2004 2005 2006 2007
tract, prostate, colorectal and skin cancer will be
considered.
Lung cancer
The ACS estimated there would be
219,440 new cases of lung cancer and 159,390
deaths nationally in 2009, accounting for 15% of
all cancer diagnoses and 28% of all cancer related deaths.19 The incidence rate for men has
been declining significantly since 1984, while
that for women is approaching a plateau after a
long period of increase. Whether women are
more susceptible than man to lung cancer by
cigarette smoking has been controversial. Recent reports, however, suggest that women are
not more susceptible than men to the carcinogenic effects of cigarette smoke in the lung.20
The county distribution of age-adjusted lung
cancer deaths in Missouri is shown in Figure 94. During 2003-2007, lung cancer was the leading cause of cancer deaths among men and
women, with age-adjusted rates of 83.4 men
and 46.5 for women.
In Kansas City, the average age at death
from lung cancer in 2007 was 69.0 years and
the median age at death was 70.0 years. Over
recent years, the age-adjusted death rate due to
lung cancer has been relatively constant and at
60.6 in 2007 it was 21% higher than the Healthy
People 2010 objective of 49.9. In 2007, the ageadjusted death rate from lung cancer among
men was 1.7 times higher than that among
women (82 vs 47, respectively). And among
women, the age-adjusted death rate for lung
cancer was 2.0 times higher than that for breast
cancer, 47 vs 24.
Using the Centers for Disease Control
and Prevention’s Adult and Maternal and Child
Health Smoking-Attributable Mortality, Morbidity,
and Economic Costs (SAMMEC) software
(www.cdc.gov/tobacco/sammec),21 the Office of
Epidemiology and Community Health Monitoring
determined that 80% of lung cancer deaths in
Kansas City during 2003-2007 could be attriCANCER
Page 136 of 294
information on the number of deaths by
age group and race/ethnicity for 20032007, while Tables 9-2 and 9-3 show
the distribution of lung cancer deaths
by zip code.
It is generally accepted that 8590% of lung cancer deaths occur
among persons who actively smoke,
while the remaining 10-15% occurs
among former smokers and persons
who never smoked. The deaths among
former smokers and non-smokers, if
considered a separate category, would
rank among the 6-8 most common fatal
cancers in the US.22 Exposure to
second-hand smoke is generally attributed as the etiology of lung cancer
among non-smokers. Some studies
suggest that lung cancer among women non-smokers is rising or is higher
Figure 9-4 Age-adjusted lung cancer death rates, Mo,
2003-2007 (source: Missouri Department of Health and Senior
Services)
buted to smoking; 86% of male and 72% of female lung cancer deaths.
The age-adjusted death rates for lung
cancer among non-Hispanic whites and nonHispanic blacks are shown in Figures 9-5 and 96. Figure 9-7 displays annualized lung cancer
death rates by median zip code level family income; the death rate was highest for those between $60,000 and $79,999. Non-Hispanic
blacks had a higher age-adjusted death rate
than non-Hispanic whites. Table 9-1 provides
Figure 9-5 Age-adjusted death rates for
lung cancer, Kansas City, Mo
1998-2002
66
62
All
CANCER
61
2003-2007
67
White, nonHispanic
75
lung cancer by race/ethnicity, Kansas
City, Mo
All
64 58
White, non-Hispanic
73
2003
68
81
64 61
60
2004
78
Black, non-Hispanic
68 67 72
2005
2006
61 55
75
2007
Figure 9-7 Annualized lung cancer death
rates per 10,000 population by zip code
median family income level, Kansas City,
Mo, 2003-2007
79
Black, nonHispanic
6.0
6.3
5.5
5.1
$20-39,999
$40-59,999
$60-79,999
$80-99,999
Page 137 of 294
Table 9-1 Lung cancer deaths among Kansas City, Mo, residents by age group and
race/ethnicity, 2003-2007
Age-group
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/not listed
Total
25-34
1
0
0
0
0
0
1
35-44
9
7
0
0
1
1
18
45-54
67
55
1
1
0
1
125
than the rate among men,23 yet comprehensive
reviews find that male non-smokers are about
25% more likely to die from lung cancer.24 The
rate for non-Hispanic black women non-smokers
is higher than that for non-Hispanic white women. While quitting smoking following a diagnosis
of lung cancer does not improve survival
chances, there is evidence to suggest that individuals who quit have better performance status
(well-being) than those who continued to
smoke.25
Genetics can play a role in the development of lung cancer.26 27 Persons with a variant
copy of the nicotinic acetylcholine receptor gene
cluster on chromosome 15q24 are 30% more
likely to develop lung cancer than those without
the variant. Inheriting two copies of the variant
increases the risk by 80%. A smoker with two
copies of the variant has a 1 in 4 chance of developing lung cancer. The variant is present in
approximately half of the people of European
ancestry.
Breast cancer
Excluding cancers of the skin, breast
cancer is the most commonly diagnosed cancer
among women in the US and the 2nd leading
cancer cause of death after lung cancer. After
continuously increasing for more than two decades, female breast cancer incidence rates began decreasing starting in 2001.28 Breast cancer
55-64
171
104
5
0
1
1
282
65-74
251
132
8
1
2
0
394
75-84
314
91
4
1
1
0
411
>85
82
25
2
0
0
0
109
Not
listed
1
1
0
0
0
0
2
Total
896
415
20
3
5
3
1,342
rates fell more substantially in urban and lowpoverty, affluent counties than in rural or highpoverty counties. These patterns likely reflect a
major influence of reductions in hormone therapy use after July 2002, but cannot exclude possible effects due to screening patterns, particularly among rural populations where hormone therapy use was probably less prevalent. 29 30
A woman has a probability of 1 in 8 for
developing breast cancer during her lifetime,
with women who have a history of smoking being at increased risk.31 Non-Hispanic white
women have a higher incidence rate of breast
cancer than non-Hispanic black women.32
In addition to women, men also can develop breast cancer. ACS estimated that in
2009, 192,370 new cases of invasive breast
cancer in women and 1,910 new cases in men
would be diagnosed. It further estimated that
40,170 women and 440 men would die from
breast cancer. Men have a higher case fatality
rate than women largely due to delayed diagnosis.33 34 During 2003-2007, Missouri recorded 36
cases of men dying from breast cancer and 2 of
these men were residents of Kansas City. In
Missouri, non-Hispanic whites accounted for
94% of the male breast cancer cases and nonHispanic blacks 6%.
Despite having about an 11% lower incidence rate for breast cancer, non-Hispanic
black women are 35% more likely to die from
their breast cancer are non-Hispanic white
women.35 This disparity in survival has been atCANCER
Page 138 of 294
comorbidities than of breast cancer
itself.36 Also, non-Hispanic black
White,
Black,
women are 1.4 to 3.6 times more
Total
nonnonlikely than non-Hispanic whites to
Zip code
deaths
Male
Female
Hispanic
Hispanic
be diagnosed with advanced breast
64101
0
0
0
0
0
64102
0
0
0
0
0
cancer.37 And, treatment varies by
64105
9
6
3
6
2
64106
6
5
1
2
4
race and ethnicity, with non64108
12
6
6
7
3
Hispanic blacks, Native Americans,
64109
44
30
14
12
32
64110
46
24
22
14
30
and Hispanics more likely to refuse
64111
35
20
15
30
4
64112
14
7
7
13
0
surgery or undergo a type of sur64113
29
18
11
29
0
gery not recommended by national
64114
97
43
54
89
8
64116
36
21
15
36
0
cancer guidelines.
64117
49
28
18
44
1
During 2003-2007, 343 fe64118
61
34
27
58
2
64119
42
26
16
40
0
male residents of Kansas City died
64120
2
2
0
2
0
64123
29
17
12
25
1
of breast cancer (Table 9-4). The
64124
30
18
12
23
4
annual incidence rate for breast
64125
5
4
1
5
0
64126
21
12
9
14
7
cancer deaths among women >25
64127
67
44
23
19
43
years of age was 4.5 per 10,000.
64128
60
37
23
2
57
64129
31
16
15
26
4
For non-Hispanic whites the annual
64130
108
74
34
9
99
64131
60
26
34
34
26
death rate was 4.6 per 10,000 and
64132
44
29
15
14
30
for non-Hispanic blacks, 5.6.
64133
61
33
28
50
10
64134
60
32
28
39
20
For the most recent years,
8
0
64136
8
5
3
64137
39
21
18
33
6
the age-adjusted death rate for
64138
40
16
24
27
13
breast cancer has been below the
64139
6
2
4
5
1
64145
37
19
18
34
1
Healthy People 2010 objective
64146
5
5
0
4
1
(Figure 9-8). A comparison of the
64147
0
0
0
0
0
64149
1
1
0
1
0
age-adjusted death rates for the
64151
48
26
22
46
1
64152
18
14
4
15
1
periods 1998-2002 and 2003-2007,
64153
8
5
3
8
0
however, showed an 11.4% in64154
16
8
8
14
2
64155
33
16
17
32
1
crease for non-Hispanic blacks and
64156
5
2
3
5
0
64157
12
7
5
12
0
a 4% increase for non-Hispanic
64158
4
0
4
4
0
white women (Figure 9-9).
64160
0
0
0
0
0
64161
1
1
0
1
0
The Healthy People 2010
64163
1
1
0
1
0
objective is that 70% of women >40
64164
2
2
0
2
0
64165
1
0
1
1
0
years old receive a mammogram at
64166
0
0
0
0
0
64167
0
0
0
0
0
least every two years. Yet, nation64192
0
0
0
0
0
ally there is a declining trend in the
All others1
2
2
0
1
1
Total
1,345
765
577
896
415
use of mammography to detect
1
Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190, 64191,
breast cancer. According to 2006
64195, 64196, and 64199 are associated with post office box numbers; zip codes 64144,
64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197, 64198, 64944, and
BRFSS) data, 65% of women in
64999 are associated with unique entities, and zip codes 64012, 64030, 64079, and
64081 are associated with Belton, Grandview, Platte City, and Lee’s Summit, respectively.
Missouri reported ever having a
mammogram and 61% of all women who had ever had a mammotributed to the fact that more non-Hispanic black
gram had one within the last year. 38 Among
women with breast cancer die of competing
women >40 and older, 10% had never had a
Table 9-2 Deaths due to lung cancer among Kansas City,
Mo, residents by zip code, 2003-2007
CANCER
Page 139 of 294
discomfort of coming out to health
care providers. The PULSE 2006 survey found that 46.5% of lesbians perRate per 1,000 population
formed monthly breast examinations,
0.0-0.9
1.0-1.9
2.0-2.9
3.0-3.9
4.0-4.9
=>5.0
although only 36.5% had an annual
64012
64106
64108
64105
64114
64136
mammogram (www.kcmo.org/health).
64030
64111
64110
64109
64128
64139
64079
64112
64113
64116
64130
64145
The Kansas City affiliate of the
64081
64155
64119
64117
64133
64161
Susan
G
Komen Breast Cancer Foun64101
64158
64120
64118
64156
64163
64102
64123
64126
64164
dation (www.kckomen.org) identified
64147
64124
64127
64165
13 gaps in breast health care, 8 of
64166
64125
64129
which dealt with educational needs.
64167
64131
64137
64192
64132
64146
Based on that assessment, the local
64134
64154
affiliate ranked its priorities as 1) edu64138
64157
64129
cation of both women and men, as
64151
well as lowering to a 3rd grade level
64152
64153
the reading comprehension of materials provided priTable 9-4 Breast cancer deaths among women by age and race/ethnicity,
marily to women, 2)
addressing fears of
Age-group
25-34 35-44 45-54 55-64 65-74 75-84
>85
Total
women concerning
White, non-Hispanic
2
12
29
40
37
56
38
214
breast cancer
Black, non-Hispanic
2
11
27
21
25
25
13
124
screening, treatHispanic
0
0
2
0
2
0
1
5
Total
4
23
58
61
64
81
52
343
ment, etc, and 3)
access to care.
Table 9-3 Distribution of lung cancer deaths by zip
code and rate per 1,000 population, Kansas City, Mo,
2003-2007
mammogram. In the Kansas City metropolitan
area 75.5% of women >40 years old had a
mammogram in the prior 2 years.39
In Missouri, 88% of women of all ages
reported ever having a clinical breast examination (CBE) with 67% reported having had a CBE
in the past year. The percent of women who had
a CBE increased with the levels of educational
attainment and income.
According to the Lesbian Cancer Project
of the Lesbian and Gay Community Center of
Greater Kansas City, lesbians are at a higher
risk of breast, cervical and ovarian cancers than
other women because they are less likely to
have children by age 30, if at all; are less likely
to visit a doctor for routine gynecological services and therefore less likely to have cancers detected at an earlier, more treatable stage; and,
are less likely to seek health care because of
Female reproductive tract cancers
Between 2003 and 2007, an average of
35 Kansas City women died each year from
Figure 9-8 Age-adjusted female death
rates from breast cancer, Kansas City, Mo
20
21
24
18
18
18
16
14
Yr 2010 objective for breast cancer deaths is 22.3
2000
2001
2002
2003
2004
2005
2006
2007
CANCER
Page 140 of 294
tionally, in 2009, cancer deaths from these four
body sites would number 28,120 and account for
about 10.4% of all cancer deaths among females. In Kansas City, they accounted for 8.3%
1998-2002 2003-2007
of cancer deaths among women during 200339
2007.
35
27 28
Despite improvements in aggressive
24 25
surgery and the initial good response of patients
to chemotherapies, there has been little improvement in the survival rates from ovarian
cancer for over three decades.40 About 65% of
All
Hispanic
women with epithelial ovarian cancer will die
within five years of their diagnosis. Early-stage
ovarian cancers are often asymptomatic and the
recognized signs and symptoms, even of latecancers of the female reproductive tract (Table
stage disease, are vague. Consequently, most
9-5). Over half the women who died from uterine
patients are diagnosed with advanced disease.
and ovarian cancers were >65 years of age as
BRFSS data for 2006 show that 94% of
were 38% of those who died from cervical canwomen
in Missouri reported ever having a pap
cer (Figure 9-10). The ACS estimated that natest and 80% reported having one within the past 3 years (in the Kansas City
metropolitan area 84.8% had a pap test
Table 9-5 Deaths from cancers of the female reproductive tract, Kansas City, Mo, 2003-2007
in the prior 3 years). Women of higher
White,
Black,
education and income levels were signonnonnificantly more likely to report having
Hispanic
Hispanic
Hispanic
Total
Cervical cancer
17
9
1
27
had a pap test in the past 3 years. Six
Uterine cancer
32
17
1
50
percent (6%) of women age 18 to 69
Ovarian cancer
61
24
4
89
years and 8% of women >70 years reVagina/vulva
8
3
0
11
ported
never having a pap test. Low
Total
118
53
6
177
income and educational attainment
were associated with
higher percentages of
Figure 9-10 Age at time of death from cancers of the female reprowomen reporting that they
ductive tract, Kansas City, Mo, 2003-2007
had not had a pap smear
Cervical
Uterine
Ovarian
Vaginal
within the past 3 years.
Figure 9-9 Age-adjusted female death
rates from breast cancer by race, Kansas
City, Mo
55
35
31
0
0
1
15-24
11
6
0
0
2
5
0
25-44
Age at death (years)
CANCER
15
45-64
10
Prostate cancer
6
=>65
Prostate cancer is
the leading cause of cancer in men and the 2nd
leading cancer cause of
death. The ACS estimated that, in 2009, the
Page 141 of 294
US would record 192,280 new cases of prostate
cancer and 27,360 deaths. For reasons that remain unclear, incidence rates are significantly
higher among black men than whites. Since
1995, prostate cancer incidence rates have leveled off for both black and white males and
while death rates decreased more rapidly
among black men they remain more than twice
as high as those for whites. The narrowing of
racial disparity in the prostate cancer stage at
diagnosis has decreased significantly since
1988.41
Between 2003 and 2007, Missouri recorded 2,812 prostate cancer deaths (ageadjusted rate for males of 23.2). The ACS projected 3,620 new cases of prostate cancer and
660 deaths among Missourians in 2009.
Kansas City recorded 209 prostate cancer deaths among residents during 2003-2007
(Table 9-6). The age-adjusted death rate for
prostate cancer deaths fluctuated annually, but
hovered around the target set by Healthy People
2010 (Figure 9-11). A comparison of the ageadjusted deaths for 1997-2001 and 2002-2006
found declines of 19% and 33% for nonHispanic white and non-Hispanic black males,
respectively (Figure 9-12). The disparity ratio for
the two time periods declined from 3.0 to 2.7.
The National Prostate Cancer Coalition
report card for 2007 downgraded Missouri from
a B to a C-. The state-by-state grading is based
on current prostate cancer screening rates, mortality rates, and if the state currently has laws in
place guaranteeing insurance coverage for testing (www.fightprostatecancer.org).
prostate cancer, Kansas City, Mo
37
31
29
27
29
32
28
27
Yr 2010 objective is 28.8 deaths per 100,000 men
2000
2001
2002
2003
2004
2005
2006
2008
prostate cancer, Kansas City, Mo
1998-2002
2003-2007
72
53
35
26
All
24
20
White, nonHispanic
Black, nonHispanic
In 2006, 63% of Missouri men >40 years
reported on the BRFSS that they had ever having a prostate specific antigen test (PSA) and
42% reported having one within the past year. In
the Kansas City metropolitan area in 2006,
56.3% of men >40 years reported having had a
PSA test in the prior 2 years. A significantly
higher percentage of men with more than a high
school education (71%) reported ever having a
PSA compared to men with a high school education (54%) and less than a high school education (51%). Seventy-three percent (73%) of men
>40 years ever had a
digital rectal exam and
49% had one in the past
Table 9-6 Prostate cancer deaths among men by age and
race/ethnicity, Kansas City, Mo, 2003-2007
year. Men with more
Age-group
than a high school edu15-24
35-44
45-54
55-64
65-74
75-84
>85
Total
cation (80%) were signifWhite, non-Hispanic
0
0
5
7
16
54
28
110
icantly more likely to
Black, non-Hispanic
1
1
1
11
23
29
23
89
Hispanic
0
0
0
0
4
4
1
9
have had a digital rectal
Asian
0
0
0
0
0
0
1
1
exam than men with a
Total
1
1
6
18
43
87
53
209
CANCER
Page 142 of 294
since 1998.44 The decrease partly reflects an
increase in screening which can detect and remove colorectal polyps before they progress to
cancer. 45 Figure 9-13 displays age-adjusted
colorectal cancer deaths in Missouri for 20032007; the Kansas City counties were in the 2nd
and 3rd quintiles.
In 2006, a significantly higher percentage of adults >50 years old in the Southwest
(51%), Kansas City (51%) and Northwest (51%)
regions of the state reported ever having a blood
stool test compared to adults in the St. Louis
(36%), Northeast (38%), and Southeast (39%)
regions. In the bi-state Kansas City metropolitan
Colorectal cancer
area, 25% of adults >50 years old had a blood
Colorectal cancer accounts for about
stool
testing the prior 2 years. A higher percen10% of all cancer deaths each year in the US.
rd
tage of adults age 50 and older in the St. Louis
Nationally, it is the 3 most common cancer in
nd
(64%) and Kansas City (63%) regions reported
both men and women, and the 2 leading cause
ever having a colonoscopy test compared to the
of cancer death in men and women. Colorectal
Southeast (45%), Northwest (51%) and Northcancer incidence rates have been decreasing for
east (51%) regions.
most of the last 2 decades and more steeply
The ACS projected the
US would experience 106,100
cases of colon and 40,870 cases
Figure 9-13 Age-adjusted colorectal cancer death rates, Mo,
of rectal cancer in 2009 along
2003-2007 (source: Missouri Department of Health and Senior Services)
with an estimated 49,920 deaths.
Also, it projected Missouri would
record 3,100 new cases and
1,100 deaths. Between 2003 and
2007, Missouri recorded 5,909
colorectal cancer deaths for an
overall age-adjusted death rate of
18.6. Women accounted for 2,976
of the deaths and men for 2,933
(age-adjusted death rates of 15.8
and 22.4, respectively). NonHispanic black females and
males had higher age-adjusted
death rates than their nonHispanic white counterparts.
For 2003-2007, Kansas
City recorded 419 deaths from
colorectal cancer (Table 9-7). The
age-adjusted death rate for colo-
high school education (64%).
Four percent (4%) of Missouri men >40
years old had been ever been told by a health
care professional that they had prostate cancer.
Significantly more white men (4%) reported receiving a diagnosis of prostate cancer than black
men (<1%).
According to the literature, obesity increases the risk of prostate cancer and its recurrence following radical prostatectomy for both
black and white men.42 43
CANCER
Page 143 of 294
lorectal cancer
was 73.8 years,
with a median
65-74
75-84
>85
Total
age of 75 years.
47
94
60
261
Nationally, blacks
38
31
26
143
have lower sur2
4
2
12
vival rate from
0
1
0
1
0
0
0
2
colorectal cancer
87
130
88
419
than whites and
the disparity may
be rising due to
blacks being diagnosed in later stages of disease than whites and blacks being less likely to
have surgery to remove the cancer.46 Compared
with whites, blacks have a higher prevalence of
large polyps (>9 mm).47 The existing racial disparities in survival following diagnosis of colon
cancer have been reported to be non-existent
after accounting for socioeconomic factors and
treatment differences.48
The primary risk factor for colorectal
cancer is age, with >90% of cases diagnosed in
individuals >50 years old. Risk is increased by
certain genetic mutations, a personal or family
history of colorectal cancer and/or polyps, or a
personal history of inflammatory bowel disease.
Several modifiable factors are associated
with the risk of colorectal cancer. Among these
are obesity, physical inactivity, smoking, heavy
alcohol consumption, a diet high in red or
processed meats, and inadequate intake of fruits
and vegetables. Current drinking, smoking, and
smoking plus drinking are associated with onset
of colorectal cancer at younger ages.49 Regular
use of non-steroidal anti-inflammatory drugs
(such as aspirin), estrogen and progestin hormone therapy, and HMG Co-A reductase inhibitors taken to reduce cholesterol, possibly reducing colorectal cancer risk.
Table 9-7 Colorectal cancer deaths by age and race/ethnicity, Kansas City,
Mo, 2003-2007
Age-group
15-24
25-34
35-44
45-54
55-64
0
1
0
0
0
1
1
0
1
0
0
2
5
5
0
0
0
10
18
15
1
0
0
34
36
27
2
0
2
67
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Other/not listed
Total
colorectal cancer, Kansas City, Mo
23
22
21
18
23
20
19
17
Yr 2010 objective is 13.9 deaths per 100,000 population
2000
2001
2002
2003
2004
2005
2006
2007
colorectal cancer, Kansas City, Mo
1998-2002
2003-2007
32
23
20
All
19
28
17
White, nonHispanic
Black, nonHispanic
rectal cancer was 23 for 2007 (Figure 9-14)
which exceeded the Healthy People 2010 objective of 13.9 deaths per 100,000. The breakout by
race/ethnicity is shown in Figure 9-15. The ageadjusted death rates declined for both nonHispanic whites and non-Hispanic blacks between the periods 1998-2002 and 2003-2007. In
2007, the average age at time of death from co-
Skin cancer
The World Health Organization estimates that 60,000 persons a year die from exCANCER
Page 144 of 294
arms or legs.53 Individuals who develop a melanoma are at twice the future risk for developing
a new primary cancer.54
There are two pathways to melanoma:
via exposure to the sun and via moles. The most
powerful risk factor for melanoma is the number
of moles a person has.55 Although sun exposure
has long been suspected to be a risk factor for
melanoma, the relation between sun exposure
and melanoma is complex. It is hypothesized
that host response to ultraviolet radiation is more
important than dose of sun exposure. There is
no direct evidence that reducing sun exposure
has had an effect on melanoma incidence.
The ACS projected that nationally, in
2009, melanoma would be diagnosed in 68,720
persons and that there would be 8,650 deaths,
in addition, ACS projected 2,940 deaths from
other non-epithelial skin cancers. In Missouri,
since 1990, the number of melanoma deaths
has been gradually increasing (Figure 9-16).
Between 2003 and 2007, 963 Missouri residents
(39 of whom were Kansas City residents) died
from malignant melanoma, 919 (97.5%) of
whom were non-Hispanic whites. Among nonHispanic whites, 62% of the deaths involved
males. Nine melanoma deaths occurred among
non-Hispanic blacks (7 in males, 2 in females)
and 4 deaths among Hispanics (2 males, 2 females).
posure to the sun, with the bulk of cases attributed to skin cancers. In the US the number of
new cases and deaths from skin cancers, primarily malignant melanoma, increased rapidly in
the last few decades. In addition, more than 1
million cases of basal cell or squamous cell cancers occur annually, 50 but most of these forms
of skin cancer are highly curable. The American
Academy of Dermatology warns that 1 in 5
Americans will develop skin cancer during their
lifetime, and that the risk doubles if he or she
has had 5 or more sunburns.
The most serious form of skin cancer is
melanoma. The observed increase in reported
melanomas has been characterized by some as
an epidemic, although others feel it has resulted
from earlier diagnoses of melanoma and that the
rates of diagnoses of later-stage melanoma
have not changed.51
Melanomas rarely present in non-white
people, in whom the incidence is 10 to 20 times
lower than in white people. Having fair skin with
a poor ability to tan, or a freckled complexion
with or without red hair, doubles a person’s risk
of melanoma. Individuals who have melanoma
of the scalp or neck have lower survival rates
than persons who experience melanoma elsewhere on their bodies, including the extremities,
trunk, face, and ears.52 They have twice the risk
of dying as persons with melanomas on their
Figure 9-16 Deaths from malignant melanoma, Missouri, 1990-2007
210
192
154
185
168
159
146
143
156
153
163
165
99
00
215
196
187
168
155
126
90
CANCER
91
92
93
94
95
96
97
98
01
02
03
04
05
06
07
Page 145 of 294
Figure 9-17 Deaths due to skin cancer by
age group (years), Kansas City, Mo, 20032007
10
Renehan AG et al. Body-mass index and incidence of
cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569-578.
11
14
Gritz ER et al. Successes and failures of the teachable
moment: smoking cessation in cancer patients. Cancer
2006;106:17-27.
15
11
10
12
Rowland J et al. Cancer survivorship – United States,
6
1
2
3
20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Figure 9-17 shows the age distribution
of deaths for skin cancer in Kansas City.
13
Jemal A et al. Annual report to the nation on the status of
cancer, 1975-2001, with a special feature regarding survival.
Cancer 2004;101:3-27.
14
Paltoo DN, Chu KC. Patterns in cancer incidence among
American Indians/Alaska Natives, United States, 1992-1999.
Public Health Rep 2004;119:443-45.
15
Singh GK et al. Persistent area socioeconomic disparities
in US incidence of cervical cancer mortality, stage, and survival, 1975-2000. Cancer 2004;101:1051-1057.
16
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Albain KS et al. Racial disparities in cancer survival among
randomized clinical trials patients of the Southwest Oncology
Group. J Natl Cancer Inst 2009;101:984-992.
1
17
2
18
3
19
Renehan AG et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective
observational studies. Lancet 2008;371:569-578.
Reeves GK et al. Cancer incidence and mortality in relation
to body mass index in the Million Women Study: cohort
study. Brit Med J 2007 Dec 1;335(7630):1134.
National Center for Health Statistics. Summary health statistics for US adults: National Health Interview Survey, 2008.
NCHS Vital Health Stat 2007;10(242). www.cdc.gov/nchs
4
Missouri Department of Health and Senior Services. 2007
Behavioral Risk Factor Surveillance System.
www.dhss.mo.gov/BRFSS
Shootman M, Yun S. Cancer disparities between AfricanAmericans and whites in Missouri. Missouri Med 2009;106;913.
American Cancer Society. Cancer Facts & Figures for
African Americans 2009-2010. Atlanta: American Cancer
Society, 2009. www.cancer.org.
American Cancer Society. Cancer Facts & Figures 2009.
Atlanta: American Cancer Society, 2009. www.cancer.org.
20
Freedman ND et al. Cigarette smoking and subsequent
risk of lung cancer in men and women: analysis of a prospective cohort study. Lancet Oncol 2008;9:649-656.
21
Jemal A et al. Cancer statistics 2008. CA Cancer J Clin
2008;58:71-96.
Malarcher AM et al. Methodological issues in estimating
smoking-attributable mortality in the United States. Am J
Epidemiol 2000;152:573-584.
6
Kort EJ et al. The decline in US cancer mortality in people
born since 1925. Cancer Res 2009;69:6500-6505.
22
7
Kansas City Health Department. 2004 Health Assessment
Survey. www.kcmo.org/health.
23
8
24
5
Jemal A et al. Annual report to the nation on the status of
cancer, 1975–2005, featuring trends in lung cancer,
tobacco use, and tobacco control. J Natl Cancer Inst
2008;100:1672–1694.
9
Danaei G et al. Causes of cancer in the world: comparative
risk assessment of nine behavioural and environmental risk
factors. Lancet 2005;366:1784-1793.
Ries L et al. SEER cancer statistics review, 1975-2002.
National Cancer Institute, 2005. www.cancer.gov/statistics.
Subramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol 2007;25:561-570.
Thun MJ et al. Lung cancer occurrence in never-smokers:
an analysis of 13 cohort and 22 cancer registry studies.
PLoS Med 2008;5:e185.
25
Baser S et al. Smoking cessation after diagnosis of lung
cancer is associated with a beneficial effect on performance
status. Chest 2006;130:1784-1790.
26
Hung RJ et al. A susceptibility locus for lung cancer maps
to nicotinic acetylcholine receptor subunit genes on 15q25.
Nature 2008;452:633-637.
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27
Thorgeir E et al. A variant associated with nicotine dependence, lung cancer, and peripheral artery disease. Nature
2008;252:638-642.
28
Stewart SL et al. Decline in breast cancer incidence –
United States, 1999-2003. MMWR Morb Mortal Wkly Rep
2007;56:549-553.
29
Hausauer AK et al. Recent trends in breast cancer incidence in US white women by urban/rural and poverty status.
BMC Med 2009;7:31.
30
Kerlikowske K et al. Declines in invasive breast cancer
and use of postmenopausal hormone therapy in a screening
mammography population. J Natl Cancer Institute
2007;99:1335-1339.
31
Coghan IT et al. The role of smoking in breast cancer
development: an analysis of a Mayo Clinic cohort. The
Breast J 2009;15:489-495.
32
Smigal C et al. Trends in breast cancer by race and ethnicity: update 2006. CA Cancer J Clin 2006;56:168-183.
33
Pituskin E et al. Experiences of men with breast cancer: a
qualitative study. J Men’s Health Gender 2007;4:44-51.
34
Niewoeher CB, Schorer AE. Gynaecomastia and breast
cancer in men. Brit Med J 2008;336:709-713.
35
National Cancer Institute. Surveillance, Epidemiology, and
End Results (SEER) Program. http://seer.cancer.gov
36
Tammemagi CM et al. Comorbidity and survival disparities
among black and white patients with breast cancer. J Am
Med Ass 2005;294:1765-1772.
37
Li CI et al. Differences in breast cancer stage, treatment,
and survival by race and ethnicity. Arch Intern Med
2003;163:49-59.
38
Behavioral Risk Factor Surveillance System Annual Report:
Health Risk Behaviors of Adult Missourians. June 2007.
www.dhss.mo.gov/BRFSS/2006AnnualReport.pdf
39
Kilmer G et al. Surveillance of certain health behaviors and
conditions among states and selected local areas – Behavioral Risk Factor Surveillance System (BRFSS), United
States, 2006. MMWR Surv Summ 2008;57:SS-7.
40
Lawernson K, Gayther SA. Ovarian cancer: a clinical challenge that needs some basic answers. PLoS Med
2009;6:e1000025.
41
Shao YH et al. Contemporary risk profile of prostate cancer in the United States. J Natl Cancer Inst 2009;101:12801283.
42
Hernandez BY et al. Relationship of body mass, height
and weight gain to prostate cancer risk in a multiethnic co-
CANCER
hort. Cancer Epidemiol Biomarkers Prev 2009;18:24132421.
43
Jayachandran J et al. Obesity as predictor of adverse
outcomes across black and white race. Cancer 2009;10
August [epub ahead of print].
44
Jackson-Thompson J et al. Descriptive epidemiology of
colorectal cancer in the United States, 1998-2001. Cancer
2006;107(5 suppl):1103-1111.
45
Joseph DA et al. Use of colorectal cancer tests – United
States, 2002, 2004, and 2006. MMWR Morb Mortal Wkly
Rep 2008;57:253-258.
46
Yan B et al. Racial differences in colorectal survival in the
Detroit metropolitan area. Cancer 2009; 13 July [epub ahead
of print].
47
Lieberman DA et al. Prevalence of colon polyps detected
by colonoscopy screening in asymptomatic black and white
patients. J Am Med Ass 2008;300:1417-1422.
48
Du XL et al. Meta-analysis of racial disparities in survival in
association with socioeconomic status among men and
women with colon cancer. Cancer 2007;109:2161-2170.
49
Zisman AL et al. Associations between the age at diagnosis and location of colorectal cancer and the use of alcohol
and tobacco. Arch Intern Med 2006;166:629-634.
50
Christenson LJ et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. J
Am Med Ass 2005;294:681-690.
51
Levell NJ et al. Melanoma epidemic: a midsummer night’s
dream. Brit J Dermatol 2009;161:630-634.
52
Lachiewicz AM et al. Survival differences between patients
with scalp or neck melanoma and those with melanoma of
other sites in the Surveillance, Epidemiology and End Results (SEER) program. Arch Dermatol 2008;144:515-521.
53
Lachiewicz AM et al. Epidemiologic support for melanoma
heterogeneity using the survival, epidemiology, and end
results program. J Invest Dermatol 2008;128:1340-1342.
54
Cantwell MM et al. Second primary cancers in patients
with skin cancer: a population-based study in Northern Ireland. Br Med J 2009;100:174-177.
55
Bataille V, de Vries E. Melanoma – Part 1:epidemiology,
risk factors, and prevention. Brit Med J 2008;337:1287-1291.
Page 147 of 294
10. Cardiovascular Diseases
Cardiovascular diseases affect an estimated 79.4 million adults (1 in 3) in the United
States, 47% of whom are estimated to be >65
years of age (Table 10-1).1 The direct and indirect costs of cardiovascular diseases in 2007
were estimated at $431.8 billion. Hospital treatment for just 6 cardiovascular disease conditions
(coronary artery disease, heart attacks, congestive heart failure, irregular heartbeats, stroke,
and chest pain with no determined cause) accounted for 17.6% of the dollars hospitals spent
on patient care in 2006.2
In Missouri during 2006, hospital
<120/80 mm Hg, cholesterol <200 mg/dL and
the absence of current smoking.6 Persons with
blood pressure <120/80 mm Hg have about half
the lifetime risk of stroke as those with hypertension.7
Heart disease
Heart disease is typically thought of as
coronary heart disease (syn: coronary artery
disease), but other conditions also can affect the
structures or function of the heart such as abnormal heart rhythms or arrhythmias, heart fail-
Table 10-1 Prevalence estimates for cardiovascular diseases in Americans
Heart disease
Coronary heart disease
Hypertension
Stroke
White, nonHispanic
11.9%
6.6%
21.2%
2.5%
Black, nonHispanic
9.6%
5.2%
29.2%
3.2%
charges for heart disease and stroke were $3
billion and $495 million, respectively. In Missouri, the indirect costs due to lost productivity
from premature deaths from heart disease and
stroke were estimated at $1.75 billion and $252
million, respectively.3 Given various dynamics,
eg, aging population, obesity epidemic, underuse of prevention strategies, and suboptimal
control of risk factors, the future burden of cardiovascular diseases could be exacerbated.4 5
Of the different components of the rubric known as cardiovascular diseases, this report will address only heart disease in general,
coronary heart disease, stroke, and hypertension. Blood pressure is a prevailing issue for
these diseases. For example, low risk for coronary heart disease is defined as blood pressure
Hispanics
9.2%
6.0%
19.6%
2.8%
Native
Americans
11.6%
7.6%
25.4%
5.1%
Asians
6.7%
4.2%
16.9%
2.4%
Native Hawaiians/
Pacific Islanders
13.8%
13.8%
20.7%
8.1%
ure, valve disease, congenital heart disease,
heart muscle disease (cardiomyopathy), pericardial disease, aorta disease, Marfan syndrome, and vascular disease (blood vessel disease). People with coronary heart have significantly poorer health related quality of life compared to persons without coronary heart disease
and women have a lower quality of life compared to men.8
Prevalence
According to the National Health Interview Survey (NHIS) 2008, 12% of adults >18
years of age have some sort of heart disease,
with 6% having coronary heart disease.9 Males
had a higher prevalence of both heart disease
overall and coronary heart disease than feCARDIOVASCULAR DISEASES
Page 148 of 294
males. Prevalence rates increased with age,
were inversely associated with educational attainment, income and poverty status, and were
highest in the Midwest and South regions of the
country. National Behavioral Risk Factor Surveillance System (BRFSS) data for 2008, demonstrated that 4.2% of respondents had a history of
myocardial infarction and 4.3% had a history of
angina/coronary heart disease (CHD).10 Men
had a significantly higher prevalence of these
conditions than women and persons without a
high school diploma had nearly twice the prevalence of college graduates. Missouri had one of
the highest prevalence rates for heart disease in
the nation. The 2007 Missouri BRFSS revealed
that 4.7% of adults (6.0% of males; 3.6% of
women) reported that a doctor had ever told
them that they had a heart attack.11
It has been reported that 1 in 100 black
men and women will develop heart failure before
50 years of age.12 Hypertension, obesity, and
systolic dysfunction that are present before a
person is 35 years of age are important antecedents that may be targets for the prevention of
heart failure.
Mortality
The long-term decreasing trends in
death from heart disease and stroke continued
in 2007, with heart disease remaining the number one cause of death for Americans.13 Mortality has been declining males but has not in females.14 However, recent studies suggest that
the decline in mortality is ending.15 16 In Missouri, the death rates for heart disease and
stroke declined 29% and 27%, respectively, between 1998 and 2007. While heart disease and
cancer are the top two causes of death in the
nation, cancer is replacing heart disease as the
leading cause of death.
Decreases in coronary heart disease
mortality have been attributed almost equally to
reductions in risk factors and to medical therapies.17 18 19 Despite the attribution of half of the
CARDIOVASCULAR DISEASES
decline to reductions in risk factors, the National
Center for Health Statistics found no appreciable
difference in the distribution of 10-year risk for
developing coronary heart disease.20 This observation may have to do with individuals not
truly making life-style changes in their behaviors
such as diet.21 Also, a high serum cholesterol
level indicates a potential increased risk for
heart disease and 16% of adults >20 years of
age who participated in National Health and Nutrition Examination Surveys (NHANES) during
2005-2006, had serum total cholesterol levels
>240 mg/dL.22
Among persons experiencing heart attacks, those with chronic health conditions have
diminished chances of surviving to hospital discharge, about 16% less for each chronic condition.23 Black heart attack patients have worse
outcomes than their white counterparts; most of
the disparities can be attributed to patient characteristics present before admission.24 About
20% of black patients die within two years of a
heart attack, compared with 9% for whites; nearly 30% of blacks have severe chest pain 28%,
compared with 18% of whites; and, blacks are
less likely to undergo procedures to unblock
clogged coronary arteries.
Stroke
Stroke is a cerebrovascular accident
that results in the sudden death of a portion of
the brain; symptoms vary depending on the area
of the brain affected. An estimated half million
Americans suffer strokes each year and nearly 4
million are survivors of stroke, although many
are disabled as a result.
Prevalence
According to the 2008 NHIS, 2.6% of
adults >18 years of age have experienced a
stroke. The prevalence was higher among
males, increased with age, was inversely associated with educational attainment, income and
Page 149 of 294
poverty status, and was highest
Figure 10-1 Heart disease death rates by county, Missouri
in the South. Blacks have a high2003-2007 (source: Missouri Department of Health and Senior Services)
er incidence of stroke and more
severe strokes than whites,25 and
among stroke survivors, blacks
experience greater activity
tions than whites. 26 It has been
reported that middle aged women in the US have had a tripling
in strokes attributed to the obesity epidemic.27 High body mass
index or BMI also has been
linked to strokes in men.28
Among postmenopausal
women, those who sleep more
than 9 hours a night are reported
to be at increased risk of
stroke.29 Exposure to cigarette
smoke also is a risk factor. Moderate smoking has been associated with a 4.3 times higher risk
of stroke in young women while
heavy smoking carried a 9.1
times greater risk.30 Smoking
cessation has been associated with significant
Mortality
reductions in the risk of stroke and myocardial
infarction, but simply reducing the number of
In 2007, stroke was the 3rd leading
cigarettes smoked does not significantly reduce
cause of death in the US. The age adjusted
either risk.31 In addition, non-smokers married to
death rate for stroke declined 4.6% from that in
smokers have a 42% greater risk of stroke com2006. Nearly 50% of stroke deaths occur prior to
pared to non-smokers married to non-smokers.32
transport to a hospital.35 The proportion of preThe Kansas City Stroke Study reported
transport deaths increases with age and is highdifferences by sex in stroke recovery and that
er among females, whites, and non-Hispanics.
prestroke physical functioning and symptoms of
Blacks have the highest proportion of deaths
depression were important factors that influthat occur in emergency departments and the
33
enced recovery. Lower recovery of activities of
same is true for Hispanics compared to nondaily living and physical function were found
Hispanics. Asians have the highest proportion of
among women.
post-transport deaths that occur in a hospital.
It was estimated that 780,000 Americans would experience a stroke in 2008,
150,000 would die, and 15-30% of stroke surviHeart disease and stroke in
vors would be permanently disabled.34
Missouri
According to the Missouri Department of
Health and Senior Services, of the 50 states in
Page 150 of 294
2005, Missouri ranked 9th highest in the prevalence of heart disease and 7th highest in the prevalence of stroke. Death rates for blacks from
heart disease and stroke were 25-33% higher
than for whites. The distribution of countyspecific age-adjusted heart disease death rates
for 2003-2007 is shown in Figure 10-1 with the
Kansas City area being in the lowest quintiles for
mortality.
ic lower respiratory diseases. A total of 769
Kansas Citians died as the result of heart disease, while another 199 died from stroke (Table
10-2). Among all males who died in 2007, 22.6%
died from heart disease and 3.9% from stroke.
For females, 19.0% died from heart disease and
6.9% from stroke.
While the average age of death in 2007
for Kansas Citians was 74.7 years for heart disease and 77.3 years for stroke, a significant
proportion of the deaths were premature (prior to
age 65 y) (Table 10-3). In Kansas City, the perHeart disease and stroke in
centages of men who died prematurely from
Kansas City
heart disease (34.4%) and stroke (19.4%) were
In 2007, heart disease was the 2nd leadhigher than among women (16.3% for heart dising cause of death behind cancer and stroke
ease, 15.0% for stroke). Statewide, in 2007,
was the 4th leading cause of death behind chronpremature deaths from heart disease and stroke
occurred at lower rates.
Higher percenTable 10-2 Deaths and crude mortality rates per 10,000 population
tages of non-Hispanic
from heart disease and stroke, by sex and race, Kansas City, Mo,
black males and fe2007
males died prematurely
2000
Heart disease
Stroke
Population Deaths
Rate
Deaths
Rate
from heart disease and
All
stroke than did nonTotal
441,545
769
17.4
199
4.5
Hispanic whites. The
White, non-Hispanic
254,471
498
19.6
123
4.8
proportions of nonBlack, non-Hispanic
136,921
237
17.3
70
5.1
Hispanic black males
Hispanic
30,604
25
8.2
5
1.6
and females dying preAsian
8,675
3
3.5
1
1.2
Native American
2,122
5
23.6
0
0.0
maturely from heart
Not listed
1
0
disease and stroke
Male
were significantly higher
Total
213,141
419
19.7
72
3.4
than for non-Hispanic
White, non-Hispanic
124,252
277
22.3
40
3.2
white males and feBlack, non-Hispanic
62,779
125
19.9
29
4.6
males. For both nonHispanic
16,454
14
8.5
3
1.8
Asian
4,319
2
4.6
0
0.0
Hispanic whites and
Native American
1,034
1
9.7
0
0.0
non-Hispanic blacks,
Not listed
0
0
males died prematurely
Female
from heart disease at
Total
228,404
350
15.3
127
5.6
disproportionately highWhite, non-Hispanic
130,219
221
17.0
83
6.4
er rates than females.
Black, non-Hispanic
74,142
112
15.1
41
5.5
Hispanic
14,150
11
7.8
2
1.4
The same held true for
Asian
4,356
1
2.3
1
2.3
non-Hispanic white
Native American
1,088
4
36.8
0
0.0
males and stroke; there
Not listed
1
0
was no difference be1
NC = not calculated due to low number of deaths
Page 151 of 294
death rate per 100,000
population from coronary
heart disease decreased
Black,
non36.4% between 2000 and
Hispanic
Hispanic
2007 and has been below
the Healthy People 2010
33.5%
29.4%
27.3%
16.7%
national objective since
2002 (Figure 10-2). A little
32.9%
16.0%
over two-thirds of all
24.3%
40.0%
deaths from heart disease
are due to coronary disease (Table 10-4). A listing of specific causes of
Table 10-3 Percent of deaths occurring prematurely (prior to age
65 years old) from heart disease and stroke, 2007
Male
Female
White,
nonHispanic
26.9%
18.9%
11.4%
11.0%
17.2%
11.3%
34.4%
19.4%
16.3%
15.0%
23.3%
10.6%
Missouri
Heart disease
Stroke
Kansas City
Heart disease
Stroke
tween non-Hispanic black males and females.
An examination of premature deaths
among Hispanics in Kansas City requires data
for 2003-2007; 98 heart disease deaths and 33
stroke deaths. Of the deaths due to heart disease, 23.5% were premature while for stroke
21.2% were premature. Males were significantly
more likely to die prematurely from heart
ease than females (33.9% for males, 9.5% for
females), but there was no statistically significant difference in premature deaths due to
stroke (28.6% for males, 15.6% for females).
Figure 10-2 Age-adjusted death rates due
to coronary heart disease, Kansas City,
Mo
198
180
161
152
152
134
134
126
Yr 2010 objective is 166 deaths per 100,000
Heart disease
In Kansas City, the overall age-adjusted
2000
2001
2002
2003
Table 10-4 Distribution of deaths from all heart disease and from coronary heart disease by age for selected race/ethnic groups, Kansas City,
Mo, 2003-2007
White, nonHispanic
Age
(years)
Total
deaths
<1
7
1-4
3
5-14
3
15-24
11
25-34
40
35-44
132
45-54
349
55-64
498
65-74
637
75-84
1,283
>85
1,298
Not listed
3
Total
4,264
Percent coronary
heart disease
All
4
1
2
2
13
57
176
272
354
856
1,016
3
2,756
Coronary
0
0
0
0
6
38
139
214
264
584
605
3
1,853
67.2%
Black, nonHispanic
All
2
1
1
8
23
70
162
213
254
383
254
0
1,371
Coronary
1
0
0
3
7
37
112
153
186
268
178
0
945
68.9%
Hispanic
All
0
1
0
1
2
3
6
10
19
36
20
0
98
Coronary
0
0
0
0
1
1
4
7
15
25
8
0
61
62.2%
2004
2005
2006
2007
heart disease deaths
is shown in Table
10-5.
The majority
of heart disease
deaths (77.8%) occurred among residents of the Jackson
County portion of the
City; 16.0% occurred
among those living
in the Clay County
portion, and 6.5%
among those in the
Platte County portion
(Table 10-6). The
distribution of heart
Page 152 of 294
disease deaths by zip code is
Table 10-5 Classification of deaths from heart disease,
shown in Tables 10-7 and 10-8.
The zip code area death rates for
Cause listed on death certificate
Deaths
Acute rheumatic fever and chronic rheumatic heart diseases
5
both heart disease and stroke deHypertensive heart disease
13
clined as median family incomes
Hypertensive heart and renal disease
27
Acute myocardial infarction
131
rose (Figure 10-3).
Atherosclerotic cardiovascular disease, so described
127
Age-adjusted heart disAll other forms of chronic ischemic heart disease
220
Heart failure
67
ease death rates, overall and for
Pulmonary heart disease & diseases of the pulmonary circulation
20
coronary heart disease, declined
All other forms of heart disease
159
from 1998-2002 to 2003-2007
Total deaths from heart disease
769
(Figures 10-4 and 10-5). The overall decline was largest for nonTable 10-6 Death rates per 10,000 populaHispanic whites (24.6%) and lowest for Hispantion1 for heart disease and stroke in difics (4.7%). Non-Hispanic whites also had the
ferent areas of Kansas City, Mo, 2007
largest decline for coronary heart disease
Heart disease
Stroke
Pop.
Deaths Rate Deaths Rate
deaths (30.3%) while non-Hispanic blacks had
Clay
96,790
121
12.5
29
3.0
the smallest decline (16.4%).
County
In 2007, Kansas City residents made
Jackson
313,936
598
19.0
155
5.1
County
1,189 visits to emergency departments because
Platte
39,508
50
12.7
15
3.8
of heart disease and experienced 5,764
County
1
July 2007 census population estimates
lizations. Heart disease increased in importance
for emergency department visits with increasing
age; it was the 2nd leading reason following
area counties are in the middle to lower quincomplications of pregnancy and birth. By age
tiles.
group, heart disease was the leading reason for
For the periods 1998-2002 and 2003hospitalization for individuals >55 years old.
2007, both non-Hispanic whites and nontween 2000 and 2007, there were significant
Hispanic blacks experienced decreases of
reductions in hospitalizations for both heart dis19.6% and 9.6%, respectively, in their ageease and stroke (Figure 10-6). The quality of
adjusted death rates, while Hispanics remained
hospital care for persons experiencing heart
unchanged (Figure 10-9).
tacks or heart failure in Kansas City can be acTables 10-2 and 10-3 contained the incessed at www.healthykansascity.org.
formation on stroke deaths by sex,
race/ethnicity, and percent premature while the
distribution of stroke deaths by county was in
Stroke
Table 10-6. Table 10-9 summarizes the age distribution of stroke deaths by race/ethnicity for
It is estimated that 147,000 Missourians
36
2003-2007, while Tables 10-10 and 10-11 show
>18 years of age have a history of stroke.
the distribution of deaths by zip code. Figure 10Among Kansas City residents, the age-adjusted
3 displayed stroke rates by median zip code
death rate for stroke fluctuated annually befamily income.
tween 2000 and 2007, but it has been at or beIn 2007, there were 272 emergency delow the Healthy People 2010 national objective
partment
visits and 1,486 hospital admissions
since 2005 (Figure 10-7). Figure 10-8 shows the
for
stroke.
By age-groups, stroke does not apcounty-specific age-adjusted stroke death rates
for Missouri during 2003-2007; the Kansas City
Page 153 of 294
pear in the top 10 leading causes for
hospitalization for persons <55 years of
age.
Table 10-7 Deaths due to heart disease among
Kansas City, Mo, residents by zip code, 2003-2007
Zip code
Hypertension
Deaths
Male
Female
White,
nonHispanic
Black,
nonHispanic
64101
2
2
0
2
0
64102
2
0
2
0
2
64105
31
18
13
22
7
64106
62
32
30
34
22
64108
53
29
24
13
21
64109
137
67
70
25
109
64110
131
63
68
34
96
64111
229
110
119
164
50
64112
59
24
35
52
4
64113
81
48
33
78
1
64114
394
171
223
377
13
64116
86
43
43
79
2
64117
117
60
57
114
1
64118
114
63
51
104
5
64119
130
70
60
119
7
64120
5
3
2
3
0
64123
90
47
43
83
3
64124
95
46
49
81
8
64125
22
15
7
20
0
64126
68
34
34
52
12
64127
208
105
103
70
131
64128
193
94
99
10
178
64129
98
54
44
68
26
64130
344
199
145
20
323
64131
211
119
92
129
76
64132
155
87
68
36
116
64133
145
82
63
124
19
64134
181
105
76
119
59
64136
16
7
9
14
2
64137
87
35
52
52
33
64138
104
55
49
83
19
64139
39
7
32
36
3
64145
122
37
85
111
9
64146
19
10
9
18
1
64147
0
0
0
0
0
64149
2
1
1
1
1
64151
118
60
58
115
2
64152
38
19
19
33
3
64153
26
8
18
25
0
64154
89
38
51
86
1
64155
116
49
67
112
2
64156
5
4
1
5
0
64157
21
9
12
17
1
64158
8
6
2
8
0
64160
0
0
0
0
0
64161
2
1
1
2
0
64163
1
1
0
1
0
64164
1
1
0
1
0
64165
0
0
0
0
0
64166
0
0
0
0
0
64167
0
0
0
0
0
64192
0
0
0
0
0
All others1
7
5
2
4
3
Total
4,264
2,143
2,121
2,756
1,371
1
Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190,
64191, 64195, 64196, and 64199 are associated with post office box numbers; zip
codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197,
64198, 64944, and 64999 are associated with unique entities, and zip codes 64012,
64030, 64079, and 64081 are associated with Belton, Grandview, Platte City, and
Lee’s Summit, respectively.
Hypertension is high blood
pressure generally defined as systolic/diastolic blood pressure measurements of equal to or greater than
140/90 mm Hg. Nationally, the ageadjusted prevalence of hypertension
varied only slightly between 28% and
30% during the period 1999 and
2006.37 Prevalence increased with age
and was inversely correlated with educational attainment and poverty status.
Blacks, regardless of ethnicity, had the
highest prevalence rate.38
Economically, hypertension is
5th among the top 15 health care problems accounting for the rise in medical
care costs in this country.39 It is the
most frequent chronic condition resulting in doctor and hospital outpatient
visits.40 Hospitalizations for hypertension are more prevalent among blacks
and Hispanics.41
Hypertension is a major modifiable risk factor for many diseases, such
as heart disease, stroke, damage to
blood vessels, aortic dissection, kidney
damage and failure, and vision loss.
Conversely, favorable blood pressure
levels are associated with a greater
probability of survival to age 85 as well
as increased longevity without major
co-morbidities.42
In addition to high blood pressure there is prehypertension which
affects about 37% of persons >20 years
old. It is defined as a systolic blood
pressure between 120 and 139 mm Hg
or diastolic blood pressure between 80 and 89
mm Hg. Also there is residual hypertension
which is a systolic pressure of 140 mm Hg or
Page 154 of 294
higher despite treatment. Beginning at a
Table 10-8 Distribution of heart disease deaths
blood pressure of 115/75 mm Hg, the risk of
by zip code and rate per 1,000 population, Kancardiovascular disease doubles with each
sas City, Mo, 2003-2007
Rate per 1,000 population
increment of 20/10 mm Hg.
Prehypertension is considered a sig0.0-1.9
2.0-3.9
4.0-5.9
6.0-7.9
8.0-9.9
=>10.0
nificant health problem associated with in64012
64102
64101
64110
64106
64030
64079
64158
64118
64112
64108
64105
creased risk for myocardial infarction and
64081
64120
64113
64117
64109
43
coronary artery disease, but not stroke.
64147
64149
64116
64123
64111
64165
64152
64119
64127
64114
Men have a higher age-adjusted prevalence
64166
64156
64124
64129
64125
of prehypertension than women. Non64167
64134
64131
64126
64192
64151
64132
64128
Hispanic blacks, 20-39 years old, have a
64153
64133
64130
higher prevalence of prehypertension than
64155
64137
64136
64157
64139
whites and Hispanics, but their prevalence is
64163
64145
lower at older ages because of a higher pre64146
valence of hypertension. Persons with pre64154
64161
hypertension are 1.7 times more likely to
64164
have at least 1 other adverse risk factor for
heart disease and stroke than those with
traceptives, etc. A 12 to 13 point reduction in
normal blood pressure.
blood pressure among people with hypertension
Blood pressure itself can be affected by
can reduce heart attacks by 21%, strokes by
many factors including genetics, volume of water
37%, and total cardiovascular disease deaths by
in the body, salt content of the body, kidney
25%.44
function, and blood vessel health. “Essential”
Usually, persons with hypertension have
hypertension comprises over 95% of all high
no symptoms, but very high and dangerously
blood pressure cases and has no identifiable
high (termed malignant) hypertension generally
cause. “Secondary” hypertension is high blood
are associated with symptoms such as severe
pressure caused by other disorders such as tuheadache, confusion, tiredness, vision changes,
mors, kidney disorders, medications, oral conetc. According to NHANES findings, overall,
Figure 10-3 Annualized heart disease and
stroke death rates per 10,000 population
by zip code median family income levels,
Heart disease
100,000 population due to heart disease
by race/ethnicity, Kansas City, Mo
1998-2002
Stroke
2003-2007
318
273
19.9
19.3
240
17.9
181
14.1
4.7
4.8
169 161
4.4
2.1
$20-39,999
$40-59,999
$60-79,000
$80-99,999
White, nonHispanic
Black, nonHispanic
Hispanic
Page 155 of 294
78% of persons with hypertension were aware of
their condition but this varied by age, sex, and
100,000 population due to coronary heart
disease, Kansas City, Mo
1998-2002
2003-2007
226
189
175
130
122
97
race/ethnicity. Only 6.6% of persons with high
blood pressure claimed to have never been told
of their condition.
Hypertension is controllable with treatment, requiring lifelong monitoring, and the
treatment may require periodic adjustments.
From NHANES data, 68% of persons with
hypertension were treated with antihypertensive
medication. Only 64% of these individuals (or
44% overall) had successfully controlled their
blood pressure, meaning that 56% of persons
with hypertension did not have it controlled.
Substantial ethnic differences in hypertension
control exist.45
Hypertension in Kansas City
White, nonHispanic
Black, nonHispanic
Hispanic
Figure 10-6 Age-adjusted rates per
100,000 population for hospitalization due to heart disease and stroke,
Kansas City, Mo
Heart disease
Stroke
1,861.21,764.6
1,705.71,661.5
1,693.8
1,591.9
1,413.21,384.1
469.4 493.4 427.9 447.0 412.6 402.2
349.7 359.6
2000 2001 2002 2003 2004 2005 2006 2007
Figure 10-7 Age-adjusted stroke death
rate per 100,000 population, Kansas City,
Mo
65
58
66
53
59
44
48
48
Yr 2010 objective is 48 deaths per
2000 2001 2002 2003 2004 2005 2006 2007
According to the 2007 Missouri BRFSS
data, 29.4% of Missourians have hypertension
(29.8% of males; 29.1% of females).46 And, the
2007 Missouri County-Level Study found a prevalence rate of 19.6% statewide and prevalence
rates of 17.3%, 18.0%, and 15.7%, in Clay,
Jackson, and Platte counties, respectively,
which were not statistically different from the
statewide prevalence rate
(www.dhss.mo.gov/CommunityDataProfiles).
The most recent data for Kansas City comes
from the 2004 Health Assessment Survey,
commissioned by the Kansas City Health Department which reported that 29.5% of respondents suffered from hypertension
(www.kcmo.org/health).
Between 2003 and 2007, 205 Kansas
City residents died from hypertension (Table
12). The death rate per 10,000 population was
57% higher for females. Non-Hispanic black
men and women had the highest rates.
Hypertension and prehypertension prevalence rates of 6.9%-24.6% and 8.6%, respectively have been reported among adolescents,
with higher prevalences among the overweight
and obese.47 48 In Kansas City, the Score 1 for
Health project examined school-aged children 513 years of age using National Heart Lung and
Page 156 of 294
Figure 10-8 Stroke death rates by county, Missouri 20032007 (source: Missouri Department of Health and Senior Services)
nearly 13 times higher for overweight or obese children than
normal weight children.
Risk factors
Blood Institute criteria for elevated blood pressure.49 While the incidence of blood pressure
referrals was not high across the Score 1 population (1.5%), it did increase as children got older and heavier; it occurred disproportionally
among children who were obese. The likelihood
of a child having elevated blood pressure was
stroke by race/ethnicity, Kansas City, Mo
1998-2002
83
2003-2007
75
57
54
57
41
White, nonHispanic
Black, nonHispanic
Hispanic
Certain modifiable risk
factors, including high blood pressure, high cholesterol, diabetes,
tobacco use, obesity, and lack of
exercise are the main targets for
primary and secondary prevention
of heart disease and stroke.50 Improving diet and lifestyle are critical components of the American
Heart Association’s strategy for
cardiovascular disease risk reduction in the general population.51
All forms of tobacco use (smoking, chewing, and inhalation of
second hand smoke) should be
discouraged to prevent cardiovascular disease.52
A substantial proportion of the population has multiple risk factors, increasing their
likelihood of heart disease and stroke.53 Nationally, blacks and Native Americans had the highest prevalences of multiple risk factors, 48.7%
Table 10-9 Deaths from stroke by age for selected racial/ethnic groups, Kansas City, Mo,
2003-2007
Age
(years)
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
>85
Not listed
Total
Deaths
1
1
0
4
21
57
96
148
352
352
1
1,033
White,
nonHispanic
1
0
0
2
9
17
34
73
229
259
0
624
Black,
nonHispanic
0
1
0
2
10
36
56
68
109
83
1
366
Hispanic
0
0
0
0
2
1
4
6
11
9
0
33
Page 157 of 294
and 45.7%, respectively, followed by
Table 10-10 Deaths due to stroke among Kansas City,
Hispanics, 39.6%, whites, 35.5%, and
White,
Black,
Asians, 25.9%. There were no differZip
nonnonences between men and women but
code
Deaths
Male
Female
Hispanic
Hispanic
differences existed by income and edu64101
0
0
0
0
0
64102
0
0
0
0
0
cational attainment. A recent study re64105
6
1
5
4
2
64106
12
2
10
5
4
ported no difference in traditional risk
64108
15
8
7
2
4
factors for cardiovascular mortality
64109
29
11
18
6
23
64110
26
11
15
4
21
among blacks and whites of the same
64111
45
15
30
27
16
64112
12
3
9
12
0
sex.54 In Missouri, 38.9% of persons
64113
12
5
7
11
1
surveyed had multiple risk factors.
64114
132
39
93
121
10
64116
12
4
8
11
0
Modest reductions in major risk
64117
20
11
9
19
1
factors for heart disease, for example,
64118
27
10
17
24
3
64119
29
14
15
26
1
can lead to gains in life-years 4 times
64120
1
0
1
1
0
64123
26
11
15
23
1
higher than cardiological treatments.55
64124
28
12
16
18
2
Except for diabetes, cardiovascular risk
64125
4
2
2
4
0
64126
13
10
3
8
2
factors have declined considerably over
64127
50
21
29
13
35
64128
50
22
28
2
48
the past 40 years among adults with
64129
18
10
8
10
7
different BMI.56 Although obese persons
64130
91
36
55
8
83
64131
63
23
40
28
33
have higher risk factor levels than lean
64132
33
13
20
6
25
persons, the levels of these risk factors
64133
43
17
26
38
5
64134
41
16
25
22
18
are much lower than in previous dec64136
2
1
1
2
0
64137
15
7
8
11
4
ades.
64138
28
8
20
20
7
According to the National Cen64139
8
2
6
6
2
64145
38
12
26
32
5
ters for Health Statistics, about 30% of
64146
2
0
2
2
0
adults (33% of women versus 26% of
64147
0
0
0
0
0
64149
2
2
0
2
0
men) have adopted at least 6 primary
64151
30
11
19
28
2
64152
8
2
6
8
0
lifestyle modifications to reduce cardi64153
2
1
1
2
0
ovascular disease risk.57 Persons >60
64154
18
5
13
17
1
64155
35
12
23
34
0
years old and persons with the highest
64156
0
0
0
0
0
64157
4
1
3
4
0
incomes were more likely to embrace
64158
1
0
1
1
0
such lifestyle modifications.
64160
0
0
0
0
0
64161
0
0
0
0
0
High blood cholesterol is a ma64163
0
0
0
0
0
jor modifiable risk factor for atheroscle64164
0
0
0
0
0
64165
0
0
0
0
0
rotic cardiovascular disease. The pla64166
0
0
0
0
0
64167
0
0
0
0
0
que buildup in the neck arteries of ob64192
0
0
0
0
0
ese children or those with high cholesAll others1
2
0
2
2
0
Total
1,033
391
642
624
366
terol, for example, is similar to levels in
1
Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190,
middle-aged adults; eg “vascular age”
58
codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197,
approximately 45 years. Obese child64198, 64944, and 64999 are associated with unique entities, and zip codes 64012,
64030, 64079, and 64081 are associated with Belton, Grandview, Platte City, and
ren who have high triglycerides are the
Lee’s Summit, respectively.
most likely to have prematurely aging
arteries.
disease. The risk of dying for diabetics is twice
Diabetes is a major risk factor influenthat for non-diabetics.59 And, among diabetics
cing survival among persons with cardiovascular
Page 158 of 294
Table 10-11 Distribution of stroke deaths by zip
code and rate per 1,000 population, Kansas
City, Mo, 2003-2007
0.0-0.9
64012
64079
64081
64101
64102
64147
64153
64156
64158
64161
64163
64164
64165
64166
64167
64192
1.0-1.9
64106
64110
64112
64113
64116
64117
64118
64119
64120
64125
64129
64134
64136
64137
64146
64151
64152
64157
2.0-2.9
64105
64108
64109
64111
64123
64124
64126
64127
64131
64132
64133
64138
64155
3.0-3.9
64128
64130
64154
4.0-4.9
=>5.0
64030
64114
64139
64145
64149
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Abell JE et al. Differences in cardiovascular disease mortality associated with body mass between black and white persons. Am J Public Health 2008;98:63-66.
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Deaths
29
45
1
0
0
75
Rate
0.5
1.4
0.1
0.0
0.0
0.7
Females
Deaths
58
65
6
0
1
130
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1.8
0.8
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1.1
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Campbell A, Stering TK. Score 1 for Health. 2008 Community Report. www.score1forhealth.org
33
Lai, S et al. Sex differences in stroke recovery. Prev
Chronic Dis 2005;2(3):
www.cdc.gov/pcd/issues/2005/jul/04_0137.htm.
34
American Heart Association. Heart disease and stroke
statistics. 2008 update. www.americanheart.org
35
Harris C et al. Place of death after stroke – United States,
50
Mensah GA et al. State of disparities in cardiovascular
health in the United States. Circulation 2005;111:1233-1241.
51
Lichtenstein AH et al. Diet and Lifestyle Recommendations
Revision 2006. A scientific statement from the American
Heart Association Nutrition Committee. Circulation
2006114:82-96.
Page 160 of 294
52
Teo KK et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a casecontrol study. Lancet 2006;368:647-658.
53
Hayes DK et al..Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke –
2005;54:113-117.
54
Carnethon MR et al. Comparison of risk factors for cardiovascular mortality in black and white adults. Arch Intern
Med 2006;166:1196-1202.
55
Unal B et al. Life-years gained from modern cardiological
treatments and population risk factor changes in England
and Wales, 1981-2000. Am J Public Health 2005;95:103108.
56
Gregg EW et al. Secular trends in cardiovascular disease
risk factors according to body mass index in US adults. J Am
Med Ass 2005;293:1868-1874.
57
Wright JD et al. One-third of US adults embraced most
heart healthy behaviors in 1999-2002. NCHS Data Brief
2009;17:May. www.cdc.gov/nchs
58
Le J et al. Advanced “vascular age” in children with dyslipidemia. Circulation 2008;118:S_1056.
59
Fox CS et al. Trends in cardiovascular complications of
diabetes. J Am Med Ass 2004;292:2495-2499.
60
Malmberg K et al. Intense metabolic controls by means of
insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity.
Eur Heart J 2005;26:650-661.
Page 161 of 294
11. Asthma
The word asthma comes from the
Greek, aazein, which translates as “to breathe
with open mouth or pant”. It first appeared in
Homer’s Iliad meaning short of breath, and
probably was first used in a medical sense by
Hippocrates. Today the emerging general consensus is that asthma is unlikely to be a single
disease entity, but rather a clinical manifestation
of several distinct diseases. Therefore, it has
been proposed that the term asthma should be
abolished altogether.1
Asthma is a chronic lung condition characterized by difficulty in breathing. People with
asthma have extra sensitive or hyper-responsive
airways that react by narrowing or obstructing
when they become irritated. Narrowing or obstruction is caused by airway inflammation and
broncho-constriction and results one or more of
the following symptoms: wheezing, coughing,
shortness of breath, and chest tightness. About
60% of persons with asthma suffer from allergic
asthma.
Two factors provoke asthma, triggers
which result in broncho-constriction and inducers which result in inflammation of the airways.
Common triggers of broncho-constriction include
everyday stimuli such as cold air, dust, strong
fumes, exercise, inhaled irritants, emotional upsets, and smoke. Second-hand smoke has been
shown to aggravate asthma symptoms, especially in children. In contrast to triggers, inducers
cause both airway inflammation and airway hyper-responsiveness and hence are recognized
as causes of asthma. Inducers result in symptoms which may last longer, are delayed and
less easily reversible than those caused by triggers. The most common inducers are allergens
and respiratory viral infections.
Asthma statistics distinguish between
persons who had ever been diagnosed with
asthma and persons who currently have asthma.
Therefore, the reader needs to distinguish be-
tween these two types of statistics.
National prevalence
Prevalence estimates of asthma must
be based largely on interview surveys as physician reporting of incident asthma cases does not
exist in the absence of mandatory reporting
laws.2 Asthma is the 2nd most costly medical
treatment for children <18 years of age at $8
billion per year; only treatment for mental disorders costs more.3
In 2005, 7.7% of the US population currently had asthma, according to the National
Centers for Health Statistics.4 Rates increased
with age; 8.9% of children had asthma compared to 7.2% of adults. When race/ethnicity is
considered, Puerto Ricans had a current asthma
prevalence rate 125% higher than non-Hispanic
whites and 80% higher than non-Hispanic
blacks. When only race is considered, Native
Americans and blacks had a 25% higher prevalence than whites. Females had a 40% higher
prevalence rate than males. This pattern was
reversed among children aged 0-17 years. The
current asthma prevalence for boys (10%) was
30% higher than for girls (7.8%). The difference
in prevalence between blacks and whites is
greater for children than for adults. Black race is
associated with worse asthma outcomes, including a greater risk of emergency department visits and hospitalizations, even in health care settings that provide uniform access to care.5
Asthma is more prevalent among persons living below the federal poverty level
(10.3%) than those at or above the federal poverty level (6.4% to 7.9%).6 Asthma prevalence
is higher in the Midwest than the South or West,
but lower than that in the Northeast. There is an
association between obesity and asthma, and
this is stronger among women than men; this
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Page 162 of 294
association holds for most racial and ethnic subgroups.7 It is estimated that asthma results in the
loss of 10-12 million work days and 13-15 million
school days each year in the US.8
In 2005, an estimated 4.2% of people
(12.2 million) had at least one asthma attack in
the previous year resulting in an estimated 12.8
million school days missed, 10.1 million work
days missed, 14.7 million physician and hospital
outpatient visits, 1.8 million emergency department visits, and 497,000 hospitalizations each
year. Black and Hispanic children who come
from low-income families receive care for their
asthma from emergency departments more often than children from higher income families.9 10
Between 2002 and 2005, prescriptions for asthma medications for children rose by more than
46%.11 During 2005, 3,884 persons died from
asthma, although questions have been raised
whether mortality rates for person >55 years of
age are overestimated.12
A child’s birthweight and gestational age
may influence their risk of developing asthma,
with increasing risk as birthweight or gestational
age declines.13 14 Neighborhood characteristics
are strong predictors of childhood asthma; this
may be related to cockroach allergens in the
home environment.15 16
Missouri
According to the Missouri 2007 Behavioral Risk Factor Surveillance System data,
8.5% of adults (7.0% of males; 10.0% of females) currently had asthma.17 The Missouri
Department of Health and Senior Services’ Missouri Asthma Surveillance Report 2006
(www.dhss.mo.gov/asthma), estimated that
400,000 adults and 150,000 children in the state
are currently living with asthma. Among adults,
women had a higher rate of asthma (10.3%)
than men (7.9%) with essentially no difference
by race/ethnicity. And, prevalence declined with
increasing age, increasing income, and increasing level of educational attainment. Of the estiASTHMA
mated 400,000 adults with asthma, 30,000
(7.5%) were told by their health care provider
that their asthma was work related.
Among adults with asthma, 28.4% were
current smokers (compared to 26% for persons
without asthma) and regular exposure to
second-hand smoke was common.18 The prevalence of exposure to second-hand smoke varied
between 19.9% and 36.4% depending on the
setting: 22% in the home, 36% in a vehicle, and
nearly 20% in the workplace. Those asthmatics
with college or technical school education, and
blacks were less likely to be current smokers,
although among non-current smokers, blacks
were more likely to be exposed to second hand
smoke. Of the asthmatic current smokers who
had visited a physician in the past 12 months,
30% were not advised to quit smoking.
When the Missouri data is broken down
into regions, the Kansas City Metro Region
(consisting of Cass, Clay, Clinton, Jackson, Lafayette, Platte and Ray counties) was estimated
to have 83,000 adults and 25,000 children living
with asthma. The asthma prevalences among
adults and children were 9.8%, respectively,
higher than the statewide estimates of 9.1% for
adults and 8.0% for children. There were 6,925
asthma related visits to emergency departments
in the region during 2003. The age-adjusted
asthma emergency department visit rate also
was higher in the region (6.3 per 1,000 persons
vs 5.6 statewide). Children accounted for 42.7%
of the asthma related emergency department
visits compared to 45.0% statewide. NonHispanic blacks accounted for 15.6% of the region’s population, but 48.5% of the asthma related emergency department visits. And, emergency department visit rates were higher among
females than males.
Similar to the emergency department
visits, the region also had higher asthma related
hospital admission rates than statewide, 15.0
per 10,000 vs 13.9 per 10,000 statewide. Women were more likely to be hospitalized than
men.19 Children in the region accounted for
Page 163 of 294
33.3% of all asthma related hospital admissions (36.7% statewide). Non-Hispanic blacks
accounted for 35.6% of all asthma hospital admissions. Asthma in the region accounted for
5,192 days of hospital care in 2003 at a cost of
$14.1 million in hospital charges.
Nationally, important differences exist
in charges incurred by children with asthma
based on patient and hospital characteristics.20
Charges are lower for non-children’s hospitals,
higher for minority children, and higher for
children on Medicaid. In Missouri, children on
Medicaid have higher rates of emergency department use and costs than children covered
by private insurance.21
Between 2003 and 2007, 356 Missourians died from asthma (226 females, rate 1.3
per 100,000; 130 males, rate 1.0). Death rates
increased with age from 0.3 for those <15
years of age to 3.7 for persons >65 years. Two
hundred and sixty deaths occurred among nonHispanic whites (82 males; 178 females) and
91 among non-Hispanic blacks (44 males; 47
females).
Kansas City
The counties in which Kansas City is situated have an age-adjusted asthma prevalence
rate that is intermediate when compared to other
Figure 11-1 Missouri multi-county asthma prevalence, 2002-2003 (source: Missouri Department of
Health and Senior Services)
Missouri counties (Figure 11-1). A 2004 telephone survey commissioned by the Kansas City
Health Department found a 12.5% prevalence
rate for asthma among respondents.22 BRFSS
data for 2006 found that 7.7% of adults in the bistate metropolitan area had asthma.23
Figure 11-2 Historical asthma emergency department visits and quarterly projections with
95% confidence intervals for 2007-2009, Kansas City, Mo
1600
1200
800
400
Projected 879 visits per quarter
0
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Page 164 of 294
The Asthma and Allergy Foundation of
America ranks metropolitan areas as Asthma
Capitals and its 2009 report ranked Kansas City
79th or average, while St Louis City ranked 1st,
the worst in the nation (www.aafa.org).
Asthma was the 6th leading cause of visits to Kansas City emergency departments in
2007, with 4,042 visits. Among non-Hispanic
blacks it was the 3rd leading reason for emergency department visits and the 6th leading
cause for hospitalization; for non-Hispanic
whites it was the 8th leading reason for emergency department visits. Figure 11-2 displays
the estimated number of emergency department
visits for asthma for 2007-2009 plus the 95%
confidence intervals for those projections.
Asthma visits to emergency departments and hospitalizations peak in Kansas City
during May and October each year. The specific
causes for these peaks is not known, although
Canadian researchers believe the Fall peak in
their country is driven by kids, colds, and the
return to school.24 Data reported by Children’s
Mercy Hospital at the 2006 annual meeting of
the American College of Allergy, Asthma and
Immunology, suggested that rising temperatures
locally are causing earlier pollen seasons in
Kansas City which, in turn, could affect asthmatic individuals who are sensitive to spring pollens.
For the period 2003-2007, 38 Kansas
City residents died from asthma (17 nonHispanic whites, 4 male and 13 female; 20 nonHispanic blacks, 10 male, 10 female; 1 nonHispanic Asian male). All but 4 of the deaths
occurred among persons >25 years of age. The
asthma death rate in Missouri was 1.2 per
100,000 population, while in Kansas City the
rate was 1.8 compared to 2.8 in St Louis City.
2
Trepka MJ et al. A pilot asthma incidence surveillance system and case definition: lessons learned. Public Health Rep
2009;124:267-279.
3
Agency for Healthcare Research and Quality. The Five
Most Costly Children's Conditions, 2006: Estimates for the
U.S. Civilian, Noninstitutionalized Children, Ages 0 to 17.
Med Expend Panel Survey Stat Brief 2009;242.
www.meps.ahrq.gov/mepsweb/data_stats/Pub_ProdResults
_Details.jsp?pt=Statistical%20Brief&opt=2&id=903
4
Akinbami L. Asthma prevalence, health care use and mortality: United States, 2003-05. NCHS Health E-stats November 2006. www.cdc.gov/nchs
5
Erickson SE et al. Effect of race on asthma management
and outcomes in a large, integrated managed care organization. Arch Intern Med 2007;167:1846-1852.
6
Gupta RS et al. The protective effect of community factors
on childhood asthma. J Allergy Clin Immunol
2009;123:1297-1304.
7
Kim S, Camargo CA. Sex-race differences in the relationship between obesity and asthma: the Behavioral Risk Factor Surveillance System, 2000. Am J Epidemiol 2003;13:666673.
8
Akinbauni L. Asthma prevalence, health care use and mortality, United States, 2003-05. NCHS Health E-Stats, Dec
2006. www.cdc.gov/nchs
9
Kim H et al. Health care utilization by children with asthma.
Prev Chronic Dis: Public Health Res Pract Policy 2009;6:111. www.cdc.gov/pcd
10
Akinbami L et al. Status of childhood asthma in the United
States, 1980-2007. Pediatrics 2009;[March supplement]
123:S131-S145.
11
Cox ER et al. Trends in the prevalence of chronic medication use in children: 2002-2005. Pediatrics 200;122:e1053e1061.
12
Brunner WM et al. Review of asthma mortaily rate for
Minnesota residents aged 55 years or older, 2004-2005:
when death certificates deserve a second look. Prev Chronic
Dis 2009;6(3).
www.cdc.gov/pcd/issues/2009/jul/08_0154.htm
13
Nepomnyaschy L, Reichman NE. Low birthweight and
asthma among young urban children. Am J Public Health
2006;96:1604-1610.
14
Literature cited
Dombkowski KJ et al. Prematurity as a predictor of childhood asthma among low-income children. Ann Epidemiol
2008;18:290-297.
15
1
Anon. A plea to abandon asthma as a disease concept.
Lancet 2006;368:705.
ASTHMA
Gruchalla RS et al. Inner City Asthma Study: relationships
among sensitivity, allergen exposure, and asthma morbidity.
J Allergy Clin Immunol 2005;115:478-485.
Page 165 of 294
16
Claudio L et al. Prevalence of childhood asthma in urban
communities: the impact of ethnicity and income. Ann Epidemiol 2006;16:332-340.
17
18
Yun S et al. 2006. Active and passive smoking among
asthmatic Missourians: implications for health education.
Prev Med 42:286-290.
19
Baibergenova A et al. Sex differences in hospital admissions from emergency departments in asthmatic adults: a
population-based study. Ann Allergy Asthma Immunol.
2006;96:666-72.
20
Gupta RS et al. 2006. Predictors of hospital charges for
children admitted with asthma. Ambul Pediatr 6:15-20.
21
Missouri Department of Health and Senior Services.
Asthma-related emergency room visits by children under age
18. Focus, May 2006. www.dhss.mo.gov
22
23
24
Johnston NW et al. 2006. The September epidemic of
asthma hospitalizations: school children as disease vectors.
J Allergy Clin Immunol 117:557-562.
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Page 167 of 294
12. Chronic Lower Respiratory Disease
Chronic lower respiratory diseases
Figure 12-1 Age-adjusted death rates per 100,000
(CLRD) are a diverse group of disorders
population due to chronic lower respiratory diswith most involving impairment of lung
ease, Kansas City, Mo
function. These diseases account for about
5% of all deaths nationally1 and, in 2005,
Yr 2010 objective for chronic lower respiratory disease is 60 deaths per
100,000 population
CLRD was the 4th leading cause of death in
2
the United States. In Kansas City, CLRD
51.9
50.7
50.0
49.4
47.3
was the 3rd leading cause of death in 2007
42.7
42.3
41.2
(5th among men, 4th among women).
The primary consequence of CLRD
that contributes to illness is breathlessness.
Deaths generally occur among the older
2000
2001
2002
2003
2004
2005
2006
2007
age groups, with 85.3% of CLRD deaths in
Kansas City being among persons >65
years old (Table 12-1). In 2007, the averrates between these groups has remained unage age of death from CLRD among Kansas
changed since 1991.3 In 2007, males had an
City residents was 75.1 years. The Healthy
age-adjusted death rate of 58.0 compared to a
People 2010 objective for CLRD deaths is 60
rate of 40.5 for females. Figure 12-3 shows the
per 100,000 population; Kansas City has been
distribution of age-adjusted CLRD death rates in
below this level for several years (Figure 12-1).
Missouri. The Kansas City area counties fall into
Between 1998-2002and 2003-2007, the
the 3rd and 4th highest quintiles.
age-adjusted death rates due to CLRD in KanFor the period 2003-2007, the breaksas City decreased for non-Hispanic whites and
down of CLRD deaths among Kansas City resinon-Hispanic blacks, 5.6% and 2.8%, respecdents was as follows: 0.2% bronchitis, 3.9%
tively (Figure 12-2). Despite these decreases,
asthma, 7.0% emphysema, and 88.8% other
the age-adjusted death rate for non-Hispanic
lower respiratory tract diseases.
whites was 46% higher than for non-Hispanic
According to the 2006 National Health Inblacks. The disparity ratio in age-adjusted death
terview Survey, 2% of US adults >18 years of
Table 12-1 Deaths from chronic lower respiratory disease by age and race/ethnicity, Kansas
City, Mo, 2003-2007
Age-group
White, non-Hispanic
Black, non-Hispanic
Hispanic
Asian
Native American
Other/not listed
Total
1-14
0
2
1
0
0
0
15-24
0
2
0
0
0
0
25-34
1
1
0
0
0
0
35-44
2
8
0
0
0
0
45-54
29
7
0
0
1
0
55-64
68
18
0
0
0
2
65-74
190
43
4
1
0
0
75-84
304
69
4
0
2
1
>85
179
23
1
1
2
0
Not
listed
1
0
0
0
0
0
3
2
2
10
37
88
238
380
206
1
Total
774
173
10
2
5
3
967
CHRONIC LOWER RESPIRATORY DISEASES
Page 168 of 294
Figure 12-2 Age-adjusted death rates due
to chronic lower respiratory disease,
Kansas City, Mo
1998-2002
54
2003-2007
51
36
White, non-Hispanic
35
Black, non-Hispanic
eases that contribute to the overall disability.
Approximately, 80% of COPD is caused by
smoking.5 After an average of 7.5 years, most
COPD patients are no longer capable of productive work. Often, COPD patients receive medical
care that is not appropriate for their condition.6
Deaths from COPD in the US have been increasing with more women than men dying.7
Exposure to ozone and particulate matter with an aerodynamic diameter of <10 µm
(PM10) is associated with respiratory hospital
admissions including CLRD.8 In Kansas City in
2007, CLRD was responsible for 2,101 visits to
emergency departments and 1,049 hospitalizations.
age have been diagnosed with emphysema, 4%
with chronic bronchitis, and 11% with asthma.4
Men were more likely to be diagnosed with emphysema while women were more likely to be
diagnosed with asthma or chronic bronchitis.
Adults in poor families have higher prevalence
rates of emphysema, asthma and chronic bronchitis than adults in families that are not poor.
Emphysema, asthma, and chronic
bronchitis are more common among
Figure 12-3 Age-adjusted death rates by county for
persons >65 years old who are inchronic lower respiratory diseases, 2003-2007 (source:
sured by Medicaid or Medicare than
Missouri Department of Health and Senior Services)
those with only private health insurance. The likelihood of having a diagnosis of emphysema or chronic
bronchitis declines as the level of
educational attainment rises.
Depending on the severity,
breathlessness may result in restrictions ranging from inability to climb
stairs to constant breathlessness and
difficulty in sleeping. Impaired lung
function probably contributes to more
frequent, severe, and prolonged viral
and bacterial respiratory infections.
Conditions such as chronic obstructive pulmonary disease (COPD) are
largely irreversible and progressive
and occur among older individuals
who often have multiple chronic
Page 169 of 294
Literature Cited
1
Centers for Disease Control and Prevention. The burden of
chronic diseases and their risk factors. National and state
perspectives. 2004. 185 p. www.cdc.gov/nccdphp.
2
Kung HC et al. Deaths: final data for 2005. Natl Vital Stat
Rep 2008;56(10). www.cdc.gov/nchs.
3
Hoff GL, Cai J. Minority Health Indicators. Kansas City
Health Department. 2008. www.kcmo.og/health
4
Pleis JR, Lethbridge-Cejku M. Summary health statistics for
US adults: National Health Interview Survey 2006. NCHS
Vital Health Stat 2007;10(235). www.cdc.gov/nchs
5
Rennard SI. COPD: overview of definitions, epidemiology,
and factors influencing its development. Chest
1998;113(suppl 4):235S-241S.
6
Lindenauer PK et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006;144:894-903.
7
Brown DW et al. Deaths from chronic obstructive pulmonary disease – United States, 2000-2005. MMWR Morb
Mortal Wkly Rep 2008;57:1229-1232.
8
Medina-Ramon M et al. The effect of ozone and PM10 on
hospital admissions for pneumonia and chronic obstructive
pulmonary disease: a national multicity study. Am J Epidemiol 2006;163:579-588.
Page 171 of 294
13. Diabetes
Diabetes is a serious, costly, and increasingly common chronic disease that can cause
devastating complications as well as resulting in
disability and death.1 2 It can also increase a
person’s risk for other health problems, eg, diabetics taking medication to lower their blood
glucose levels have the same risk of cardiovascular disease as a non-diabetic who had a prior
myocardial infarction.3 In 2002, it was estimated
that about $132 billion was spent on diabetes
care and management.4 Among adults >20
years of age, 7.8% were diagnosed as having
diabetes,5 whereas the prevalence of diabetes
among those <20 years of age was approximately 0.2%.6 It is estimated that 33% of Americans born in 2000 will develop diabetes during
their lifetime and that the incidence of the disease will double by 2050.7
In addition to clinically recognized diabetes there is the issue of undiagnosed diabetes. This is an important health problem, but
much less so than 25 years ago. Although race
and ethnic differences in undiagnosed diabetes
were eliminated over the last 25 years, the disparities became larger across other measures of
disadvantage, such as education.8
Classification
The classification of diabetes reflects the
complexity of the disease. Type 1 diabetes accounts for 5-10% of all diabetes cases and develops when the body's immune system destroys pancreatic beta cells. Autoimmune disease, genetic and environmental factors are believed to cause type 1 diabetes.
Type 2 diabetes accounts for 90-95% of
diabetes cases. It usually begins as insulin resistance, a disorder in which the cells do not use
insulin properly. As the need for insulin rises, the
pancreas gradually loses its ability to produce it.
Risk factors for type 2 diabetes include older
age, obesity, family history of diabetes, a prior
history of gestational diabetes, impaired glucose
tolerance, physical inactivity, and race/ethnicity.
Many people with type 2 diabetes develop more
than one other serious health problem associated with the disease;9 therefore, it is not surprising that nearly half of adults with diabetes
report their health is fair or poor.10
Gestational diabetes is a type of diabetes that occurs in 2-5% of all pregnancies,
but usually disappears when a pregnancy is
over.11 It is a form of glucose intolerance and
requires treatment to normalize maternal blood
glucose levels to avoid complications in the infant. Untreated gestational diabetes can cause
problems for both mothers and babies. Risk factors for gestational diabetes include a body
mass index greater than 30; previous macrosomic baby above 4.5 kg (9 lb, 15 oz); previous
gestational diabetes; family history of diabetes;
family origin with high prevalence of diabetes,
such as South Asian, black Caribbean, and Middle Eastern; lower socioeconomic status, and
increased maternal age.12 Women who have
had gestational diabetes are at increased risk for
later developing type 2 diabetes. In some studies, nearly 40% of women with a history of gestational diabetes developed diabetes in the future. Yet, among women who had gestational
diabetes this condition does not appear to motivate the women to take better care of their
selves following the pregnancy.13
Type 1 and type 2 diabetes are polygenic; meaning the risk of developing these forms of
diabetes is related to multiple genes. Environmental factors, such as obesity in the case of
type 2 diabetes, also play a part in the development of polygenic forms of diabetes. Polygenic
forms of diabetes often run in families.
DIABETES
Page 172 of 294
Some rare forms of diabetes result from
mutations in a single gene and are called monogenic. Monogenic forms of diabetes account for
about 1-5% of all cases of diabetes in young
people. In most cases of monogenic diabetes,
the gene mutation is inherited; in the remaining
cases the gene mutation develops spontaneously. Most mutations in monogenic diabetes reduce the body’s ability to produce insulin. The
two main forms of monogenic diabetes are neonatal diabetes mellitus (NDM) and maturityonset diabetes of the young (MODY). MODY is
much more common than NDM and usually first
occurs in children or adolescents but may be
mild and not detected until adulthood. NDM first
occurs in newborns and young infants.
Prediabetes
Prediabetes is defined as having at least
two fasting plasma glucose levels of 100-125
mg/dL (100-109 mg/dL is termed type 1 prediabetes, and 110-125 mg/dL is termed type 2 prediabetes).14 Like type 2 diabetes, it is linked to
obesity and physical inactivity. At least 25% of
US adults are known to have prediabetes.15 16
Medical care costs for persons with type 2 prediabetes are 32% higher than those for persons
with normal fasting glucose levels. Much of the
additional cost associated with both type 1 and
type 2 prediabetes is due to concurrent cardiovascular disease.17
It has been proposed that the concept of
prediabetes be eliminated and that persons with
this condition be considered as diabetic and
treating them as such.18
In July 2008, the American Association
of Clinical Endocrinologists formalized recommendations for the treatment of prediabetes and
recommended that persons with metabolic syndrome (defined by three or more of the following:
elevated triglycerides, low HDL cholesterol, high
fasting glucose, big waist circumference, and
high blood pressure) be considered at high risk
DIABETES
for prediabetes, as well as women with prior
gestational diabetes, persons with a family history of type 2 diabetes, and obese individuals.
Prevalence
The Centers for Disease Control and
Prevention estimated that about 35% of the
adult population has either prediabetes or diabetes, with prevalence rising with age. National
Health Interview Survey 2006 data reported that
8% of adults >18 years old had diabetes.19
There are racial/ethnic differences in the prevalence of diagnosed diabetes with Native Americans (16.5%), non-Hispanic blacks (11.8%),
Hispanics (10.4%), and Asians (7.5%) having
higher rates than non-Hispanic whites (6.6%),
but there are no differences by sex or among
persons with undiagnosed diabetes. The prevalence of undiagnosed diabetes and/or prediabetes is significantly higher in men.20 21 The prevalence of diabetes decreases with increasing
levels of educational attainment and income.
Among youth, non-Hispanic whites have
the highest incidence of type 1 diabetes while
minority youth have the highest incidence of
type 2 diabetes.22 Type 2 diabetes is being more
commonly diagnosed and there was a doubling
of prescriptions for its treatment among youth
between 2002 and 2005.23 Deaths from diabetes
are uncommon among youth with <80 per year
nationwide, however, the death rate for black
youth is significantly higher than for whites.24
The Healthy study is a 3-year middle
school-based primary prevention trial targeting
nutrition and physical activity behaviors to moderate the risk of type 2 diabetes, conducted in 21
schools across the US. An interim report has
been published.25
Between 1971 and 2000, the overall
death rate among adult male diabetics declined
significantly (43%) as did deaths from heart disease (48%), but both rates remained unchanged
among diabetic adult women.26
Page 173 of 294
Disability affects 20-50% of the diabetic
population,27 eg an association between hearing
impairment and diabetes.28
Annual healthcare costs for a person
with type 2 diabetes complications are about
three times that of the average American without
diagnosed diabetes. The State of Diabetes
Complications in America report estimated that,
in 2006, poorly managed type 2 diabetes cost
the US healthcare system $22.9 billion in direct
expenditures to deal with complications of the
disease (www.stateofdiabetes.com). Diabetes
accounted for 12% of dollars spent by federal
government health care programs (USA Today
6/19/07, 9D).
The prevalence of diabetes is more
common among obese individuals, but it is the
diabetes and not their obesity that raises the risk
of severe health problems.29 Weight loss is the
key factor in reducing diabetes risk for high-risk,
overweight persons.30 It also has been reported
that active smoking increases the risk of type 2
diabetes.31 Early detection and improved delivery of care, and better self-management are
key strategies for preventing much of the burden
of diabetes.32 However, there is no direct evidence on the health benefits of detecting type 2
diabetes by either targeted or mass screening,
and indirect evidence also fails to demonstrate
health benefits for screening general populations.33 Persons with hypertension probably
benefit from screening because blood pressure
targets for persons with diabetes are lower than
those for persons without diabetes.
Missouri
Diabetes has been ranked among the 10
leading causes of death in the US since 1932; it
was 7th in 2007.34 However, mortality statistics
alone clearly understate the impact of diabetes.
Because people die of the complications of diabetes rather than the disease itself, diabetes is
underreported as the underlying or even
buting cause of death.35 It is estimated that diabetes is listed on the death certificates of less
than half of the decedents who actually had diabetes.36 In 2005, 9% of all Missouri resident
deaths were diabetes-related.37 According to the
Missouri Department of Health and Senior
vices (MDHSS), diabetes-related mortality has
been increasing over recent years. It increases
dramatically with age, doubling and tripling with
each 10 year increase in age.
Figure 13-1 displays the age-adjusted
diabetes death rates for Missouri during 20032007. The rates for the Kansas City area were in
the 2nd and 3rd quintiles. Black males had the
highest age-adjusted death rate at 51.8 followed
by black females (48.0), white males (26.0) and
white females (18.7).
According to Behavioral Risk Factor
Surveillance System (BRFSS), 8% of Missouri
adults have been diagnosed with diabetes (Figure 13-2),38 and the age-adjusted incidence of
diabetes increased 69% during 2005-2007 compared to 1995-1997.39 The prevalence of diabetes was inversely associated with educational attainment levels and income levels, and was
highest among persons who were overweight or
obese. Forty-five percent (45%) of the adult respondents with a diabetes diagnosis learned of
their condition at age 55 or older.
Of BRFSS respondents with diabetes,
29% were currently taking insulin and 72% were
taking pills to help control their condition. Yet,
9% reported not having seen a doctor in the past
year while 4% had not had an A1C test in the
past year (41% had 1 to 2 tests in the year, and
81% had >2 tests during the year). Seventy-one
percent (71%) checked their blood glucose 1 or
more times per day.
Foot care and vision care are important
among diabetics and 68% reported checking
their feet for sores at least once a day and 71%
reported having had an annual foot exam within
the past year. Overall, 17% of diabetics reported
having had sores or irritations on their feet that
DIABETES
Page 174 of 294
Figure 13-1 Age-adjusted diabetes death rates, Missouri,
2003-2007 (source: Missouri Department of Health and Senior Services)
Figure 13-2 Prevalence of diabetes by
weight among adults, 2000-2004, Missouri BRFSS 2006
14.2%
6.4%
3.7%
2.9%
Under
Normal
Over
Obese
took >4 weeks to heal. Annual dilated eye exams were reported by 68% of respondents.
Twenty-six percent (26%) of respondents reported being told by a doctor that diabetes had
affected their eyes or that they have retinopathy.
DIABETES
Kansas City
BRFSS data found that
6.5% of adults in the bi-state
metropolitan area were diabetic.40 BRFSS also found that
6.8% of adults in Clay County
had diabetes compared to 8.5%
in Jackson County and 6.5% in
Platte County. A 2004 telephone survey commissioned by
the Kansas City Health Department had 13.1% of respondents report that they were diabetic.41 And a 2007 telephone
survey conducted by MDHSS
found 10.2% of Kansas City
respondents reporting they had
diabetes.
Since 2000, the overall
age-adjusted death rates due to
diabetes remained stable between 25 and 33
deaths/100,000 population
(Figure 13-3). Annual rates for
non-Hispanic blacks were 2-3
times higher than those for non-Hispanic whites.
The overall and non-Hispanic white rates were
well below the Healthy People 2010 objective of
45 deaths/100,000 population, while the rates
for non-Hispanic blacks exceeded the objective
each year. Between 1998-2002 and 2003-2007,
the annualized age-adjusted death rates declined for both non-Hispanic blacks (7%) and
non-Hispanic whites (23%) (Figure 13-4).
In 2007, diabetes was the 9th leading
cause of death among residents with 103 persons dying. It was the 7th leading cause of death
for non-Hispanic blacks, and Hispanics, but was
not among the top 10 leading causes of deaths
for non-Hispanic whites. The average age at
death was 70.9 years of age. Among males who
died from diabetes, 34.0% of the deaths were
premature compared to 20.0% of deaths among
females. An earlier analysis of diabetic deaths in
Page 175 of 294
Figure 13-3 Age-adjusted death rates per 100,000 population due
to diabetes, Kansas City, Mo
All
57
56
53
33
31
White, non-Hispanic
29
26
23
2000
2001
Black, non-Hispanic
59
48
48
48
47
26
25
26
25
16
15
2004
2005
33
19
21
2002
2003
100,000 population due to diabetes by
race/ethnicity, Kansas City, Mo
1998-2002
2003-2007
58
21
52
17
White, non-Hispanic
ly income. The death
rates decline as the income levels rise.
Black, non-Hispanic
Kansas City found that almost one-third of
deaths due to diabetes were premature as the
individuals died before the age of 65 years old.42
This situation had not changed during the period
2003-2007.
Figure 13-5 displays the number of diabetes deaths projected to occur each year between 2008 and 2012 along with 95% confidence intervals for each year’s projection. While
the number of projected deaths remained constant at 104 across the five years, the confidence intervals widened each year.
The distributions of deaths by zip code
are shown in Tables 13-1 and 13-2. Figure 13-6
displays the annualized death rates per 10,000
population for diabetes by zip code median fami-
Emergency department visits &
hospitalizations
According to various reports by the Na2006
2007
tional Center for Health
Statistics
(www.cdc.gov/nchs), individuals with diabetes made 23.8 million visits to
their physicians, 4.3 million visits to hospital outpatient clinics, and experienced 584,000 hospitalizations due to their disease. Among persons
receiving home health care, 7.9% were diabetic
and among persons in nursing homes, 17.0%
were diabetic.
During 2007, in Kansas City, diabetes
was responsible for 1,291 emergency department visits and 1,254 hospitalizations. Among
persons >45 years of age, diabetes varied between the 5th and 10th leading reason for a visit
to an emergency room. Overall, it was the 10th
leading cause of hospitalization and its importance varied with age beginning as young as 514 years old.
In April 2006, MDHSS released updated
diabetes data
(www.dhss.mo.gov/ASPsDiabetes/Main.php?cnt
y=521). Between 1999 and 2003, 5,212 hospital
admissions occurred among Kansas City residents for which diabetes was the principal diagnosis and 50,919 admissions were it was either
the principal or secondary diagnosis. For the
admissions with diabetes as the principal diagnosis, the rate of age-adjusted admissions per
10,000 population for blacks was 2.9 times that
for whites (41.7 and 14.6, respectively). These
rates were similar to statewide rates of 13.3 for
whites and 41.9 for blacks. For emergency de17
15
DIABETES
Page 176 of 294
Figure 13-5 Five year projection of diabetes deaths with 95% confidence intervals, Kansas
City, Mo, 2007-2011
140
126
139 143
131 135
120
100
80
82
60
77
72
69
65
10
11
12
40
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
104 diabetes deaths per year projected for 2008 to 2012
partment visits in 2003 with diabetes as the principal diagnosis, the black:white disparity ratio in
age-adjusted rates per 1,000 population was 5.4
(6.5 blacks, 1.2 whites). The rate for whites was
similar to that for whites statewide (1.1) while the
rate for blacks was 1.4 times higher than the
statewide rate for blacks (4.6).
In 2003, admissions with diabetes as
the principal diagnosis resulted in 5,440 days of
care provided with hospital charges of
$17,952,226.
There were 2,385 days of care provided
to whites with hospital charges of $8,004,154
and 2,759 days of care provided to blacks with
hospital charges of $9,127,338. For the 1,272
emergency department visits in 2003 the hospital charges were $1,489,210 (363 visits by whites
and $450,466 in charges; 825 visits by blacks
and $943,639 in charges).
In addition to the above, there were
2,831 admissions with a diabetes related lower
extremity condition listed as the principal diagnosis, and 705 individuals (304 of whom were
white and 325 black) underwent lower extremity
amputation as a result of their diabetes. The
age-adjusted amputation rate for blacks (5.9 per
10,000 population) was nearly three times that
for whites (rate of 2.0). The statewide amputation rate for whites was 2.1 while that for blacks
was 7.1, or 3.4 times higher than that for whites.
DIABETES
Quality improvement for diabetes treatment is a major issue both from an individual
patient perspective and from a disparities perspective. In general, Hispanic and non-Hispanic
blacks have worse glycemic control than nonHispanic whites.43 Yet, studies have shown that
whites are more likely than blacks to reach
commonly accepted benchmarks for diabetes
control even when receiving the same level of
care from the same physicians.44 Consequently,
the Kansas City Quality Improvement Consortium has developed standards against which it
measures individual physician performance for
management of diabetes and other health conditions (www.kcqic.org). Annual report cards for
diabetes indicate growing improvements in
management of individual patients.45 Similar reviews elsewhere suggest that successful quality
improvement can contribute to reducing health
disparities in diabetes care.46 The MDHSS reported that quality improvement efforts statewide
have allowed Missouri to achieve the Healthy
People 2010 goal of at least 65% of persons
with diabetes receiving two or more A1C blood
tests in a year.47
Page 177 of 294
Table 13-1 Deaths due to diabetes among Kansas City,
Zip code
Total
deaths
Male
Female
White, nonHispanic
Black,
nonHispanic
64101
0
0
0
0
0
64102
0
0
0
0
0
64105
1
1
0
1
0
64106
9
4
5
2
6
64108
19
11
8
2
11
20
64109
21
14
7
1
64110
20
7
13
3
15
64111
11
4
7
2
9
64112
4
3
1
4
0
64113
6
3
3
6
0
64114
35
20
15
29
3
64116
11
6
5
11
0
64117
12
6
6
11
0
64118
26
10
16
25
1
64119
16
8
8
12
0
64120
2
1
1
1
0
64123
9
4
5
5
1
64124
12
6
6
8
1
64125
6
3
3
5
0
64126
10
1
9
6
4
64127
34
14
20
8
24
64128
40
15
25
3
37
64129
9
5
4
7
1
64130
82
36
46
3
78
64131
30
16
14
10
20
64132
27
9
18
1
26
64133
12
9
3
10
2
64134
16
7
9
8
6
64136
7
3
4
5
0
64137
8
5
3
6
1
64138
17
6
11
11
6
64139
8
1
7
6
2
64145
10
4
6
4
5
64146
1
1
0
1
0
64147
0
0
0
0
0
64149
0
0
0
0
0
64151
12
6
6
11
1
64152
6
5
4
1
0
64153
0
0
0
0
0
64154
3
2
1
3
0
64155
12
3
9
11
0
64156
1
1
0
1
0
64157
2
1
1
1
1
64158
0
0
0
0
0
64160
0
0
0
0
0
64161
0
0
0
0
0
64163
0
0
0
0
0
64164
1
1
0
1
0
64165
0
0
0
0
0
64166
0
0
0
0
0
64167
0
0
0
0
0
64192
0
0
0
0
0
All others1
2
2
0
2
0
Total
570
264
306
281
533
1
Zip codes 64121, 64141, 64148, 64168, 64171, 64172, 64179, 64188, 64190,
codes 64144, 64170, 64180, 64183, 64184, 64185, 64187, 64193, 64194, 64197,
64198, 64944, and 64999 are associated with unique entities, and zip codes
64012, 64030, 64079, and 64081 are associated with Belton, Grandview, Platte
City, and Lee’s Summit, respectively.
DIABETES
Page 178 of 294
Table 13-2
Distribution of diabetes deaths by zip
code and rate per 1,000 population, Kansas City, Mo,
2003-2007
0.0-09
1.0-1.9
2.0-2.9
64012
64079
64081
64101
64102
64105
64111
64112
64113
64117
64119
64123
64124
64133
64134
64145
64146
64147
64149
64151
64153
64154
64155
64156
64157
64158
64161
64163
64164
64165
64166
64167
64192
64106
64109
64110
64114
64116
64118
64125
64126
64127
64129
64131
64132
64137
64138
64152
64108
64120
64128
64130
3.0-3.9
4.0-4.9
=>5.0
64136
64030
64139
Figure 13-6 Annualized death rates per
10,000 population by zip code median
family income levels, Kansas City, Mo,
2003-2007
3.4
2.1
$20-39,999
DIABETES
$40-59,999
1.7
$60-79,999
0.7
$80-99,999
Page 179 of 294
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Kengne AP, Patel A. How important is diabetes as a risk
factor for cardiovascular and other diseases in older adults.
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2
Buse JB et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus. A scientific statement
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3
Schramm TK et al. Diabetes patients requiring glucoselowering therapy and nondiabetics with a prior myocardial
infarction carry the same cardiovascular risk. A population
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4
Hogan P et al. Economic costs of diabetes in the US in
2002. Diabetes Care 2003;26:917-932.
5
Ong KL et al. Prevalence, treatment, and control of diagnosed diabetes in the US National Health and Nutrition Examination Survey 1999-2004. Ann Epidemiol 2008;18:222229.
6
SEARCH for Diabetes in Youth Study Group. The burden
of diabetes mellitus among US youth: prevalence estimates
from the SEARCH for Diabetes Youth Study. Pediatrics
2006;118:1510-1518.
7
Narayan KMV et al. Impact of recent increase in incidence
on future diabetes burden, US, 2005-2050. Diabetes Care
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Expert Committee on the Diagnosis and Classification of
Diabetes. Follow up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-3167.
15
Rolka DR et al. Self-reported prediabetes and riskreduction activities – United States, 2006. MMWR Morb
Mortal Wkly Rep 57;44:1203-1205.
16
Benjamin SM et al. A change in definition results in an
increased number of adults with prediabetes in the United
States. Arch Intern Med 2004;164:2386.
17
Nichols GA, Brown JB. Higher medical costs accompany
impaired fasting glucose. Diabetes Care 2005;28:2223-2229.
18
Ratner RE. Redefine diabetes to lower costs of care. Intern Med News June 1 ,2008, p 10.
19
Pleis JR, Lethbridge-Cejku M. Summary health statistics
for US adults: National Health Interview Survey, 2006.
20
Cowie CC et al. Prevalence of diabetes and impaired fasting glucose in adults in the US population. Diabetes Care
2006;29:1263-1268.
21
Signorello LB et al. Comparing diabetes prevalence between African Americans and whites of similar socioeconomic status. Am J Public Health 2007;97:2260-22067
22
The Writing Group for the SEARCH for Diabetes in Youth
Study Group. Incidence of diabetes in youth in the United
States. J Am Med Ass 2007;297:2716-2724.
Smith JP. Nature and causes of trends in male diabetes
prevalence, undiagnosed diabetes, and the socioeconomic
status health gradient. Proc Nat Acad Sci 2007;104:1322513231.
Cox ER et al. Trends in the prevalence of chronic medication use in children: 2002-2005. Pediatrics 2008;122:e1053e1061.
9
24
Burrows NR et al. Prevalence of self-reported cardiovascular disease among persons aged >35 years with diabetes –
United States, 1997-2005. MMWR Morb Mortal Wkly Rep
2007;56:1129-1132.
23
Akiknbami LJ et al. Racial disparities in diabetes mortality
among persons aged 1-19 years – United States, 19792004. MMWR Morb Mortal Wkly Rep 2007;56:1184-1187.
25
Pan L et al. Self-rated fair or poor health among adults
with diabetes – United States, 1996-2005. MMWR Morb
Mortal Wkly Rep 2006;55:1224-1228.
The HEALTHY Study Group. HEALTHY study rationale,
design, and methods: moderating risk of type 2 diabetes in
multi-ethnic middle school students. Int J Obes 2009;33:S1S67.
11
26
10
Mugglestone MA. Management of diabetes from preconception to the postnatal period: summary of the NICE guidance. Brit Med J 2008;336:714-717.
12
Anna V et al. Sociodemographic correlates of the increasing trend in prevalence of gestational diabetes mellitus in a
large population of women between 1995 and 2005. Diabetes Care 2008;31:2288-2293.
13
Kieffer EC et al. Health behaviors among women of reproductive age with and without a history of gestational diabetes
mellitus. Diabetes Care 2006;29:1788-1793.
Gregg E et al. Mortality trends in men and women with
diabetes, 1971-2000. Ann Intern Med 2007;147:149-155.
27
Eberhardt MS et al. Mobility limitation among persons
aged >40 years with and without diagnosed diabetes and
lower extremity disease – United States, 1999-2002. MMWR
Morb Mortal Wkly Rep 2005;54:1183-1186.
28
Bainbridge KE et al. Diabetes and hearing impairment in
the United States: audiometric evidence from the National
Heath and Nutrition Examination Survey, 1999 to 2004. Ann
Intern Med 2008;149:July
29
Slynkova K et al. The role of body mass index and diabetes in the development of acute organ failure and subse-
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quent mortality in an observational cohort. Crit Care
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30
Hamman RF et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care 2006;29:21022107.
31
Willi C et al. Active smoking and the risk of type 2 diabetes. A systematic review and meta-analysis. J Am Med
Ass 2007;298:2654-2664.
32
Mukhtar Q et al. Prevalence of receiving multiple preventive-care services among adults with diabetes – United
States, 2002-2004. MMWR Morb Mortal Wkly Rep
2005;54:1130-1133.
33
Norris SL et al. Screening adults for type 2 diabetes: a
review of the evidence for the US Preventive Services Task
Force. Ann Intern Med 2008;148:855-868.
34
Hamilton BE et al. Deaths: preliminary data for 2007. Natl
Vital Stat Rep 2009:57(12). www.cdc.gov/nchs
35
Hempstead K. The accuracy of a death certificate checkbox for diabetes: early results from New Jersey. Public
Health Rep 2009;124:726-732.
36
Sayhad SH et al. Review of performance of methods to
identify diabetes cases among vital statistics, administrative,
and survey data. Ann Epidemiol 2004;14:507-116.
37
Missouri Department of Health and Senior Services. Diabetes-related mortality in Missouri. Focus March 2007.
www.dhss.mo.gov
38
Behavioral Risk Factor Surveillance System Annual Report:
Health Risk Behaviors of Adult Missourians. June 2007.
www.dhss.mo.gov/BRFSS/2006AnnualReport.pdf
39
Kirtland KA et al. State-specific incidence of diabetes
among adults –participating states, 1995-1997 and 20052007. MMWR Morb Mortal Wkly Rep 2008;57:1169-1173.
40
41
Kansas City Health Department. 2004. 2004 Health Assessment Survey. www.kcmo.org/health.
42
Kansas City, Missouri, Health Department. Diabetes assessment. Kansas City, Missouri, residents. 1990-1998.
2000. 25 p.
43
Heisler M et al. Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans
in the Health and Retirement Study. Arch Intern Med
2007;167:1853-1860.
44
Adams AS et al. Medication adherence and racial differences in A1C control. Diabetes Care 2008; 31:916-921.
DIABETES
45
Bavely A. Diabetes report cards: care make strides. Kansas City Star 2/08/06.
46
Sequist TD et al. Effect of quality improvement on racial
disparities in diabetes care. Arch Intern Med 2006;166:675681.
47
Missouri Department of Health and Senior Services. Missouri recognized for efforts to address diabetes. Press release, 4/05/06.
Page 181 of 294
14. Obesity – A Kansas City Health Department Priority
Obesity is weight that endangers health
because of its high body fat relative to lean body
mass. Whether obesity should be considered a
disease has been controversial.1 Nevertheless,
the Council of the Obesity Society concluded
that considering obesity as a disease is likely to
have far more positive than negative consequences and to benefit the greater good by soliciting more resources into prevention, treatment,
and research of obesity; encouraging more highquality caring professionals to view treating the
obese patient as a vocation worthy of effort and
respect; and reducing the stigma and discrimination heaped on many obese persons.2
Persons are classified as underweight,
normal weight, overweight, and obese using the
body mass index (BMI), expressed as
weight/height2 (kg/m2); obese is subdivided into
moderately obese (BMI >30 to <40) and morbidly obese (about 100 lb overweight or BMI >40).
Although it is recognized that these distinctions
are imperfect and somewhat arbitrary, this method of classification is standard.3 4 Other terminology such as “at risk of overweight” and
“overweight” for children have been used by the
Centers for Disease Control and Prevention
(CDC) and are recommended to be replaced by
“overweight” and “obese” (www.amednews.com
7/9/07); those recommendations will be followed
in this report
Obesity is highly prevalent in societies in
the developed world and is linked to very high
rates of chronic illnesses, higher than living in
poverty, and much higher than smoking or drinking.5 Although excess body weight during midlife
has been reported to have an increased risk of
death,6 analyses of data from the National
Health Interview Survey Linked Mortality Files
indicate that overweight and mild obesity are not
associated with lower life expectancy, while BMI
categories >35 are associated with lower ex-
pected survival.7 Extremely obese individuals –
those >80 lb over normal weight – live 3-12
years less than their normal weight peers.
Physical inactivity and poor diet are
stated to be the most important contributors to
obesity, although other contributing factors play
an important role as well.8 For example, having
been born with a birthweight of >4,000 gm, especially >4,500 gm, places a child at increased
risk of adolescent obesity.9 Being overweight at
5 years of age has been shown to predict diabetes at age 21.10 And, weight gain during teen
years may worsen adult heart health.11 12
In comparison to men, women suffer a
disproportionate burden of disease attributable
to overweight and obesity.13 Adolescent females
who are overweight, for example, have higher
health expenditures than adolescent males who
are overweight.14 Being obese in mid-life is
strongly related to a reduced probability of
healthy survival among women who live to older
ages.15 As smoking prevalence decreases, obesity may become the biggest attributable cause
of cancer in women.16
Obesity is associated with increased risk
for cardiovascular health problems including diabetes, hypertension, and stroke. These cardiovascular afflictions increase risk for cognitive
decline and dementia. Higher BMI is associated
with detectable brain volume deficits in cognitively normal elderly subjects.17 Persons who are
obese appear to be less likely to die by suicide
than persons with lower BMI.18
Prevalence
Obesity has increased at an alarming
rate in the US over the past three decades.19
The prevalence of morbidly obese is increasing
faster in the US than the prevalence of moderately obese.20 In addition, it is believed that the
OBESITY
Page 182 of 294
obesity epidemic among children will lead to a
large number of younger adults with type 2 diabetes.21
One of the Healthy People 2010 objectives (19-3) is to reduce to 5% the number of
children and adolescents who are obese. Data
from the Early Childhood Longitudinal Study,
Birth Cohort, show that >18% of 4 year old children in the US are obese and that the prevalence
of obesity varies by race/ethnicity.22 Nationally,
the prevalence of obesity among low-income,
preschool-aged children was 14.6% in 2008.23
Obese adolescents have the same risk of premature death in adulthood as people who smoke
more than 10 cigarettes a day, while those who
are overweight have the same risk as less heavy
smokers.24
Projections based on National Health
and Nutrition Examination Surveys (NHANES)
data suggest that by 2030, 86.3% of adults in
the US will be overweight or obese; and 51.1%
obese.25 Black women and Mexican-American
men would be the most affected. By 2048, all
American adults would become overweight or
obese, while black women would reach that
state by 2034. The prevalence of overweight
and obesity in children would double by 2030;
severe obesity in children already has tripled
over the past 25 years, with significant differences by race, sex, and poverty.26 Total healthcare cost attributable to obesity/overweight
would double every decade, accounting for 1618% of total US health care dollars by 2030.
Current estimates of obesity in the
population can be derived from NHANES and
the Behavioral Risk Factor Surveillance System
(BRFSS), however, it is believed that the
BRFSS underestimates the actual prevalence of
overweight and obesity.27 28 This is because
men and women significantly over report their
height, increasingly so at older ages, plus men
tend to overestimate their weight and women
under report their weight, more so at younger
ages.29 Similarly, parents underestimate their
children’s height when providing height and
OBESITY
weight data on surveys.30 These behaviors then
lead to faulty BMI calculations.
Based on current NHANES data, 66% of
adults are overweight or obese; 34% of children
are overweight, 16% are obese, and 11.5% of
children 6-23 m old are obese
(www.cdc.gov/nchs). Further, it is estimated that
21.4% of aged Medicare beneficiaries and
39.3% of disabled beneficiaries are obese.31
There are some indications that levels of obesity
may be leveling off in children, adolescents and
adults.32 33
Significant differences in obesity exist by
race/ethnicity and by age, and can be influenced
by culture.34 These differences may partially be
explained by racial/ethnicity differences in
weight perception. While weight misperception is
highly prevalent in the US population, the odds
of weight misperception are much higher among
non-Hispanic blacks and Hispanics.35
Approximately 30% of non-Hispanic
white adults are obese compared to 45% of nonHispanic blacks and 36.7% of Hispanics. NonHispanic black and Hispanic children are much
more likely to be overweight than non-Hispanic
white children. Non-Hispanic black females and
Hispanic males have the highest prevalences of
being overweight among children and adolescents.36 BMI, as it is currently employed, however, may misdiagnose Asians, many of whom
experience metabolic risks such as hypertension
and diabetes at a much lower threshold than is
associated with other racial/ethnic groups. Poor
children with a sedentary lifestyle are 3.7 times
more likely to be obese than their active, affluent
counterparts.37 Race, socioeconomic status, and
behavioral factors are independently related to
childhood and adolescent obesity.
Interestingly, NHANES data also found
that adults who slept <6 hours a night had the
highest rate obesity (33%) while those who slept
7-8 hours had the lowest (22%).38 This pattern
was found for both men and women and across
all age groups and most race/ethnicity groups.
The association between sleep and obesity was
Page 183 of 294
less striking among adult >65 years old than
among younger adults. Similarly, the highest
rates for physical inactivity were among those
individuals who slept <6 hours or >9 hours. More
recently it has been shown that rates of short
sleep duration (<6 hours) were 12% for blacks
and 8% for whites and the rates of obesity were
52% for blacks versus 38% for whites.
(www.dhss.mo.gov/CommunityDataProfiles).
For Clay County, the prevalence rates were
32.3% overweight and 29.2% obese, for Jackson County, the rates were 34.8% overweight
and 28.3% obese, and for Platte County, 39.3%
overweight and 22.4% obese. With the exception of the obesity prevalence in Platte County,
which was statistically lower than the statewide
rate, all of the other rates were not different from
the rates for Missouri overall. In 2003, 12.1% of
high school students in the state were obese.
Figure 14-1 displays the relationship between
income and BMI in Missouri based on the 2007
BRFSS. There has been an increase in the percent of Missouri high schools in which students
cannot buy candy, salty snacks, soda or sports
drinks from vending machines or at a school
store, canteen, or snack bar.41
Missouri
While NHANES focuses on national level data, BRFSS can provide estimates of obesity
at national, state and local levels. In 2008, state
aggregated BRFSS yielded an estimate of
26.1% for adult obesity with Missouri’s adult obesity rate at 28.5% (www.cdc.gov/obesity
/data/trends.html). For 2006-2008, BRFSS found
that 37.5% of non-Hispanic black adults were
obese as were 28.7% of Hispanics and 23.7%
for non-Hispanic whites.39 In Missouri, the rates
were 36.1% for non-Hispanic blacks, 28.8% for
Hispanics, and 26.5% for non-Hispanic whites.
BRFSS data for 2007 found 41.7% of adult
males and 28.8% of females in Missouri were
overweight while 28.5% of adult males and
27.9% of females were obese.40
The 2007 Missouri County-Level Survey
data recorded adult prevalences of 37.7% for
overweight and 29.1% for obesity
Kansas City
22.5%
39.7%
28.0%
36.6%
32.3%
7.0%
33.2%
33.2%
31.6%
34.8%
34.2%
27.1%
Based on a summary of Missouri Department of Health and Senior Services’ BRFSS
surveys from 2005-2008 that recorded zip code
level data for Kansas City, 2.2% of adult respondents >18 years old were underweight,
32.4% were of normal weight, 35.7% were
overweight, and 29.7% were obese; the obesity
rate was highest among non-Hispanic black female respondents (Tables
14-1 and 14.2).
Overweight is associated
Figure 14-1 Overweight and obesity by income level, Missouri,
with decreased cognitive
2007 (source Missouri 2007 BRFSS report)
functioning among schoolOverweight
Obese
age children and adolescents.42 This raises serious
concerns for academic
success and one’s life
course. From the National
Survey of Children’s Health
2003, approximately 16%
of Missouri youth 10-17
years of age were obese.43
<$15,000
$15-24,999
$25-34,999
$35-49,999
$50-74,999
=>$75,000
OBESITY
Page 184 of 294
Table 14-1 Body mass index status of adults responding to BRFSS telephone surveys, Kansas
City, Mo, 2005-2008
All respondents
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Other
Total
Underweight
#
%
27
2.2
7
2.1
3
1.9
37
2.2
Normal weight
#
%
423
35.0
73
22.0
54
34.6
550
32.4
Overweight
#
%
432
35.8
118
35.5
55
35.3
605
35.7
#
352
134
44
503
Obese
Male
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Other
Total
Underweight
#
%
7
1.5
3
2.8
0
0.0
10
1.6
Normal weight
#
%
132
28.1
25
23.1
19
28.8
176
27.4
Overweight
#
%
203
43.3
45
41.7
24
36.4
272
42.3
#
127
35
23
185
Female
Race/ethnicity
White, non-Hispanic
Black, non-Hispanic
Other
Total
Underweight
#
%
20
2.7
4
1.8
3
3.3
27
2.6
Normal weight
#
%
291
39.4
48
21.4
35
38.9
374
35.6
Overweight
#
%
229
31.0
73
32.6
31
34.4
333
31.7
#
198
99
21
318
Total
%
26.9
40.4
28.2
29.7
Obese
1,207
332
156
1,695
Total
%
27.1
32.4
34.8
28.8
Obese
469
108
66
643
Total
%
26.8
44.2
23.3
30.2
738
224
90
1,052
Table 14-2 Body mass index status by age for adults responding to BRFSS telephone surveys,
All respondents
Age category
18-29 years
30-39 years
40-49 years
50-59 years
60-69 years
>70 years
Total
Underweight
#
%
5
3.0
3
1.1
8
2.6
1
0.3
8
1.7
15
4.3
37
2.2
Normal weight
#
%
69
41.1
92
35.0
97
31.5
93
28.5
67
23.1
136
38.7
554
32.5
Overweight
#
%
53
31.5
88
33.5
105
34.1
119
19.5
119
41.0
125
35.6
609
35.7
#
41
80
98
113
99
75
506
Male
Age category
18-29 years
30-39 years
40-49 years
50-59 years
60-69 years
>70 years
Total
Underweight
#
%
3
4.3
2
1.9
1
0.8
0
0.0
0
0.0
4
3.5
10
1.5
Normal weight
#
%
30
42.9
29
28.2
25
21.2
26
21.3
30
24.6
37
32.7
177
27.3
Overweight
#
%
20
28.6
46
44.7
57
48.3
55
45.1
48
39.3
48
42.5
274
42.3
#
17
26
35
41
44
24
187
Female
Age category
18-29 years
30-39 years
40-49 years
50-59 years
60-69 years
>70 years
Total
Underweight
#
%
2
2.0
1
0.6
7
3.7
1
0.5
5
3.0
11
4.6
27
2.6
Normal weight
#
%
39
39.8
63
39.4
72
37.9
67
32.8
37
22.0
99
41.6
377
35.6
Overweight
#
%
33
33.7
42
26.3
48
25.3
64
31.4
71
42.3
77
32.4
335
31.7
#
24
54
63
72
55
51
319
OBESITY
Obese
Total
%
24.4
30.4
31.8
22.3
34.1
21.4
35.7
Obese
168
263
308
326
290
351
1,706
Total
%
24.3
25.2
29.7
33.6
36.1
21.2
28.9
Obese
70
103
118
122
122
113
648
Total
%
25.4
33.8
33.2
35.3
32.7
21.4
30.2
98
160
190
204
168
238
1,058
Page 185 of 294
For local information regarding overweight and obesity in children, the Kansas City
University of Medicine and Biosciences’ Score 1
for Health initiative provides some data.44 That
project found that Hispanic students in grades K5 had the highest prevalence of being overweight/obese (Figure 14-2). While levels of being overweight were similar across grade levels,
the prevalence of obesity was higher in later
grades. The prevalence of being overweight/obese was higher in white students at
lower socioeconomic status schools compared
to higher socioeconomic status schools; the reverse was true to black students.
Of Score 1 participants whose BMI’s
were screened in 2002 and 2006, the percent
who had normal BMI in kindergarten and 1st
grade declined 6% by the time they were in 4th
or 5th grade and there was a corresponding increase in overweight or obesity. Most students
who started out obese remained obese or overweight (93%), whereas students who started out
overweight had a 1 in 3 chance of becoming
normal weight, staying the same or becoming
obese. The likelihood of changing from overweight to normal weight was significantly higher
for students with higher socioeconomic status
and was not associated with race.
Using the CDC standards for BMI per-
Figure 14-2 Percent of school-aged
children in grades K-5 who were overweight/obese, 2006-2007, Kansas City,
Mo, metropolitan area (source: Score 1 for
Asian
Black
Hispanic
40.0%
38.0%
43.0%
51.0%
Female
39.0%
36.0%
30.0%
Male
41.0%
Health 2008 Community Report, Kansas City University of Medicine and Biosciences)
White
centiles in children, Score 1 participants had
higher BMIs than ideal across the BMI spectrum.
The Score 1 population had higher rates of
overweight and obesity than Missouri and Kansas state statistics indicate.45
America’s 2006 Obesity Report Card
awarded Missouri a grade of B overall and for
childhood obesity
(www.ubalt.edu/experts/obesity). And, Trust for
America’s Health’s report, F as in Fat: How Obesity Policies are Failing in America, 2009,
ranked Missouri as having the 13th highest rate
of adult obesity at 28.1% and the 23rd highest
rate for overweight/obese children at 31.0%
(http://healthyamericans.org/ reports/obesity
2009).
Health consequences
Being overweight or obese contributes to
many health and safety issues ranging from increased risk of breast cancer, complications of
pregnancy, increased risk of birth defects, impotence in males, and ability to receive certain diagnostic imaging procedures, to motor vehicle
crash injury and death. It also has led to an increase in gastric bypass surgeries as a method
of weight loss. According to the Obesity Reduction Survey, obese Missourians are 3.5 and 2.43
times more likely to develop type 2 diabetes
mellitus and hypertension.46 The only positive
health benefit to being obese (aka obesity paradox) is that these individuals have a lower risk of
death from cardiovascular problems than lean
persons.47 48
Obesity appears to lessen life expectancy markedly, especially among younger adults.49
50
Particularly at higher levels, obesity has been
associated with increased mortality relative to
persons of normal weight; yet demonstrating
causality has been elusive.51 52 53 Overweight
and obese women have lower mortality rates
than males up until age 45, after which women’s
mortality rates are much higher than men’s.54
While the impact of obesity on mortality may be
OBESITY
Page 186 of 294
decreasing over time,55 perhaps due to improvements in public health and health care,
obesity remains the 2nd leading actual cause of
death in the US.56 Nationally, children and adolescents who are obese experience a lower
health-related quality of life, often as low as that
reported by young cancer patients.57 58
Obesity is significantly associated with
increased length of disabled life in older men
and women, and, in combination with arthritis,
significantly decreases active life.59 It has a
dramatic effect on people’s ability to manage the
five basic activities of daily living: bathing, eating, dressing, walking across a room, and getting in or out of bed.60 While men with moderate
obesity have a 50% increased probability of having limitations on these abilities; severe obesity
is associated with a 300% increased probability.
The effects are even larger for women. These
differences underscore the need to distinguish
between moderate and more severe levels of
obesity.
Both chronic health conditions and limitations on the abilities to perform basic activities
of daily living contribute to increased levels of
disability among obese individuals.61 Disability
rates are increasing among the non-elderly and
the increases cut across all demographic and
economic groups. Although mental health is one
of the most important causes of disability among
the non-elderly, the fastest growing causes are
diabetes62 and musculoskeletal problems, 63
conditions that are associated with obesity. Disability is projected to increase 1% per year in 5069 year olds if there were no further gains in
weight.64 Women suffer a disproportionately
large share of the disease burden of overweight
and obesity that is not due solely to differences
in medical comorbidity.65
Economic impact
Obesity accounts for 9.1% of health
spending in the US.66 It is estimated that the
medical costs associated with obesity were $147
OBESITY
billion per year in 2008. More than half of obesity
related medical costs are paid for through Medicare and Medicaid.67 Insurance spending on
obese individuals is 56% higher than that for
people of normal weight, partially due to the
number of medical conditions treated among the
obese. And, for morbidly obese individuals, who
comprise 3% of the US adult population, health
care costs are nearly double those of normalweight adults and are >10% of all health care
spending.68
Data show that young adults are obese
(>30 lb overweight) will incur $5,000-21,000
more in lifetime medical bills while those who
are very obese (>70 lb overweight) will incur
$15,000-29,000 more in lifetime medical expenditures. Expenditures related to higher BMI
have risen dramatically among white and older
adults, but not blacks or those younger than 35
years old.69 The higher spending for obese patients is mainly attributable to treatment for diabetes and hypertension.70 Hospitals are having
to buy expensive new equipment such as reinforced toilets and oversized beds to treat the
growing number of severely obese patients.
Obesity outranks both smoking and
drinking in its deleterious effect on health care
costs.71 And, obesity and smoking are primary
risk factors for several chronic conditions and
early death. Among the obese, 4.7% or about 9
million individuals smoke.72 Further, there may
be an association between a woman’s smoking
during pregnancy and her child being overweight
by 8 years of age.73
While it is desirable to reduce the prevalence of obesity and obesity-related morbidity
and mortality, as well as the economic burden of
obesity, there are data to suggest that although
effective obesity prevention will lead to a decrease in costs for obesity-related diseases, this
decrease will be offset by cost increases due to
diseases unrelated to obesity during the lifeyears gained.74 In addition, the current economic
environment favors underinvestment in obesity
prevention by insurance companies.75 The im-
Page 187 of 294
pact of successful obesity prevention is likely to
be larger in women than men, and similar in
whites and blacks.76
In addition to medical expenditures, obesity affects employers. Overweight and obese
attributable costs range from $175 per year for
overweight male employees to $2,485 for obese
female employees with a BMI of 35-39.9.77 The
costs of obesity at a firm with 1,000 employees
are estimated to be $285,000 per year with
~30% of the costs associated with absenteeism.
Obesity is a significant predictor of long-term (>7
days) sick leave usage.78 Morbidly obese employees (BMI >40), while representing only ~3%
of the workforce, account for 21% of the obesity
associated costs.
Prevention
The CDC published a set of 24 recommended community strategies to prevent obesity.79 These strategies are divided into 6 categories: 1) strategies that promote the availability of
affordable healthy food and beverages; 2) strategies to support healthy food and beverage
choices; 3) a strategy to encourage breastfeeding; 4) strategies to encourage physical activity
or limit sedentary activity among children and
youth; 5) strategies to create safe communities
that support physical activity; and, 6) a strategy
to encourage communities to organize for
change.
There are two basic approaches to prevention of obesity-related morbidity and mortality. The first involves medical intervention often
starting in childhood,80 81 and which must recognize ethnic/cultural differences in weight control
practices.82 The other approach takes a more
global view and focuses on the two most amenable risk factors - lack of regular physical activity and poor diet.83
Physical activity
Regular physical activity performed on
most days of the week reduces the risk of dying
prematurely, dying from coronary heart disease,
and developing diabetes and colon cancer.
Regular activity also reduces blood pressure
among people with hypertension, promotes psychological well being, and builds and maintains
healthy bones, muscles, and joints so that older
adults can avoid falls and maintain functional
independence. Combined with poor diet, the
lack of regular physical activity leads to obesity.
Physical activity guidelines for Americans can be
found at www.health.gov/paguidelines.
In Missouri, 2007 BRFSS data found
that 25.5% of adults were physically inactive
(23.4% of males; 27.6% of females) while 2006
data found that 20.8% of adults in the bi-state
metropolitan area had no physical activity in the
prior month. The 2004 Health Assessment Survey commissioned by the Kansas City Health
Department found that 43% of respondents
usually or always exercised 3 times a week and
41% reported eating 5 servings of fruits and
vegetables on most days, if not daily.
One contributing factor to reduced activity is the composition of the built environment.84 85 For example, the ability of citizens to
walk for recreation or business often comes
down to whether sidewalks are available and if
those walkways are considered safe to use. According to the federal Highway Administration,
Americans make <6% of their daily trips on foot.
Many public health experts say the way neighborhoods are built is to blame. The Urban Land
Institute estimates that only 5-15% of new development follows the principles of “walkable
neighborhoods”. However, there are reports that
find no link between obesity and urban sprawl
(www.registerguard.com). In a national ranking
of the 40 largest cities in the US, Kansas City
ranked 34th in walkability with a score of 44,
which reflected the community’s dependence on
automobiles (www.walkscore.com).
There is a growing awareness in public
health about the need to integrate community
development or infrastructure to the health and
well being of the citizens.86 Kansas City with its
OBESITY
Page 188 of 294
large geographic area, low population density,
and excellent interstate system, has an infrastructure that is associated with less walking and
bicycling and with more automobile travel than
more densely populated communities. As land
use spreads further apart, existing transportation
systems offer few attractive and safe alternatives to driving.
tal community facilitators were availability of
home gardens, low cost of foods at farm stands,
and childhood exposure to fruits and vegetables.
Perceived environmental barriers included contradictory media messages related to nutrition
and health outcomes, limited worksite food options, food availability, and food cost at grocery
stores.
Diet
Exercise alone, however, is not enough
to offset obesity health risks.87 Consequently,
obesity is becoming one of the newest targets of
public health law, such as regulating sugary beverages.88 However, from a policy point of view,
the various economic and psychosocial factors
that fuel the obesity epidemic as well as increased availability of energy dense food and
reduced physical activity, demand a more equal
distribution of affordable nutritious food, and improved, more equitable, living and working conditions.89
Research has documented that the
manner in which food is marketed and advertised have a profound effect on obesity.90 Food
cues created through marketing and advertising
artificially stimulate people to feel hungry; external cues, such as food abundance, food variety
and food novelty, cause people to overeat. In
addition, portion sizes and energy intake for
specific food types have increased markedly
with greatest increases for food consumed at
fast food establishments and in the home.91
A complex web of factors and perceptions underpin nutrition behaviors.92 Individual
barriers to eating more fruits and vegetables
were food preferences, fatigue of taste buds for
certain foods, life stresses, lack of forethought in
meal planning, current personal health status,
aging, and perceived impact of food on chronic
disease status. Individual facilitators were presence of chronic disease, lifetime experience related to intake of fruits and vegetables, preferences for certain fruits and vegetables, and
personal or spousal health status. EnvironmenOBESITY
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Merrill RM, Richardson JS. Validity of self-reported height,
weight, and body mass index: findings from the National
Health and Nurtrition Examination Survey, 2001-2006. Prev
Singh GK et al. A multilevel analysis of state and regional
disparities in childhood and adolescent obesity in the United
States. J Community Health 2008;33:90-102.
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Children’s Healthcare Quality, Child Policy Research Center,
and Chld and Adolescent Health Measures Initiative. State
Obesity Profiles, 2008.
www.childhealthdata.org/content/obesity/reportcards.aspx
people age eighteen to fifty-nine, fueled by a growing obesity
epidemic. Health Aff 23: 2004;168-176.
46
Majid N. The obesity epidemic: lessons from the war on
smoking. Missouri Med 2005;102:550-554.
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Fonarow GC et al. An obesity paradox in acute heart failure analysis of body mass index and inhospital mortality for
108,927 patients in the Acute Decompensated Heart Failure
National Registry. Am Heart J 2007;153:74-81.
48
Uretsky S et al. Obesity paradox in patients with hypertension and coronary artery disease. Am J Med 2007;120:863870.
49
Fontaine KR et al. 2003. Years of life lost due to obesity. J
Am Med Ass 2005;289:187-193.
50
Prospective Studies Collaboration. Body-mass index and
cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 2009;epub 3/18/09.
51
Flegal KM et al. Excess deaths associated with underweight, overweight, and obesity. J Am Med Ass
2005;293:1861-1867.
52
Hernan MA, Taubman SL. Does obesity shorten life? The
importance of well-defined interventions to answer causal
questions. Int J Obesity 2008;32:S8-S14.
53
Cooper RS. Which factors confound or modify the relationship between body weight and mortality. Int J Obesity
2008;32:S47-S51.
54
Muennig P et al.Gender and the burden of disease attributable to obesity. Am J Public Health 2006;96:1662-1668.
55
Reuser M et al. Smoking kills, obesity disables: a multistate approach of the US Health and Retirement Survey.
Obesity 2009;17:783-789.
56
Mokdad AH et al. Correction: Actual causes of death in the
United States, 2000. J Am Med Ass 2005;293:293-294.
57
Schwimmer JB et al. Health quality of life of severely obese children and adolescents. 2003. J Am Med Ass
2003;289:1813-1819.
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Hannon TS et al. Childhood obesity and type 2 diabetes
mellitus. Pediatrics 2005;116:473-480.
Taylor ED et al. Orthopedic complications of overweight in
children and adolescents. Pediatrics 2006;117:2167-2174.
Sturm R et al. Increasing obesity rates and disability
trends. Health Aff 2004;23:1-7.
65
Mond JM, Baune BT. Overweight, medical comorbidity
and health-related quality of life in a community sample of
women and men. Obesity 2009;17:1627-1634.
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Finkelstein EA et al. Annual medical spending attributable
to obesity: payer-and service-specific estimates. Health Aff
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Finkelstien EA et al. State-level estimates of annual medical expenditures attributable to obesity. Obes Res
2004;12:18-24.
68
Arterburn DE et al. Impact of morbid obesity on medical
expenditures in adults. Int J Obes Relat Metab Disorder
2005;29:334-339.
69
Wee CC et al. Health care expenditures associated with
overweight and obesity among US adults: importance of age
and race. Am J Public Health 2005;95:159-165.
70
Thorpe KE et al. The impact of obesity on rising medical
spending. Health Aff 2004;W4-480.
71
Strum R. The effects of obesity, smoking . and drinking on
medical problems and costs: obesity outranks both smoking
and drinking in its deleterious effect on health and health
care costs. Health Aff 2002;21:245-253.
72
Healton CG et al. Smoking, obesity, and their cooccurrence in the United States: cross sectional analysis. Br
Med J 2006;333:25-26.
73
Chen A et al. Maternal smoking during pregnancy in relation to child overweight: follow-up to age 8 years. Int J Epidemiol 2006;35:121-130.
74
Tsiros MD et al. Health-related quality of life in obese
children and adolescents. Int J Obesity 2009;33:387-400.
Van Baal, PHM et al. Lifetime medical costs of obesity:
prevention no cure for increasing health expenditure. PLoS
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Reynolds SL, McIlvane JM. The impact of obesity and
arthritis on active live expectancy in older Americans. Obesity 2009;17:363-369.
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McDowell MA et al. Health characteristics of US adults by
body mass index category: results from NHANES 19992002. Public Health Rep 2006;121:67-73.
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Lakdawalla E et al. Are the young becoming more disabled? Rates of disability appear to be on the rise among
OBESITY
Finkelstein EA et al. The lifetime medical cost burden of
overweight and obesity: implications for obesity prevention.
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Han E et al. Impact of overweight and obesity on hospitalization: race and gender differences. Int J Obesity
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Finkelstein E et al. The costs of obesity among full-time
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Van Duijvenbode DC et al. The relationship between
overweight and obesity, and sick leave: a systematic review.
Int J Obesity 2009;33:807-816.
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Khan LK et al. Recommended community strategies and
measurements to prevent obesity in the United States.
MMWR Recomm Rep 2009;58:RR-7.
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Barlow SE et al. Expert committee recommendations regarding the prevention, assessment, and treatment of child
and adolescent overweight and obesity: summary report.
Pediatrics 2007;120(suppl 4):S164-S192.
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Finkelstein EA, Trogdon JG. Public health interventions for
addressing childhood overweight: analysis of a business
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Chao YM et al. Ethnic differences in weight control practices among US adolescents from 1995 to 2005. Int J Eat
Disord 2008;41:124-133.
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Kartz D et al. Public health strategies for preventing and
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Papas MA et al. The build environment and obesity. Epidemiol Rev 2007;29:129-143.
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Lopez R. Urban sprawl and risk for being overweight or
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Hu FB et al. Adiposity as compared with physical activity in
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88
Gostin LO. Law as a tool to facilitate healthier lifestyles
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Friel S et al. Unequal weight: equity oriented policy responses to the global obesity epidemic. Brit Med J
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Cohen DA. Obesity and the built environment: changes in
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Nielsen SJ, Popkin BM. Patterns and trends in food portion sizes, 1977-1998. J Am Med Ass 2003;289:450-453.
92
Boyington JEA et al. Perceptions of individual and community environmental influences on fruit and vegetable intake, North Carolina, 2004. Public Health Res Pract Policy
2009;6:1-15.
OBESITY
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15. Osteoporosis
Osteoporosis is a skeletal disease that
currently affects more than 25 million women
and men in the US.1 It is a major public health
problem though its association with age-related
fractures. Osteoporosis is a growing public
health problem in Latin America where rates of
fractures are quite similar to those of southern
Europe and slightly lower than in the US and
northern Europe.2 According to The 2004
Surgeon General’s Report on Bone Health and
Osteoporosis, by 2020, half of all men and
women >50 years of age in the US will have osteoporosis if they do not change their diet and
lifestyle.3 Some 10 million individuals are estimated to already have the disease and almost
34 million more are estimated to have low bone
mass (osteopenia) which places them at risk of
osteoporosis.
The disease is a silent affliction characterized by compromised bone strength which
predisposes the individual to an increased risk of
fractures of the hip, spine, and other skeletal
sites.4 Many risk factors are associated with osteoporotic fracture, including low peak bone
mass, hormonal factors, the use of certain
drugs, cigarette smoking, low physical activity,
low intake of calcium and vitamin D, race, small
body size, and a person or family history of fracture. Without treatment or preventive measures
the risk of morbidity and mortality are increased.
The resulting fractures can lead to decreased
efficiency of activities of daily life, disabling pain,
loss of independent living, and, in some instances, death.5 It is recommended that all
adults >50 years of age be evaluated for risk
factors of osteoporosis.6 In addition, as the
population ages and more individuals wind up
living in long-term care facilities there is an enhanced need for osteoporosis management.7
Women are four times more likely than
men to develop the disease, 8 million women
compared to 2 million men, with fracture rates
generally higher in white women than in other
population.8 The lifetime risk for osteoporotic
fracture in men is less than women and estimated at 15% among men >50 years old.9 Osteoporosis is responsible for >1.5 million fractures annually and these occur typically in the
hip (>300,000), spine (700,000), and wrist
(250,000); ~300,000 fractures occur in other
bones.
The National Osteoporosis Foundation
(www.nof.org) estimates that by 2010, more
than 1 million Missourians will have osteoporosis
or osteopenia and a Kansas City telephone survey conducted by the Kansas City Health Department found 10% of 1,229 households had at
least one person afflicted with osteoporosis and
that 82% of these individuals were female.10
Fractures
Any bone can be affected, but of special
concern are fractures of the hip and spine. A hip
fracture almost always requires hospitalization
and major surgery. It can impair a person's ability to walk unassisted and may cause prolonged
or permanent disability or even death. In 2003,
the age-adjusted rates of fatal falls or hospitalizations for hip fractures among persons >65
years of age in the United States were 583.6 for
men and 886.2 for women.11 Spinal or vertebral
fractures also have serious consequences, including loss of height, severe back pain, and
deformity.
Each year in the US osteoporotic fractures lead to >500,000 hospitalizations,
>800,000 emergency department encounters,
>2,600,000 physician office visits, and the
placement of nearly 180,000 individuals into
nursing homes. Nationally, in 2002, osteoporotic
hip fractures direct expenditures (hospitals and
OSTEOPOROSIS
Page 194 of 294
nursing homes) were $18 billion.
In 2006, the Missouri Department of
Health and Senior Services reported 7,021 Missourians were hospitalized due to a hip fracture
and that hospital costs related to those fractures
exceeded $225 million. For Kansas City, there
were 649 hospitalizations for fractures among
residents >65 years of age. Hip fractures accounted for 42.7% of the hospitalizations, with
83.0% of the hip fractures being among persons
>75 years old. Overall, direct costs for fractures
among those >65 years of age totaled
$20,497,734 for hospitalizations with hip fractures accounting for $10,660,224 or 52.0% of
the hospitalization costs. The average length of
hospitalization for a hip fracture was 3.5 days.
Risk
Significant risk has been reported in
people of all ethnic backgrounds. A nonHispanic white woman over the age of 50 has a
>40% chance of suffering a fracture sometime
during the rest of her life. While the lifetime risk
for men and non-white women is less across all
types of fractures, it is nonetheless substantial
and may be rising in some groups such as Hispanic women. Twenty percent of non-Hispanic
white women and Asian women >50 years of
age are estimated to have osteoporosis and
52% are estimated to have osteopenia. For Hispanic women the estimates are 10% and 49%,
respectively, while for non-Hispanic black women the estimates are 5% and 35%, respectively.
It is believed that that osteoporosis is both under-recognized and under-treated in both nonHispanic white and non-Hispanic black women.
Among men the estimates for both osteoporosis and low bone mass are lower than for
women,12 although the incidence and costs of
fractures in men is rising (currently estimated at
30% of total costs for treating fragility fractures).
For non-Hispanic white and Asian men >50
years of age, an estimated 7% have osteoporosis and 35% have osteopenia. For Hispanic men
OSTEOPOROSIS
the estimates are 3% and 23% respectively,
while for non-Hispanic black men they are 4%
and 19%, respectively.
Consequences
Fractures can have devastating consequences for both the individuals who suffer them
and family members. Hip fractures are associated with an increased risk of mortality that is
2.8-4 times greater among hip fracture patients
during the first 3 months after the fracture, as
compared to the comparable risk among individuals of similar age who live in the community
and do not suffer a fracture. Those persons in
poor health or living in a nursing home at the
time of fracture are particularly vulnerable. For
those that do survive, these fractures often precipitate a downward spiral in physical and mental health that dramatically impairs quality of life.
Nearly 20% of hip fracture patients end up in a
nursing home.
Prevention
Osteoporosis is not a natural part of the
aging process and can be prevented or detected
early and effectively treated. Left unchecked, the
bone health status is only going to get worse,
due primarily to the aging of the population.
Therefore, a major message of the Surgeon
General’s report was that the bone health status
of Americans can be improved, but much of
what could be done to reduce this burden is not
being done today.
Physical activity and adequate calcium
and vitamin D intake are known to be major contributors to bone health for individuals of all
ages. Even though bone disease often strikes
late in life, the importance of beginning prevention at a very young age and continuing it
throughout life is well understood. Improvements
in assessment tools have made it possible to
detect bone disease early and to identify those
Page 195 of 294
at highest risk of fracture. And, therapeutic advances in bone disease have equaled if not surpassed advances in the areas of prevention and
diagnosis. The tremendous potential offered by
these developments in bone health, unfortunately, has yet to become a reality.
Literature cited
1
Nochowitz B et al. An update on osteoporosis. Am J Ther
2009;Feb 28 [epub ahead of print].
2
Riera-Espinoza G. Epidemiology of osteoporosis in Latin
America, 2008. Salud Publica Mex 2009;suppl 1;S52-S55.
3
US Department of Health and Human Services. Bone
Health and Osteoporosis: A Report of the Surgeon General.
Atlanta, GA. Department of HHS, CDC, NCCDPHP, Office of
the Surgeon General. 2004.
4
Lane NE. Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol 2006;194 suppl 2:S3-S11.
5
Bliuc D et al. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and
women. J Am Med Ass 2009;301:513-521.
6
Lim LS et al. Screening for osteoporosis in the adult US
population: ACPM position statement on preventive practice.
Am J Prev Med 2009;36:366-375.
7
Giangregorio LM et al. Osteoporosis management among
residents living in long-term care. Osteoporos Int
2009;20:1471-1478.
8
Cole ZA et al. The impact of methods for estimating bone
health and the global burden of bone disease. Salud Publica
Mex 2009;51 suppl 1:S38-S45.
9
Briot K et al. Male osteoporosis: diagnosis and fracture risk
evaluation. Joint Bone Spine 2009;76:129-133.
10
Kansas City Health Department. 2006 Health Planning
and Assessment Survey. www.kcmo.org.
11
Stevens JA et al. Fatalities and injuries from falls among
older adults – United States, 1993-2003 and 2001-2005.
12
Melton LJ et al. Bone density and fracture risk in men. J
Bone Mineral Res 1998;13:1915-1923.
OSTEOPOROSIS
Page 197 of 294
16. Injuries and Poisonings
Injuries are described by two dimensions: the external cause (eg, car crash) and the
diagnosis (eg, fracture).1 Each dimension has
two axes—the external cause is categorized by
the mechanism (eg, firearm) and the intent (eg,
assault), and the diagnosis is categorized by the
nature of the injury (eg, open wound) and the
body region of the injury (eg, chest). In order to
design effective prevention programs to reduce
injuries or to lessen their severity, one must
know the mechanism that caused the injury.
Common examples of mechanisms include motor vehicles, firearms, and falls. The intent describes whether the mechanism was one of the
following: unintentional (accident), self-inflicted
with intent to harm oneself, homicide/assault,
legal intervention/operations of war, or undetermined intent.
Finding the appropriate language to define or categorize the circumstances leading to
injuries has posed problems for many in the injury prevention and control field because accident may imply that an event could not be prevented. The word accident is used in the International Classification of Diseases and Related
Health Problems, which is the international
standard for defining causes of mortality and
morbidity. Accidents are the fifth leading cause
of death according to the official ranking by the
National Center for Health Statistics (NCHS);
however, in deference to often preferred terminology, NCHS has added “unintentional injuries”
as a parenthetical phrase following “accidents”
in its standard mortality publications.
The National Highway Traffic Safety Administration (NHTSA) prefers to use the term
crash instead of accident. A crash is defined by
NHTSA as “an event that produces injury and/or
property damage, involves a motor vehicle in
transport, and occurs on a traffic way or while
the vehicle is still in motion after running off the
traffic way”. However, not all traffic-related
events are crashes; some are rollovers or noncollisions (eg, being thrown from a vehicle). The
Bureau of Labor Statistics uses the word incident, as in “highway and non-highway incidents”. In the International Classification of External Causes of Injury, the term accidental is an
accepted synonym for unintentional.
National
In 2007, more than 117,000 deaths
(4.8% of all deaths) in the US resulted from unintentional injuries. And, in 2004, 1.9 million
hospitalizations and 31 million initial visits to
emergency departments were attributable to
injury and accounted for 6% of all hospital discharges and almost 33% of all emergency department visits. Another 35 million initial visits to
physicians’ offices and outpatient clinics were for
the treatment of injuries.
Nationally, 10.3% of medical expenditures are due to injuries, intentional and unintentional.2 Injury death and disability that occurred
in 2000 are estimated to cost $80 billion in lifetime medical care treatment costs for physical
injuries and another $326 billion in lifetime lost
productivity, totaling more than $400 billion for
the combined economic burden of medical
treatment and lost productivity.
The two leading injury mechanisms resulting in a high rate of initial emergency department visits by teens and young adults are
motor vehicles and being struck by or against an
object or person. Falls are the leading mechanism of injury for all other age groups. Males have
higher hospitalization rates for injury among persons <65 years old. Women >75 years of age
have the highest hospitalization rates for injury
of all age and sex groups, primarily because of
hip fractures.
INJURIES & POISONINGS
Page 198 of 294
Approximately two-thirds of deaths from
all injuries are unintentional.3 Among persons 144 years of age, unintentional injuries are the
leading cause of death and the leading cause of
potential years of life lost before age 65. A
Healthy People 2010 objective calls for reducing
the death rate caused by unintentional injuries to
17.5 per 100,000 population. In 2005, the national unintentional injury mortality rate was 39.0
per 100,000 populations and has been increasing since 1999.4
About 50% of all injury episodes occur
around the home and about 25% result from
leisure activities. On average, since 2000, just
over 5,000 deaths per year are due to injuries
incurred on-the-job. In 2007, 5,657 workers died
(33 in the Kansas City Metropolitan Statistical
area and 156 in Missouri) and 4 million experienced nonfatal occupational injuries and illnesses (www.bls.gov). The occupational fatality
rate in 2007 was of 3.8 deaths per 100,000 employed workers >16 years old.
Kansas City
In 2007, Kansas City residents experienced 45,333 intentional and unintentional inju-
ries for which they received emergency department treatment or hospitalization (Table 16-1).
These injuries occurred at a rate of 10,267 per
100,000 population. Of these injuries, 88.4%
were considered unintentional, 8.3% were the
result of assault, 1.8% were self-inflicted, 0.3%
were the result of legal interventions, and the
intent was unknown for 1.0%. Falls accounted
for 27.4% of the injuries and was the leading
category for injury, followed by being struck by a
blunt object or person (16.0%), motor vehicle
crashes (12.1%), cuts and pierces (9.1%), and
over exertion (9.5%). The rate of unintentional
injuries per 100,000 population for counties for
Missouri is shown in Figure 16-1; the counties in
which Kansas City is situated were in the middle
and lower quintiles.
The age-adjusted unintentional injury
death rate for Kansas City is shown in Figure
16-2. In 2007, this rate was 2.5 times higher
than the Health People 2010 objective of 17.5
per 100,000 population. The rate trend did not
change significantly between 2000 and 2007 nor
did the visits to emergency departments or hospitalizations (Figure 16-3).
Each year, 7-8 Kansas City residents
die from injuries that were occupationally re-
Table 16-1 Kansas City residents who sought medical care at an emergency department or
hospital for selected injuries, Kansas City, Mo, 2007
Injury caused by
Abuse/neglect/rape
Cut/piercing
Drowning
Fall/jump
Fire/burn
Firearm
Machinery
Motor vehicle, traffic
Motor vehicle, non-traffic
Other transport
Weather/animals
Over exertion
Poison/overdose
Struck by/against
Suffocation/hanging
All other
Unknown
Total
Unintentional
0
3,672
11
12,394
839
91
165
5,484
663
59
1,758
4,307
708
5,186
34
4,721
0
40,092
Assault
299
322
0
2
11
365
0
5
0
0
0
0
2
2,074
1
709
0
3,790
Legal
intervention
0
1
0
0
0
8
0
0
0
0
0
0
6
1
0
142
0
158
Self-inflicted
0
117
0
3
0
6
0
2
0
0
1
0
661
0
6
30
0
826
Unknown
0
3
0
14
4
19
0
1
0
0
1
0
149
0
0
22
254
467
Total
299
4,115
11
12,413
854
489
165
5,492
663
59
1,760
4,307
1,526
7,261
41
5,624
254
45,333
Page 199 of 294
lated. This death rate has remained constant
over the past decade. According to the US Department of Labor, 156 Missourians died in 2007
as the result of work-related injuries. Men accounted for 141 (90.4%) of the fatal occupational
injuries. Transportation incidents were the event
or exposure in 48% the fatal occupational injuries that involved men and 47% of those that
involved women.
Fall-related injury
Nationally, the annualized
rate of fall injuries for noninstitutionalized adults >65 years
old is 51 falls per 1,000 individuals.5 Rates of fall injuries increase
with age and are higher for women
than men. Falls in older people are
frequent and serious; often the
very old are unable to get up after
the fall, lay for an hour or more
after falling, and those with personal assistance alarms typically
do not use them.6
Non-Hispanic white older
adults have higher rates of fall injuries compared with non-Hispanic
blacks. Older adults with certain
chronic conditions and activity limitations have higher rates of fall
injuries compared to older adults
without these conditions.
The most common cause
Figure 16-1 Unintentional injuries among Missouri residents, 2007 (source: Missouri Department of Health and Senior Services)
8,649.9
7,580.3
8,363.8
8,923.6
9,221.0
10,690.2
1,042.0
1,001.2
43.2
1,063.6
44.8
1,119.1
41.1
1,069.8
38.4
1,034.2
36.9
926.7
42.7
1,032.2
41.6
31.2
9,554.4
Figure 16-3 Age-adjusted rates for emergency department visits and hospitalizations per 100,000 population from unintentional injuries, Kansas City, Mo
9,770.5
Figure 16-2 Age-adjusted death rate per
100,000 population from unintentional
injuries, Kansas City, Mo
2000 2001 2002 2003 2004 2005 2006 2007
2000 2001 2002 2003 2004 2005 2006 2007
Emergency Dept
Inpatient
Page 200 of 294
of fall injuries among older adults
Figure 16-4 Unintentional fall-related injuries per 100,000
is slipping, tripping, or stumbling
population among Missouri residents, 2007 (source: Missouri
Department of Health and Senior Services)
and most fall injuries occur inside
or around the outside of the home.
Almost 3% of all falls among persons >65 years old involve walkers
and canes.7
Nearly one-third of older
adults who experience a fall injury
need help with activities of daily
living as a result, and over half
need this help for at least 6
months. The distribution of fall related injuries per 100,000 population for Missouri counties is shown
in Figure 16-4; those counties in
which Kansas City is situated were
in lower quintiles.
In 2007, 99.8% of the
12,413 fall-related injuries experienced by Kansas City residents
were unintentional and 29 of these
unintentional injuries were fatal.
The age-distribution of 266 fallthan did men, whereas men had higher rates for
related deaths for 2003-2007 is shown in Figure
falls from ladders, scaffolding, and buildings or
16-5.
structures. For both men and women, the total
Although women experienced 18%
number of falls involving stairs/step, ladders or
more fall-related injuries than men, men had a
scaffolding and from one level to another was
fall-specific death rate19% than that for women
not appreciably different from that resulting from
(Table 16-2). Among persons >65 years of age,
the fall-specific death rate for men was 2.1 times
higher than that for women. Non-Hispanic white
Figure 16-5 Distribution of 289 deaths
men had a fall-specific death rate 3.0 times that
from falls among Kansas City, Mo, resiof non-Hispanic black men and 2.5 times that for
dents by age, 2003-2007
Hispanic men. Among women, the fall-specific
239
death rate for non-Hispanic whites was 3.7 times
higher than that for non-Hispanic blacks or Hispanics.
An earlier analysis of fall injuries in Kan28
sas City showed that the highest rate was falls
11
6
4
1
on the same level from slipping, tripping or
stumbling.8 As might be expected, this category
0-14
15-24
25-34
35-44
45-64
>=65
also had the highest rates for hospitalizations.
Women had higher rates of emergency department visits from falls involving steps and stairs
Page 201 of 294
Table16-2 Fall-specific death rates per 1,000 fall-related injuries by sex and race/ethnicity, Kansas City, Mo, 2003-2007
Males
Age
Injuries
Total
Deaths
< 15 y
15-24 y
25-44 y
45-64 y
>65 y
Total
9,296
3,083
5,961
4,661
3,424
26,425
1
4
15
17
108
145
Age
Injuries
< 15 y
15-24 y
25-44 y
45-64 y
>65 y
Total
3,368
1,158
1,824
1,479
549
8,378
1
3
4
5
8
21
Age
Injuries
Total
Deaths
Rate
Injuries
White, non-Hispanic
Deaths
Rate
< 15 y
15-24 y
25-44 y
45-64 y
>65 y
Total
6,447
2,736
6,701
6,581
8,653
31,118
0
0
2
10
131
143
0.00
0.00
0.30
1.52
15.14
4.60
3,306
1,535
3,982
4,189
6,778
19,790
0
0
2
6
113
121
0.00
0.00
0.50
1.43
16.67
6.11
Age
Injuries
Rate
Injuries
Hispanic
Deaths
Rate
0.00
0.00
0.00
0.99
9.28
1.67
632
90
199
148
133
1,202
0
0
0
2
0
2
0.00
0.00
0.00
13.5
0.00
1.66
Black, non-Hispanic
Deaths
White, non-Hispanic
Deaths
Rate1
Injuries
0.11
1.30
2.52
3.65
31.54
5.49
4,563
1,534
3,523
2,844
2,673
15,137
0
1
7
11
94
113
0.00
0.65
1.99
3.87
35.17
7.47
Rate
Injuries
Hispanic
Deaths
Rate
0.30
2.59
2.19
3.35
14.57
2.50
933
216
336
133
67
1,685
0
0
3
1
1
5
0.00
0.00
8.93
7.52
14.93
2.97
Rate
Females
Black, non-Hispanic
Deaths
< 15 y
2,216
0
15-24 y
994
0
25-44 y
2,362
0
45-64 y
2,015
2
>65 y
1,400
13
Total
8,987
15
1
Age-specific death rate per 1,000 injuries
falls on the same level as the result of slipping,
tripping, or stumbling.
Because falls, particularly among the elderly9 and among workers on-the-job,10 are a
significant cause of injury and death, there is
considerable literature on the subject as well as
federal safety requirements for certain professions. Yet despite that literature, little attention
has been given to young and middle-aged adults
for whom falls represent a risk for injury with related expenses and potential interference with
work and family.
A study looking at falls among Baltimore’s Longitudinal Study of Aging participants
found that young adults reported injuries from
falls most frequently to the wrist/hand, knees
and ankles, while middle aged adults tended to
injure their knees.11 Senior citizens reported
more head and knee injuries. Women had a
higher percentage of injuries in all age groups.
Ambulation was cited as the cause of fall most
frequently regardless of age or sex. The survey
did not find any difference in severity of injury.
Falling often results from multiple concurINJURIES & POISONINGS
Page 202 of 294
Non-Hispanic
blacks accounted for
Ankle/
60.6% of the persons
Leg
foot
injured by a blunt ob30.5
19.4
ject and 52.0% of
30.0
45.7
29.9
39.0
those injured by fight31.8
34.6
ing. Non-Hispanic
45.4
32.4
32.5
34.1
whites incurred 28.2%
of blunt object injuries
and 40.6% of fightrelated injuries, while Hispanics experienced
6.2% of the blunt object injuries and 3.3% of the
fight injuries.
Of 358 traumatic brain injuries incurred
as the result of being struck by a blunt object or
person, 197 resulted from assaults (72 from
blunt objects, 125 from fights) and 161 from unintentional injuries. The age-distribution of assault injuries is shown is shown in Figure 16-7.
Table 16-3 Body site specific injury rate per 10,000 population by age
group, Kansas City, Mo, 2007
Age
<15 y
15-24 y
24-44 y
45-64 y
>65 y
Total
Head
139.0
31.1
27.1
35.8
151.2
63.0
Shoulder/arm
78.1
41.6
30.8
49.5
79.0
53.0
Wrist/
hand
21.8
34.9
21.3
17.1
23.4
22.8
Torso
11.0
17.3
25.9
30.0
62.3
27.0
rent problems including environmental and behavioral factors as well as disease processes.
For example, middle aged adults progressively
start to show higher incidences of diseases and
medication use, along with lower levels of physical activity, and physiological changes that begin
to alter posture stability. Events in this group are
likely to predispose individuals for the higher
risks that lead to falls in later years. For Kansas
City residents the distribution of fall injuries by
body site is presented in Table 16-3.
Hips
1.6
3.1
6.6
12.2
80.1
15.2
Stuck by/against injury
The second leading source
of injuries among Kansas City residents are those resulting from
being struck by a blunt object or by
another person (fighting). Among
Missouri counties, Jackson has
one of the highest rates for assault
injuries (Figure 16-6).
Of the 7,261 reported injuries during 2007, 71.4% were unintentional, with the percent of unintentional injuries being statistically greater among women compared to men, 73.8% and 70.1%,
respectively. Assaults contributed
to 28.5% of injuries in this category. Of the assaults, 26.8% of those
among men and 16.3% of those
among women involved being
struck with a blunt object; the remainder were due to fights.
Figure 16-6 Assault injuries per 100,000 population for
Missouri residents, 2007 (source: Missouri Department of Health
and Senior Services)
Page 203 of 294
Figure 16-7 Age distribution of assault
injuries resulting from being struck by an
object or person, Kansas City, Mo, 2007
Object
Fight
800
600
400
200
0
<15 y
15-24 y
25-44 y
45-64 y
>=65
Motor vehicle crash injuries
Motor vehicle crashes lead to property
damage, injuries and death. Such crashes are
the leading cause of injury death in the US for
persons 5-29 years of age. NHTSA reported that
37,261 persons died on the nation’s highways in
2008, a 9.7% decline from the previous year
(www.nhtsa.dot.gov). The overall national motor
vehicle crash fatality rate was 1.27 deaths/100
M vehicle miles traveled.
The Healthy People 2010 target for motor vehicle deaths is 9.2 per 100,000 population.
Nationally, the age-adjusted annual death rate
for 1999 through 2005 was largely unchanged at
15.2-15.7.12 Missouri’s age-adjusted rate was
17.0 for 2007.
Missouri
According to the Missouri State Highway
Patrol, the state experienced 155,855 traffic
crashes in 2008 with an estimated economic
loss of $3,182,874,600. Of the crashes, 75.1%
were property damage only.
In 2008, 55,149 persons were injured
and 960 persons died in motor vehicle crashes
in Missouri.13 The number of fatalities declined
3.2% from the prior year and included 665 drivers, 228 passengers, 66 pedestrians, and 1 bi-
cyclist. The injury and death rates per 100 million miles of travel were 76.0 and 1.3, respectively. The types of motor vehicle crashes are
shown in Table 16-4. Of all fatal traffic crashes,
more than half (57.5%) involved only one vehicle. Kansas City led all municipalities with 59
traffic fatalities and Jackson County led all the
counties with 83 traffic fatalities.
Speed and drinking were the top two
probable contributing circumstances in fatal
crashes; alcohol was involved in 4.9% of all motor vehicle crashes and 28.6% of fatal crashes.
Alcohol related crashes resulted in 262 fatalities
and 4,511 injuries in 2008.
Of all the persons killed in Missouri traffic crashes in 2008, 40.7% (391 deaths) were
between 16 and 35 years of age and persons 16
to 20 years old comprised 14.3% (137 deaths) of
all fatalities (Figure 16-9). A comparison of injury
rates per 100,000 population by county for 2006
is shown in Figure 16-10; Jackson County was
in the upper quintiles.
Urban areas of the state recorded
65.2% of all motor vehicle crashes, yet 63.4% of
fatalities occurred in rural area crashes. Only
12.7% of all traffic accidents occurred during
Table 16-4 Motor vehicle related fatalities,
Missouri, 2008 (source: Missouri State Highway
Patrol)
Collision with
Motor vehicle in
transport
Parked
motor
vehicle
Motor
vehicle
on other roadway
Bicycle
Railroad train
Fixed object
Other object
Pedestrian
Animal
Non-collision
overturning
Other
noncollision
Percent
of total
Number
of
crashes
Fatalities
63.3
98,726
375
7.7
12,034
6
0.2
245
9
0.4
0.0
20.7
0.9
0.9
2.8
622
40
32,227
1,457
1,320
4,420
2
6
389
4
59
3
2.3
3,513
98
0.8
1,251
9
Page 204 of 294
inclement weather.
Seat belts and air bags significantly
lower the risk of serious injury and death in motor vehicle crashes.14 Nationwide, seat belt use
was 83%. NHTSA reported Missouri’s rate of
seat belt use to be 75.8% in 2008. According to
Missouri BRFSS data, women were 26% more
likely to wear a seat belt than men and whites
were 11% more like to do so than blacks.15 Seat
belt usage increased with educational level. In
the Kansas City region of the state, seat belt
7.0%
15.8%
8.3%
9.0%
13.6%
15.3%
14.4%
14.2%
17.0%
15.0%
6.4%
3.8%
1.6%
0.7%
30.6%
25.7%
usage was 77.2%, the highest for any region,
which was consistent with 2006 BRFSS data for
the bi-state metropolitan area which found
77.9% of adults reporting that they regularly
wore their seat belts.16
Primary seat belt laws which allow police to stop a motorist and issue a citation are
more effective for increasing seat belt usage and
reducing traffic fatalities than are secondary seat
belt laws (police can only issue seat belt citation
after stopping motorist for another violation).17
The use of seat belts helps reduce the risk of death regardless
Figure 16-8 Motor vehicle related injuries and deaths, Miswhere in the vehicle a person is
souri, 2008 (source: Missouri State Highway Patrol)
sitting. Missouri does not have a
Injured Killed
primary seat belt law for adults
although it does have one for
persons <16 years of age. The
NHTSA has estimated that the
adoption of a primary seat belt
law in Missouri would save 89
<5 y
5-15 y
16-25 y 26-35 y 36-45 y 46-55 y 56-65 y
>=66 y
lives and prevent >1,000 serious
injuries each year.
Statewide, of persons
Figure 16-9 Motor vehicle-related injuries per 100,000
killed
in
2008,
69.8% of drivers and
population, Missouri 2007 (source: Missouri Department of
65.8% of passengers were not wearHealth and Senior Services)
ing a seat belt. Persons who had
been using alcohol and/or drugs
were more likely not to be wearing a
seat belt than persons who had not
been using these substances. The
majority of Missouri’s high school
students report using seat belts, with
15.5% (13.1% girls, 17.7% of boys)
rarely or never using a seat belt.18
Walking is the most dangerous mode of travel per mile in the
US. Although only 8.6% of all trips
are made on foot, 11.4% of all traffic
deaths are pedestrians.19 In Missouri,
during 2008, 66 pedestrians were
killed by motor vehicles and 1,344
were injured; 58.6% of all these pedestrians were male and 75.8% of
those killed were male.
Page 205 of 294
Figure 16-10 Pedestrians injured and killed by
motor vehicles, Missouri, 2008 (source: Missouri State
Highway Patrol)
Injured
Killed
30%
20%
10%
0%
Among Missouri counties in 2007, Jackson County recorded the 3rd highest number of
crashes involving pedestrians with 239, while
Clay ranked 10th with 24 pedestrian-related
crashes, and Platte ranked 15th with 15. Statewide 82 pedestrians were killed and 1,438 were
injured by motor vehicles, while in Kansas City
there were 205 crashes and 14 deaths.
Across the nation, motorcycle rider fatalities continued their 11-year increase, reaching
5,290 in 2008. Motorcycle rider fatalities now
account for 14.2% of total fatalities. It has been
estimated that every dollar increase in gasoline
prices will result in over 1,500 additional motorcycle fatalities annually.20 In Missouri, there
were 2,571 motorcycle crashes resulting in 107
drivers and passengers killed and 2,169 injured.
Kansas City
Kansas City is a dangerous environment
when it comes to traffic fatalities and injuries. In
2008, Kansas City led all Missouri communities
with motor vehicle crashes and motor vehicle
related fatalities. In 2008, the Kansas City Police
Table16-5 Fatal traffic crashes, Kansas
City, Mo (source: Kansas City Police Department)
Year
Fatal Crashes
Persons Killed
2004
2005
2006
2007
2008
48
66
61
52
55
54
71
62
58
59
Department (KCPD) recorded 18,718 traffic
crashes; 55 involved fatalities (59 fatalities)
and 4,164 involved injuries (Table 16-5). Between 2000 and 2007, the age-adjusted death
rate for City residents due to motor vehicle
crashes averaged 1.5 times higher than the
Healthy People 2010 objective (Figure 16-11).
In 2007, 32.8 of drivers and 37.9% of
passengers killed in Missouri motor vehicle
crashes were wearing their seat belts at the
time of their death. According to the Missouri
Figure 16-11 Age-adjusted death rates
resulting from motor vehicle crashes,
Kansas City, Mo
13
14
14
14
13
15
14
11
2000 2001 2002 2003 2004 2005 2006 2007
State Highway Patrol, seat belt usage rates by
residents of Clay, Jackson, and Platte counties
in 2007 were 96.9%, 96.3%, and 96.6%,
tively. The 2004 Health Assessment Survey
commissioned by the Kansas City Health Department found that 88% of respondents reported that they usually or always used a seat
belt when in a car and that 97% of children <5
years old used a seat belt.21 Students at Park
Hill South High School won the 2008 Kansas
City regional Battle of the Belt Challenge for the
highest seat belt use; the challenge is sponsored by the Missouri Department of Transportation.
Table 16-6 summarizes motor vehicle
crashes in Kansas City for 2007, while Table 167 provides a breakdown of traffic fatalities and
injuries by portion of the city.
Page 206 of 294
Table16-6 Motor vehicle crash characteristics, Kansas City, Mo, 2007
Type
Frequency
Ranking*
All crashes
19,138
1
Speeding
3,482
1
Alcohol involved
515
1
Driver <21 years old
2,938
1
Driver >55 years old
4,298
1
Commercial vehicle
595
2
Motorcycle
190
1
School bus
122
2
Bicycle involved
65
2
Pedestrian involved
205
2
Fixed object involved
2,683
1
Hazardous materials
1
20.5
Construction/work zones
388
1
*Ranking of Missouri municipalities with populations of
1,000 or more residents
During 2000-2007, there was a 30.1%
decline in the age-adjusted rates for emergency
department visits due to motor vehicle crashes,
and a 9.2% decline in age-adjusted hospitalization rates (Figure 16-12).
Figure 16-12 Age-adjusted rates for emergency department visits and hospitalizations due to motor vehicle crash related
injuries, Kansas City, Mo
ED visits
Hospitalizations
1,816.11,800.1
1,712.9
1,568.1
1,457.71,470.1
1,387.4
1,268.9
155.4 161.2 157.2 164.6 133.4 151.9 141.1 131.4
2000 2001 2002 2003 2004 2005 2006 2007
Page 207 of 294
Table 16-7 Traffic crash summary for Kansas City, Mo, 2007 (Source: 2007 Missouri Traffic Safety
Compendium, Missouri State Highway Patrol)
Kansas
City, all
Clay Co
portion
Jackson
Co portion
Platte Co
portion
Kansas
City , all
Clay Co
portion
Jackson
Co portion
Platte Co
portion
Kansas
City , all
Clay Co
portion
Jackson
Co portion
Platte Co
portion
Total crashes
1
State ranking
Fatal
Injury
Total crashes
Fatal
Injury
Total crashes
Fatal
Injury
Total crashes
19,438
1
48
4,072
2,173
15
412
15,532
29
3,357
Speed involved
3,482
1
20
919
385
6
82
2,760
13
757
Drinking involved
515
1
10
304
66
2
28
392
7
156
Driver <21 y
2,938
1
5
783
417
1
101
2,232
3
624
Driver >55 y
4,298
1
11
1,016
529
4
111
3,421
6
821
Total crashes
1,430
337
57
288
347
Fatal
Injury
4
320
1
80
1
20
1
57
1
84
Total crashes
1
State ranking
Fatal
Injury
Total crashes
Fatal
Injury
Total crashes
Fatal
Injury
Total crashes
Fatal
Injury
Commercial
vehicle
1,595
2
5
256
175
1
18
1,293
3
223
126
1
15
Motorcycle
190
1
4
136
31
2
20
139
2
101
20
0
15
School bus
122
2
1
30
8
0
2
109
1
28
5
0
0
Bicycle
65
2
1
48
1
0
1
62
1
46
2
0
1
Pedestrian
205
2
14
175
10
5
5
184
8
161
11
1
9
Total crashes
Fixed object
2,683
Hazardous
materials
1
Work zone
388
State ranking
Fatal
Injury
Total crashes
Fatal
Injury
1
13
674
368
3
83
Tied for 20.5
0
0
1
0
0
1
0
87
73
0
14
Total crashes
2,033
0
294
Fatal
Injury
9
523
0
0
0
72
Total crashes
281
0
21
Fatal
Injury
1
68
0
0
0
1
1
Page 208 of 294
Cutting/piercing injuries
Among the counties in which Kansas
City is situated, Jackson County has a high rate
of persons who experience a cutting/piercingrelated injury (Figure 16-13).
During 2007, there were 4,115 injuries to
Kansas City residents characterized as a cutting
or piercing wound, of which 89.2% were classified as unintentional. Three hundred and twentytwo (7.8%) of the overall injuries were the result
of assault and 117 (2.8%) were self-inflicted.
Only 99 (2.4%) persons with cutting/piercing
injuries required hospitalization: 64 assaults, 12
self-inflicted, 21 unintentional, and 2 intention
not recorded.
Of the injuries to women, 90.62% were
unintentional compared to 88.4% for men. Men
accounted for 76.1% of the assault cases and
48.7% of the self-inflicted injuries. Of the injuries
resulting from assaults, 68.3% involved nonHispanic blacks, 19.3% non-Hispanic whites,
Table 16-8 Anatomical location of cutting/
piercing injuries, Kansas City, Mo, 2006
Body site
Face, head, neck
Shoulder/arm
Wrist/hands
Torso
Legs
Ankle/foot
Total
Percent
285
371
2,448
135
341
509
4,089
7.0
9.1
59.9
3.3
8.3
12.4
100.0
and 5.6% Hispanics. Among the persons whose
injuries were self-inflicted, non-Hispanic whites
accounted for 76.9%, non-Hispanic blacks
14.5% and Hispanics 3.4%. The vast majority of
the cutting/piercing injuries were incurred on an
extremity (Table 16-8). The age-distributions for
unintentional, assault, and self-inflicted injuries
are presented in Figure 16-15.
Figure 16-13 Cutting/piercing injuries per 100,000 population, Missouri, 2007 (source: Missouri Department of Health and Senior Services)
Injuries
Over exertion
In 2007, 4,307 persons
experienced unintentional over
exertion related injuries. NonHispanic white females, nonHispanic black males, and Hispanic males were slightly more
likely to have experienced these
types of injuries than their opposite sex. Only 0.9% of the over
exertion related injuries required
hospitalization. The age distribution for injuries related to over
exertion is shown in Figure 16-15.
Weather/wildlife related
injuries
Weather related injuries
are discussed under the Environmental Health section of this
assessment report and dog bites
under the Communicable & Infectious Diseases section. Only veINJURIES & POISONINGS
Page 209 of 294
1357
Figure 16-14 Age distribution of unintentional cutting and piercing injuries, Kansas City, Mo, 2007
Figure 16-15 Age distribution of over exertion related injuries, Kansas City, Mo,
2007
2000
169
25-44 y
500
1
2
164
71
15-24 y
1000
59
14
89
25
9
5
647
657
842
1500
0
<15 y
45-64 y
>=65 y
nomous bites/stings and other bites/stings are
discussed here. Nationally, the most common
sources of non-canine injuries are bees, spiders,
and cats.22
In 2007, there were 106 emergency department visits and 75 hospitalizations resulting
from the bite/sting of a venomous creature. NonHispanic whites accounted for 36.9% of the patients, non-Hispanic blacks 51.5%, and Hispanics 4.6%. Males accounted for 50.8% of the
bite/sting victims. The age-distribution is shown
in Figure 16-16.
There were 909 injuries due to nonvenomous bites/stings. Non-Hispanic whites
accounted for 43.3% of the injured, nonHispanic blacks 47.2% among and Hispanics
4.6%. Females suffered more injuries (54.7%)
than males. Only 1.5% of these injuries required
hospitalization.
<15 y
15-24 y
25-44 y
45-64 y
>=65 y
Figure 16-16 Age distribution of venomous and non-venomous bites/sting injuries, Kansas City, Mo, 2007
Venomous
Non-venomous
350
280
210
140
70
0
<15 y
15-24 y
25-44 y
45-64 y
>=65 y
Figure 16-17 Age distribution of fire/burn
injuries, Kansas City, Mo, 2007
Fire/burns
300
In 2007, 4 individuals died from fire/burn
injuries; between 2003 and 2007 a total of 28
persons died. During 2007, 72 persons were
admitted to the hospital for fire/burn injuries
while 782 were treated in the emergency department. Males were 12% more likely to have
been treated for fire/burn injury than females.
Non-Hispanic blacks experienced 45.1% of the
250
Hospitalized
200
150
100
50
0
<5 y
5-14 y 15-24 y 25-44 y 45-64 y >=65 y
Page 210 of 294
injuries and 34.7% of the hospital admissions compared to 40.0% of the
injuries and 23.6% of the hospitalizations for non-Hispanic whites. Hispanics had 7.0% of the injuries and 5.6% of
the hospitalizations. Of the 854
fire/burn injuries, 98.2% were unintentional and 0.6% were the result of assaults. The age distribution for emergency department visits and hospitalizations is presented in Figure 16-17
while the rate of fire/burn-related injuries per 100,000 population by Missouri
county is shown in Figure 16-18.
Figure 16-18 Fire/burn-related injuries per 100,000
population, Missouri, 2007 (source: Missouri Department of
Health and Senior Services)
Poisoning/overdose
Among Missouri counties, those
in which Kansas City is situated tend to
be the in the higher quintiles for poisoning/overdose-related injuries (Figure
16-19).
The Missouri Department of
Health and Senior Services distinguish
drugs/alcohol from
gas/cleaners/caustics etc in defining
injuries within this category. In 2007,
there were 1,526 injuries from these
substances of which drugs/alcohol accounted for 1,298 or 85.1% (Table 169). Of these injuries, 41.2% resulted in
the person being admitted to the
pital. Of the persons injured by drugs
or alcohol 597 (46.0%) were admitted
to hospital (men 48.5%, women
43.9%). This was significantly higher
than the 14.0% admission rate for
those injured by other substances. The
age distributions for these types of injuries are shown in Figures 16-20 and
16-21.
Figure 16-19 Poisoning/overdose-related injuries per
100,000 population, Missouri, 2007 (source: Missouri Department of Health and Senior Services)
Page 211 of 294
were as the result of an
assault or a legal intervention. Ninety-one
Drugs/Alcohol
Gas/cleaners/caustics/etc
Male
Female
Male
Female
(18.6%) of the firearm
Intent
Injuries
%
Injuries
%
Injuries
%
Injuries
%
injuries were accidenAssault
0
0.0
1
0.1
0
0.0
1
0.9
Legal intertal, 6 (1.2%) were self0
0.0
0
0.0
1
0.8
5
4.5
vention
inflicted, and in 19
Self-injury
255
43.4
365
51.4
27
22.9
14
12.7
Unintentional
261
44.4
291
41.0
78
66.1
78
70.9
(3.9%) of the cases the
Intent un72
12.2
53
7.5
12
10.2
12
10.9
intent was unknown.
known
While approximately
Total
588
100.0
710
100.0
118
100.0
110
100.0
half of the persons injured by assault, legal
Figure 16-20 Age distribution of unintenintervention, self-infliction, or unknown intent
tional injuries from gas/cleaners/ caushad to be hospitalized, only 30.8% of those who
tics/etc, Kansas City, Mo, 2006
experienced an unintentional firearm related in70
jured were hospitalized. Age-adjusted hospitali60
zation rates for unintentional firearm injuries are
shown in Figure 16-22.
50
A breakdown of 2,261 firearm injuries
40
that occurred during 2003-2007, is shown in
30
Figure 16-23 and Tables 16-10 and 16-11. The
20
majority of men and women were injured as the
10
result of an assault with non-Hispanic blacks
0
constituting approximately three-quarters of the
<5 y
5-14 y 15-24 y 25-44 y 45-64 y >=65 y
injured persons of either sex. When measured
as annualized rates per 10,000 individuals, nonHispanic blacks were 12.5 more likely to be inFigure 16-21 Age distribution of
jured by a firearm than a non-Hispanic white and
drug/alcohol injuries, Kansas City, Mo,
3.3 times more likely than a Hispanic resident.
2007
Hispanics, in turn, were 3.8 times more likely to
Unintentional
Intentional
be injured than non-Hispanic whites. Fifty-three
Table 16-9 Poisoning/overdose injuries by mechanism/intent and sex,
350
280
Figure 16-22 Age-adjusted emergency
department and hospitalization rates resulting from gunshot injuries, Kansas
City, Mo
210
140
70
Emergency Dept
0
<5 y
5-14 y 15-24 y 25-44 y 45-64 y >=65 y
25.7
Inpatient
28.1
27.4
21.5
22.6
21.0
22.8
22.7
20.1
Firearm injuries
In 2007, 489 Kansas Citians were injured by firearms, with 45.6% being hospitalized.
The majority (74.6%) of firearm-related injuries
15.7
7.3
9.6
9.0
9.7
7.9
8.7
2000 2001 2002 2003 2004 2005 2006 2007
Page 212 of 294
point four percent
Figure 16-23 Age distribution of firearm injuries from assault, self-injury,
of assault injuries,
and unintentional causes, Kansas City, Mo, 2003-2007
52.5% of selfAssualt
Self-inflicted
Unintentional
injury, and 53.7%
of unintentional
884
injuries occurred
among residents
15-24 years of
384
age.
176
In 2005,
130
102
94
32 0 31
24 0 9
30,694 persons in
18 3 8
15 0 6
11
6 36
5
5 22
the US died from
<5 y
5-14 y
15-24 y
25-34 y
35-44 y
45-54 y
55-64 y
>=65 y
firearm injuries,
accounting for
17.7% of all injury
deaths that year. Suicide
Table 16-10 Firearm injuries by intent and sex, Kansas City, Mo,
2003-2007
and homicide were the maTotal
Men
Women
jor causes for these deaths,
Intent
Incidents
%
Incidents
%
Incidents
%
accounting for 55.4% and
Assault
1,636
72.4
1,456
73.5
180
64.7
40.2%, respectively, of all
Legal inter26
1.1
24
1.2
2
0.7
vention
firearm injury deaths. In
Self-injury
39
1.7
30
1.5
9
3.2
2005, the age-adjusted
Unintentional
439
19.4
368
18.6
70
25.2
Unknown
121
5.4
104
5.2
17
6.1
death rate for firearm injuries
Total
2,261
100.0
1,982
100.0
278
100.0
was 10.2 per 100,000 population. The rate for
males was 6.8
Table 16-11 Firearm injuries by sex and race/ethnicity, Kansas City, Mo,
times that for fe2003-2007
males and blacks
Total
Men
Women
Race/ethnicity
Incidents
%
Incidents
%
Incidents
%
had a rate that
White, non-Hispanic
251
11.9
203
11.4
48
18.9
was 2.2 times
Black, non-Hispanic
1,702
81.0
1,513
85.1
189
74.4
higher than that for
Hispanic
121
5.8
111
6.2
10
3.9
Asian
6
0.3
3
0.2
3
1.2
whites. NonNative American
1
0.04
1
0.06
0
0.0
Hispanic whites
Other/not listed
21
1.0
16
0.9
4
1.6
Total
2,102
100.0
1,777
100.0
254
100.0
had an ageadjusted death
rate 1.2 times that
About 7% of victims die from their injuries, 12%
of Hispanics while non-Hispanic blacks had a
go to other health facilities for rehabilitation or
rate 2.6 higher than that for Hispanics.
other care, and 75% recover and return home.
Nationally, injuries from gunshots result
In the Kansas City metropolitan area,
in $802 million a year in hospital charges, with
record numbers of people are applying for pernearly a third of victims being uninsured.23 More
mits to carry concealed firearms, according to an
than half of the shootings occur during assaults,
article in the Kansas City Star).
30% are accidental, and 8% are self-inflicted.
Initial stays cost, on average, $24,000 for assault cases and $30,000 for accident cases.
Page 213 of 294
Figure 16-24 Abuse/neglect/rape-related injuries per
100,000 population, Missouri, 2003-2007 (source: Missouri Department of Health and Senior Services)
Spouse/partner abuse
Of the 43 persons injured
through spouse/partner abuse, 42
(97.7%) were female. Thirty-nine
individuals (90.7%) were treated in
emergency departments and 4
(9.3%) were hospitalized. Thirtyseven of the victims were 20-44
years of age.
Physical abuse
Of the 120 persons experiencing physical abuse, 99
(82.5%) were female, with nonHispanic black females 69% more
likely to be a reported case than
non-Hispanic white females. NonHispanic black males were 71%
more likely than non-Hispanic white
males to experience this type of
injury. Only 5.8% of the victims required hospitalization. The age distributions for males and females
are shown in Figure 16-27.
Abuse/neglect/rape
Sexual abuse
Of the 45 individuals reported with sexual
This category of injuries includes a varieabuse injuries, 45 (95.6%) were female and
ty of forms of abuse: 43 spouse/partner abuse,
79.1% of the females were <15 years of age,
45 sexual abuse, 120 physical abuse, 3 negwith 42 (97.7%) being <20 years old. Only 4.4%
lect/emotional abuse, 9 rapes, and 79 abuses
unspecified. Many individuals who
experience some of these types of
Figure 16-25 Age distributions by sex of persons with
injury may not seek medical assisphysical abuse injuries Kansas City, Mo, 2006
tance or their injuries are classified
differently from those recorded by
Female
Male
the Police Department. For example,
the emergency department and hos31
pitalization data record only 9 cases
26
of rape for 2007, while the Police
20
Department reported 288 such inci14
dents. The Kansas City area ranks in
8
8
the top quintile for
3
3
2
1
1
1
1 1
0
0
abuse/neglect/rape-related injuries
(Figure 16-24).
<5 y
5-14 y 15-24 y 25-34 y 35-44 y 45-54 y 55-64 y >=65 y
Page 214 of 294
of the victims were admitted to the hospital.
Non-Hispanic black females were 22% more
likely than non-Hispanic white females to be reported as case of sexual abuse.
12
Adekoya N et al. Motor-vehicle-related death rates – United States, 1999-205. MMWR Morb Mortal Wkly Rep
2009;58:161-165.
13
Abuse unspecified
Of the 79 cases of unspecified abuse, 78
were seen in emergency departments. Of the 79
cases, 56 (70.9%) involved females.
Missouri State Highway Patrol. Missouri Traffic Crashes
2009 edition;2008 statistics. www.mshp.dps.missouri.gov
14
Cummings P, Rivara FP. Car occupant death according to
the restraint use of other occupants: a matched cohort study.
J Am Med Ass 2004;291:343-349.
15
Behavioral Risk Factor Surveillance System Annual Report.
www.dhss.mo.gov
Literature cited
1
Bergen G et al. Injury in the United States: 2007 Chartbook. Hyattsville, MD: National Center for Health Statistics.
2008.
2
Finkelstein EA et al. Medical expenditures attributable to
injuries – United States, 2000. MMWR Morb Mortal Wkly
Rep 2004;53:1-4.
3
Adekoya N, Moffett DB. State-specific unintentional-injury
deaths – United States, 1999-2004. MMWR Morb Mortal
Wkly Rep 2007;56:1137-1140.
4
Hu G, Baker SP. Trends in unintentional injury deaths, US,
1999-2005:age, gender, and racial/ethnic differences. Am J
Prev Med 209;37:188-194.
5
Schiller JS et al. Fall injury episodes among noninstitutionalized older adults: United States, 2001-2003. Adv Data
Vital Health Stat 2007;392. www.cdc.gov/nchs
6
Flemming J et al. Inability to get up after falling, subsequent time on floor, and summoning help: prospective
cohort study in people over 90. Brit Med J
2008;337:a2751.
7
Stevens JA et al. Unintentional fall injuries associated with
walkers and canes in older adults treated in US emergency
departments. J Am Geriatric Soc 2009;57:1464-1469.
8
Kansas City Health Department. Injuries and deaths from
falls among Kansas Citians. Community & Hospital Letter
2005;26(3). www.kcmo.org/health
9
Stevens T et al. Self-reported falls and fall-related injuries
among persons aged >65 years – United States, 2006.
10
Cierpich H et al. Work-related injury deaths among Hispanics – United States, 1992-2006. MMWR Morb Mortal
Wkly Rep 2008;57:597-600.
11
Talbot LA et al. 2005. Falls in young, middle-aged and
older community dwelling adults: perceived cause,
environmental factors and injury. BMC Public Health
5:86.
16
Kilmer G et al. Surveillance of certan health behaviors and
17
Centers for Disease Control and Prevention. Impact of
primary laws on adult use of safety belts – United States,
18
Grunbaum JA et al. Youth risk behavior surveillance –
2004;53:SS-2.
19
Ernst M. 2004. Mean Streets. How far have we come?
Pedestrian safety, 1994-2003. Surface Transportation Policy
Project. 2004. www.transact.org.
20
Wilson FA et al. Gasoline prices and their relationship to
rising motorcycle fatalities, 1990-2007. Am J Public Health
2009;99:1753-1758.
21
Kansas City Health Depatment. 2004 Health Assessment
22
O’Neil ME et al. Epidemiology of non-canine bites and
sting injuries treated in US emergency departments, 20012004. Publ Health Rep 2007;764-775.
23
Coben JH, Steiner CA. Hospitalization for firearm-related
injuries in the United States, 1997. Am J Prev Med
2003;24:1-8.
Page 215 of 294
17. Disabilities
In the United States, >50 million people
experience some form of disability.1 Disabilities
may be developmental or may result from life
experiences and, in turn, may be permanent or
temporary. The three most common causes of
disability in the US are arthritis or rheumatism,
back or spine problems, and heart trouble.2
Developmental disabilities are chronic
conditions that initially manifest in persons <18
years old and result in impairment of physical
health, mental health, cognition, speech, language, or self-care. It has been estimated that
within the bi-state metropolitan statistical area,
14.9% of children have special health care
needs as a result of disabilities (14.4% in Jackson County).3 The rate was higher among nonHispanic whites than non-Hispanic blacks or
Hispanics. The estimated average lifetime economic costs per person with developmental disabilities are $1,014,000 for intellectual disabilities, $921,000 for cerebral palsy, $417,000 for
hearing loss, and $566,000 for vision impairment.4 The personal costs incurred by families
caring for children with disabilities can be substantial.5 Older adults with intellectual disabilities
generally die at an earlier age than do adults in
the general population.6
Figure 17-1 Percentage of adults by number of physical limitations, US, 2001-2007
(source: NCHS Data Brief 20, July 2009)
26.7%
70-79 y
9.6%
6.6%
60-69 y
3
16.2%
7.3%
4.1%
11.5%
50-59 y
2
9.3%
5.9%
5.5%
2.9%
8.1%
1
>=80 y
As individuals age, the prevalence and
number of physical limitations increase (Figure
17-1). However, data from the US National Long
Term Care Study demonstrate that the disability
rate among people >65 years old has been declining.7 Changes in the prevalence of heart and
circulatory conditions, and visual limitations
played a major role in this decline, although it
appears that increases in obesity may have a
countervailing effect.
In the US, almost 30% of the noninstitutionalized adult population have basic actions difficulty, as indicated by reporting at least
some difficulty with basic movement (>20%) or
sensory (13%), cognitive (3%) or emotional difficulties (3%).8 Non-Hispanic blacks >50 years old
not only have higher rates of physical limitations
that non-Hispanic whites of the same age, but
they generally experience rates of physical limitations similar to non-Hispanic whites a decade
older.9 Women are more likely than men to have
physical limitations, and these differences increase with age.
In Missouri it is estimated that 21.4% of
the adult population suffers from at least one
disability with the prevalence higher among females (22.0%) than males (20.7%).10 The prevalence of disability rises with age. In the Kansas
City metropolitan area, it is estimated that 20.3%
of adults have at least one disability.11
Census 2000 identified 85,046 noninstitutionalized Kansas City residents > 5 years
of age (21.0%) who had a disability (Table 17-1).
Of those 16-64 years of age who had a disability, 56.7% were employed.
Functional limitations among Americans
55 to 84 years of age have been found to be
inversely related to social class across the full
spectrum of the socioeconomic gradient.12 This
did not extend beyond 85 years of age. Females
are more likely than males to experience functional difficulties and these increase with age.13
DISABILITIES
Page 216 of 294
Age is the
strongest risk factor for
arthritis; consequently
Age Group
Employment
AgeEmployed
the prevalence of arthriGroup
Disability
No Disability Disability
Number
16-64 y
tis is expected to in5-15 y
3,837
65,009
Sensory
14,025
3,525
crease as a result of
16-20 y
4,875
22,525
Physical
35,017
7,071
21-64 y
54,899
204,125
Mental
20,072
3,855
the aging population to
65-74 y
9,496
17,552
Self-care
11,347
1,291
an estimated 67 million
75+ y
11,939
10,477
Go-outside-home
31,379
9,403
Total
85,046
319,688
Employment
38,847
24,837
adults by 2030.19 In
Missouri, it is estimated
there will be nearly 1.6
Obese individuals report more difficulties than
million persons with arthritis in 2030 (a 14% inoverweight individuals.
crease from the prevalence in 2005) and
In public health, there is a population
631,000 persons will have arthritis-attributable
health measure known as disability-adjusted life
activity limitations.20
years or DALY. It was developed so nonfatal
Nationally, approximately 26% of adults
outcomes could be considered alongside mortalreport
having
been diagnosed with arthritis21 and
ity in the prioritization of health resources.14
8.3% report activity limitations.22 A higher prevaDALYs are composed of (a) years of life lost due
lence of arthritis is associated with being female,
to premature death and (b) years lived with disolder, and overweight or obese.23 Doctorability. Because “years lived with disability” are
diagnosed arthritis is nearly twice as prevalent in
based on perceived desirability rather than
obese individuals (38%) compared with normal
measures of activity limitations, there are those
weight individuals (20%). The prevalence rate of
who believe that the DALY does not meaningfularthritis varies by the degree of obesity; body
ly measure disability as defined by the World
mass index is an independent risk factor for
Health Organization’s International Classification
arthritis. The prevalence of arthritis is highest
of Functioning, Disability, and Health.15 16 Those
among non-Hispanic whites, persons with low
individuals argue that DALYs not be used for
educational attainment, and those in with low
resource allocation.
socioeconomic status.
According to the Agency for Healthcare
Research and Quality, approximately 9.5% of
Arthritis
persons >18 years of age use prescription medications to control arthritis pain and approximateArthritis is the leading cause of disability
ly $32 billion per year is spent for arthritis treatin the United States.17 There are approximately
ment.24
150 conditions defined by the National Arthritis
Arthritis is a potential barrier to physical
Data Work Group that are thought to represent
activity among adults25 26 and contributes to why
arthritis and other rheumatic conditions.18 The
>35% of adults do not attain the minimum level
most common form of arthritis is osteoarthritis
of aerobic physical activity outlined in the 2008
which is usually associated with aging, most ofPhysical Activity Guidelines for Americans.27 28
ten causing pain and stiffness in the fingers,
Persons with arthritis and activity limitations are
knees, and hips. A less common form of arthritis
more likely to have less than a high school eduis rheumatoid arthritis, occurring when the
cation or to be obese or physically inactive. The
body’s immune system causes pain in the joints
combination of arthritis and obesity is significantand bones; it may also affect internal organs and
ly related to a decreased active life among 70
systems.
Table 17-1 Disabilities by age group and employment, Kansas City,
Mo, Census 2000
DISABILITIES
Page 217 of 294
year old adults.29
Economic impact
Arthritis accounts for 6.2% of all hospital
admissions in the country and for 7.4% of admissions of persons who are overweight.30 In
addition, arthritis is the 3rd leading cause of work
limitation.31 Racial/ethnic differences have been
documented in the prevalence of limitations
caused by arthritis, eg non-Hispanic blacks with
rheumatoid arthritis report more severe disease
and more disability than non-Hispanic whites. 32
33
Arthritis, coupled with obesity, has been proposed as the major reason for the increasing
trend in total knee replacements.34 35 Nearly half
of US adults will develop osteoarthritis of the
knee during their lifetime, 35% of those of normal weight, 44% of those overweight, and 65%
of obese individuals.36 While whites and blacks
are at equal risk for symptomatic knee osteoarthritis, there is a racial disparity in total
knee replacements among Medicare enrollees,
with blacks in Missouri nearly 50% less likely to
receive a knee replacement.37
Updated national estimates of the costs
of arthritis and other rheumatic conditions are
$80.8 billion in direct costs and $47 billion in indirect costs.38 Between 1987 and 2000, medical
costs in the US for arthritis rose from $5.4 to
$17.9 billion.39 Forty-four percent of the increase
was attributed to increased cost per treated
case, 32% to the rise in the number of treated
cases, and 24% to the increasing numbers of
people in the population. It is estimated that
arthritis and other rheumatic conditions cost
Missourians $2.8 billion annually in direct and
indirect costs.40
Despite the increased medical costs associated with arthritis, there has been no
progress nationwide towards the Healthy People
2010 objectives related to arthritis management.41 The three objectives focus on weight
counseling, physical activity counseling, and
arthritis education.
Missouri and Kansas City
Behavioral Risk Factor Surveillance
System (BRFSS) data for Missouri found that
31.9% of respondents (28.6% of males; 34.9%
of females) said they had doctor-diagnosed arthritis. Among working age adults 18-64 years of
age, 10.0% reported that they had arthritisattributable work limitations; 5.8% for those 1844 years old and 16.7% for those 45-64 years of
age.42 Among those workers with arthritis,
41.8% claimed to have arthritis-attributable work
limitations. Nationally, the state median percent
of workers with arthritis who claimed arthritisattributable work limitations was 33.0%.
In Missouri, individuals with arthritis had
a higher prevalence of other chronic diseases,
including cardiovascular disease, diabetes, and
osteoporosis, as well as having a higher prevalence of risk factors associated with serious
chronic diseases, including high blood pressure,
high blood cholesterol, obesity, and physical
inactivity. As a result, they perceived their physical and mental health to be poorer than those
without an activity limitation.
In 1999, The Missouri Department of
Health and Senior Services conducted a survey
of residents in 10 core city zip codes of Kansas
City (www.dhss.state.mo.us/maop). That survey
found that nearly 46% of residents >45 years of
age had arthritis and 29% had limitation of their
regular activities. These rates were higher than
those statewide. Non-Hispanic blacks had
slightly higher rates than other racial and ethnic
groups in the same zip codes.
There are 7 regional arthritis centers
across the state to help Missourians cope with
the effect of rheumatoid illnesses. The Kansas
City center is at St Luke’s Hospital.
Arthritis in children
While the above discussion focused primarily on adults with arthritis, there also is the
issue of arthritis in children.43 Estimates of arthritis in children have varied widely because it is an
umbrella term for which there are many definiDISABILITIES
Page 218 of 294
tions and because it is a relatively uncommon
condition. Recently, the Centers for Disease
Control and Prevention (CDC) published on the
prevalence of pediatric arthritis and the number
of annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions
in the US.44 CDC estimated that 294,000 children have significant pediatric arthritis and other
rheumatologic conditions (SPARC). Further, it
was estimated there were 827,000 ambulatory
visits each year because of SPARC, including
83,000 emergency department visits. This study
and other evidence suggest that between
50,000 and 100,000 children suffer from juvenile
rheumatoid arthritis, which if untreated can destroy the cartilaginous tissue that protects the
joints. Without timely diagnosis, permanent joint
damage can ensue.
Further, the study estimated that 5,700
children in Missouri and 2,800 in Kansas are
living with some form of arthritis. In one sense,
these children are lucky because pediatric
rheumatologists practice in these states, although significant distances may need to be traveled to see the physicians. According to the
study, about 15,000 children with SPARC live in
11 states that do not have any pediatric rheumatologists.
A prior analysis by the Kansas City
Health Department,45 found that, between 2001
and 2005, children (0-19 years of age) living in
Kansas City made 456 emergency department
visits for arthritis. Non-Hispanic white children
made 165 visits (36.2% of the total) while nonHispanic black children had 218 visits (47.8% of
the total). Of the 456 visits, 238 (52.2%) were
made by females and 218 (47.8%) by males.
Unfortunately, the data available to the
Kansas City Health Department does not permit
identification of multiple visits by a single individual. Therefore, the actual number of children
who made the 456 visits cannot be determined.
The children making the visits came from 39
different zip codes across the City.
DISABILITIES
Hearing
The prevalence of speech-frequency
hearing loss among US adults is 16.1%.46
Among persons 20-29 years old, the prevalence
of hearing loss is 8.5% and seems to be increasing in this age group. Odds of hearing loss are
5.5 times higher in men than women and 70%
lower among blacks than whites. Increases in
hearing loss prevalence occur earlier among
persons with smoking, noise exposure, and cardiovascular risks.
The National Health Interview Surveys
show that hearing impairment among older
workers is 3 times that of visual impairment.47
Further, the surveys demonstrated that, among
persons with hearing loss, the prevalence of fair
or poor health status, difficulties with physical
functioning, and serious psychological distress
increased with the degree of hearing loss experienced.48 Adults who were deaf or have a lot of
trouble hearing were about 3 times as likely as
adults with good hearing to be in fair or poor
health and to have difficulty with physical functioning. Those adults were more than 4 times as
likely to experience serious psychological distress. Adults who had a little trouble hearing also
had higher rates of these health problems compared with adults who considered their hearing
to be good.
Diabetes and high blood pressure are
more prevalent among adults who are deaf or
have a lot of trouble hearing, compared with
adults with good hearing.49 In addition, adults
who are deaf or have a lot of trouble hearing and
those who have a little trouble hearing are more
likely than adults with good hearing to: (a) currently smoke cigarettes; (b) have had five or
more drinks in 1 day in the past year (a proxy for
at-risk drinking); (c) have engaged in no leisuretime physical activity (a measure of sedentary
behavior); (d) be obese; and (e) usually sleep 6
hours or less. Analysis of differences by age
revealed that disparities in health risk behavior
prevalence between adults with and without
hearing loss were largely concentrated among
Page 219 of 294
adults under age 65. Among adults aged 18-44
years, more than 40% of those who were deaf or
had a lot of trouble hearing currently smoked
cigarettes compared with 24% of those with
good hearing. Disparities in smoking prevalence
persisted among middle aged adults but not
among those >65 years old.
There a many causes of hearing loss
with some being genetic and others being environmental causes such as infections, head
trauma, subarachnoid hemorrhage, drug toxicity,
and exposure to sounds. In the US, 17% of
adults >18 years old have some difficulty hearing without a hearing aid.50 Non-Hispanic white
men are more likely to experience hearing problems compared to other men and women. Problems increase with age and Asian and black
adults are less likely to have some form of hearing difficulty than white or Native American
adults. Nineteen percent of non-Hispanic white
adults have difficulties compared to 11% of nonHispanic blacks and 10% of Hispanics.
Missouri newborn hearing screening
Genetic causes account for 50-60% of
childhood hearing loss in developed countries.51
Five of every 1,000 babies born in the US have
some degree of hearing loss and congenital
hearing loss is more common than cleft lip or
Down ’s syndrome. Early identification of hearing loss and enrollment in appropriate intervention services during the first 6 months of life provide infants with a greater chance of developing
speech and language consistent with their hearing peers. However, among children with bilateral permanent hearing loss, early detection of
hearing impairment is associated only with higher scores for language and not speech in midchildhood.52
With the advent of national newborn
screening, the average age at which hearing
loss is confirmed has dropped from 24-36
months to 2-3 months.53 Infants in whom remediation is begun within 6 months are able to maintain language and social and emotional devel-
opment that is appropriate for their physical development, in striking contrast with those whose
hearing loss is first detected after 6 months of
age.54
As a result of legislation passed in 1999
(RSMo 191.925 through 191.937), every infant
born in Missouri is required to have their hearing
screened prior to discharge from an ambulatory
surgical center or hospital. Follow-up of infants
who missed or did not pass a final hearing
screening is the responsibility of the Missouri
Department of Health and Senior Services’ Bureau of Genetics and Healthy Childhood.
In 2007, 81,905 newborns had their
hearing screened and 1,489 were referred for
audiologic evaluation.55 Missouri’s program
identified 49 infants with permanent hearing
loss. Newborn hearing screening data specific
for Kansas City is not available.
The Newborn Hearing Screening Service Coordination Project was initiated in 2006
between the Missouri Department of Health and
Senior Services and the Missouri Department of
Elementary and Secondary Education. This
project was implemented in the Kansas City
area and links an audiologist, an educator of the
deaf and hard-of-hearing or a speech language
pathologist with experience with deaf or hard-ofhearing children, with the First Steps service
coordinator for family interactions and service
planning related to an infant diagnosed with severe to profound permanent hearing loss.
Score 1 for Health hearing screening
Children need to have their hearing periodically assessed. About 10% of children fail
hearing screening tests at well-child visits, but
providers neither recheck nor refer more than
half of these children.56 This is important because high school students are more likely than
adults to say they have experienced 3 of the 4
symptoms of hearing loss, namely, turning up
the television or radio volume, asking people to
repeat what they say during conversations, and
ringing in the ears, according to a 2006 survey
DISABILITIES
Page 220 of 294
by the American Speech-Language Hearing Association (www.zogby.com). Only 49% of high
school students reported not experiencing any of
these symptoms compared to 63% of adults.
Hearing loss was attributed to the use of personal electronic devices and head phones.
Score 1 for Health is a health promotion
and disease prevention program for elementary
aged children and is cosponsored by the Kansas
City University of Medicine and Biosciences and
the Deron Cherry Foundation. For the 20052006 school year the frequency of hearing referrals by grade among Score 1 for Health participants was highest in the lower grades: 5.3% and
5.5% in kindergarten and 1st grade, respectively,
and relatively constant in grades 2 through 5,
between 2.6% and 3.0%.57
Vision
Uncorrected refractive error for distance
vision has recently been highlighted as the main
cause of low vision and the second leading
cause of blindness after cataract.58 It is estimated that 0.8-4.0% of the world’s population is
affected59 and it has been suggested that these
figures underestimate the true burden of visual
impairment by about 38%.60 Refractive error is
correctable with eyeglasses, contact lenses, or
laser surgery. Based on National Health and
Nutrition Examination Survey data, >110 million
Americans could or do achieve normal vision
with refractive correction.61 The annual direct
costs of correcting distance vision impairment in
the US is at least $3.8 billion, of which $780 million represents the annual cost of providing distance vision correction to persons >65 years of
age.
One of the most common vision impairments worldwide is presbyopia, a progressive
age-related diminished ability to focus on near
objects. The term presbyopia comes from Greek
word "presbus" meaning "old person". Presbyopia is generally believed to stem from a gradual
loss of flexibility in the natural lens inside the
DISABILITIES
eye. It is different from astigmatism, nearsightedness and farsightedness, which are related to
the shape of the eyeball and caused by genetic
factors, disease or trauma.
Presbyopia is a symptom caused by the
natural course of aging. The first symptoms are
usually first noticed between 40 and 50 years of
age. It is estimated that globally some 1.04 billion persons have presbyopia and approximately
49% of these individuals have no eyeglasses to
correct their vision.62 Currently, an estimated 90
million people in the US either have presbyopia
or will develop it by 2014.
According to National Health Interview
surveys, 10% of the adult population in the US
has vision problems (defined as trouble seeing,
even with glasses or contact lenses). Women
were more likely than men to have vision problems and the prevalence of vision problems increased with age. Seven percent of Asian adults
had some form of vision problem compared with
10% of white, 10% of black, and 17% of Native
American adults. Sixteen percent of adults in
poor families experienced vision problems compared with 9% of adults in families that were not
poor.
The American Academy of Ophthalmology estimates more than 43 million Americans
will develop age-related eye diseases by 2020,
and the majority of those at risk are unaware
(www.geteyesmart.org). The Academy’s EyeSmart campaign recommends that all adults be
screened for eye disease starting at age 40
years, when symptoms and vision changes typically occur. The campaign focuses on five major
eye diseases: age-related macular degeneration
(AMD), cataracts, diabetic retinopathy, dry eye,
and glaucoma. The Academy estimated that eye
diseases cost the nation $51.4 billion annually;
Medicare costs for indirect eye disease expenses were estimated at $2 billion. For example, AMD results in the loss of central vision and
dependency on peripheral vision. This condition
costs the US economy $750 million annually in
direct costs for patient services and prescription
Page 221 of 294
drugs.
Table 17-2 American Optometric Association recommenThe lifetime prevalence of
dations for eye examinations
diagnosed vision diseases is as
Age
Frequency
Infant/Toddler
0 to 24 months
By 6 months of age
follows: cataract, 8.6% (17 million);
Preschooler
2 to 5 years
At 3 years of age
glaucoma, 2.0% (4 million), macust
Before 1 grade; every 2 years theSchool age
6 to 18 years
lar degeneration 1.1% (2 million);
reafter
Adults
19
to 40 years
Every 2 to 3 years
and diabetic retinopathy 0.7% (1.3
Adults
41 to 60 years
Every 2 years
million). The prevalence of diabetic
Adults
>61 years
Every year
retinopathy, glaucoma and cataracts among persons diagnosed
health assessment survey commissioned by the
with diabetes is projected to rise as the number
Kansas City Health Department, a quarter of
of Americans with diabetes continues to inrespondents reported not receiving routine eye
crease.63
care.70 Forty-five percent of respondents reThe National Health Interview surveys
ceived routine eye care from optometrists, 21%
found an estimated 19.1 million American adults
from ophthalmologists, 7% from community
>18 years old (9.3% of adults) had impaired vihealth centers, and 2% from other sources. Sixsion (defined as distance visual acuity of 20/50
ty-percent had their eyes examined within the
or worse), including 0.7 million (0.3%) with
64
preceding two years and 80.5% within the preblindness. Approximately 80% of these indiceding 5 years.
viduals could have their vision improved to 20/40
65
or better with refractive correction. And, 3.3
Score 1 for Health vision screening
million Americans >40 years of age (1 in 28 indiOverall 22% of Score 1 for Health particviduals) were blind or had low vision; a nonipants during 2007 were identified as having or
correctable impairment that interferes with the
needing possible vision correction.71 Although
ability to perform everyday tasks. According to
~10% already had glasses, indicating prior identhe National Eye Institute, this number is extification and treatment for a vision problem,
pected to rise to 5.5 million by 2020 as the baby
20% of these children failed the Score 1 screenboomer generation ages.66 This is a major coning. Consequently, 13.8% of participants were
cern since poor vision may speed mental decline
67
referred for one or more uncorrected vision
in the elderly. Cataract surgery may prevent
68
problems: 8.1% for far vision, 4.4% for near vifalls and fractures among the elderly.
sion, 4.2% for random dot E, and 3.5% for
According to the American Optometric
hyperopia (plus lens). The frequency of vision
Association’s InfantSEE Program, 1 out of every
referrals increased in the higher grade levels
20 infants may be at risk from abnormal vision
and the frequency by school increased with de(www.infantsee.org). CDC established 3 vision
creasing school socioeconomic status. Of those
related Healthy People 2010 objectives for childfamilies who participated in the referral tracking
ren: 1) reducing visual impairment and blindprocess, 52% brought their child to an eye docness, 2) increasing the proportion of preschool
tor. White families (63%) were most likely to
children who receive vision screening, and 3)
access vision care, whereas Hispanic families
increasing the use of protective eyewear in recr(47%) were the least likely.
eational activities and hazardous situations
around the home.69
The American Optometric Association
recommendations for eye examinations for children and adults are presented in Table 17-2. In a
DISABILITIES
Page 222 of 294
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DISABILITIES
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18. Dental Health
The individual and public health impact
of dental disease is increasingly recognized as
affecting a large proportion of the population and
being linked with overall health status.1 2 Improvement of oral health may have a positive
impact on general health and delay mortality.3 4
Not only is lower cognitive function associated
with greater deterioration of oral health,5 but
complete or nearly complete tooth loss may be a
predictor of dementia late in life.6 And, deterioration of oral health may be secondary to other
major health issues.7 8 Not all dental issues are
pathological, for example, cosmetic changes in
the appearance of the teeth may be an issue
such as among smokers - 28% of who report
moderate to severe levels of tooth discoloration
compared to 15% of non-smokers.9 And, cosmetic issues may manifest as mental health
problems and influence expenditure of resources for tooth “whitening” treatments and
products.
Mouth and throat diseases, from cavities
to cancer, cause pain and disability for millions
of Americans. This fact is disturbing because
almost all oral diseases can be prevented, yet
many Americans forgo routine dental care. According to a recent Gallup-Healthways poll, 34%
of Americans did not see a dentist in the past
year.10 In the ranking of states, Missouri was the
43rd worst state with 40% of respondents reporting no dental visits; Kansas ranked 33rd with
36%. In addition, many senior citizens are unable to afford dental care because of the lack of
routine dental service coverage under Medicare.11 Low income and educational attainment
are associated with severe periodontitis independent of neighborhood socioeconomic status.12
Oral conditions affect the full scope of
health status, yet traditionally dentistry has used
specific clinical indices, such as number of teeth,
to assess the impact of dental conditions. Oral
Quality of Life (OQOL) measures have been
developed to provide population based indices
and currently are being evaluated.13
Dental caries (cavities) have declined
significantly among school-aged children since
the early 1970s, yet remain the most prevalent
chronic disease of childhood. Over the same
time period, fewer adults have experienced tooth
loss because of dental decay or periodontal disease and the prevalence of complete tooth loss
among adults has been consistently declining.
Although significant improvements in
oral health for most Americans have been made
over the past four decades, oral health disparities remain across some population groups. For
seniors, edentulism and periodontitis have declined; for adults, improvements were seen in
dental caries prevalence, tooth retention, and
periodontal health; for adolescents and youths,
dental sealant prevalence has increased and
dental caries have decreased; however, for
youths aged 2–5 years, dental caries in primary
teeth have increased.14
Among children, 20% of those who are
2-4 years old, 50% of those 6-8 years old, and
nearly 60% of those 15 years old have tooth decay.15 Low income children are disproportionately affected with about 33% having untreated decay, which can lead to pain, dysfunction, school
absenteeism, underweight, and poor appearance. Tooth decay is also a problem for older
adults who have retained most of their teeth.
Fluoridation of public drinking water supplies is
an effective approach to prevention of cavities
and tooth decay and an estimated 69% of persons served by community water supplies received optimally fluoridated water, including residents of Kansas City.16
Despite an increase in tooth retention,
tooth loss remains a problem among older
adults. National data show that 8% of adults
have lost all their natural teeth primarily because
DENTAL HEALTH
Page 226 of 294
of tooth decay and advanced gum disease.17
Absence of natural teeth is inversely associated
with education; 15% of adults with <12 years
education have lost all their natural teeth compared with 3% of those with a bachelor’s degree
or higher. The poor and near poor are more likely to have lost all their natural teeth than those
who are not poor. Among persons aged <65
years, the risk of death from all causes is 19%
for persons who have lost all their natural teeth
compared to 10% for persons who have not.18
In Missouri, during 2002, the ageadjusted percentage of persons >65 years old
who had most of their natural teeth (loss of 5 or
fewer teeth) was 44.6%, while 26.4% had lost all
their natural teeth.19 In the Kansas City metropolitan area, 19.5% of adults had lost all their
natural teeth.20 There also is an association between tooth loss and the number of live births a
woman had although this relationship is not
moderated through dental care, psychosocial
factors, or dental health damaging behaviors.21
In 2004, Americans made about 500
million visits to dentists and an estimated $78
billion was spent on dental services. Yet, 4.7
million children 2-17 years of age (7%) had unmet dental needs because their families could
not afford dental care.22 Thirty-five percent of
uninsured children had no dental contact for
more than 2 years compared with 17% of children on Medicaid and 13% of children with private
health insurance. Twenty-three percent of uninsured children had unmet dental needs compared with 4% of children with private insurance
and 9% of children with Medicaid. Hispanic
children were 1.6 times as likely as white children and 1.4 times as likely as black children to
have had no dental contact for more than 2
years. Children enrolled in Medicaid or the State
Children’s Health Insurance Program (SCHIP)
were 1.7 times more likely to have untreated
dental caries than other children, with those
enrolled in SCHIP) being significantly less likely
to have untreated dental caries than those
enrolled in Medicaid.23 This is due to improveDENTAL HEALTH
ments in funding for SCHIP dental services.24
One of the major complications of diabetes is periodontal disease. Adults with diabetes have both a higher prevalence of periodontal disease and more severe forms of the
diseases, contributing to impaired quality of life
and substantial oral functional disability. In addition, periodontal disease has been associated
with development of glucose intolerance and
poor glycemic control among adults with diabetes. Behavioral Risk Factor Surveillance
System (BRFSS) data show that nationally 67%
of dentate adults with diabetes had a dental visit
during the preceding 12 months.25 For Missouri,
the rate was 61.4% and for Kansas 78.7%. The
Healthy People 2010 national objective is to
have 71% of dentate adults with diabetes have
an annual dental visit.
Missouri
The National Oral Health Surveillance
System reported that 63.4% of Missourians visited a dentist or dental clinic within the past
year, 63.0% had their teeth cleaned within the
past year, 25.2% of persons 65+ years of age
had lost all of their teeth, 26.6% of 3rd grade students had untreated tooth decay, and that
27.4% of 3rd grade students had one or more
sealants on their permanent 1st molar teeth
(www.cdc.gov/nohss). Also, 82.0% of Missourians using public water systems are receiving
fluoridated water.
Kansas City
The April 2008 issue of Men ’s Health
magazine ranked dental health in 100 US cities;
Kansas City was ranked 77th and received a
score of D+ based on frequency of flossing and
dentist visits, number of teeth pulled, and percent of water fluoridation.
The 2004 Health Assessment Survey
commissioned by the Kansas City Health De-
Page 227 of 294
partment found that 60% of respondents had
dental health insurance (www.kcmo.org/health).
Of those with dental insurance, 67% had it
through their employer, 25% through a governmental program, and for 8% it was selfpurchased. Of all respondent households, 55%
had all members covered and 45% had either no
one covered or had a portion of the household
not covered, usually adults.
Among survey respondents, 75% reported a dental check-up in the prior 2 years
while 2% reported never having dental checkups. In addition, 33% of respondent households
did not have their teeth cleaned on a regular
basis. Of those that did have their teeth cleaned,
90% were seen at a dental office, 4% at the University of Missouri’s School of Dentistry, 5% at
community health centers, and 0.6% at other
venues. Seventy-six percent of respondents reported usually or always brushing their teeth at
least twice a day.
Kansas City is fortunate to have the only
dental school in the state. Of the local health
departments serving the Missouri side of the
metropolitan area, only the Clay County Health
Department has a dental health program. The
Platte County Health Department does provide
emergency dental services.
Dental care is the most commonly cited
unmet health care need in the nation26 and patients with dental complaints often go to a hospital emergency department. The only published
analysis of dental complaint visits to emergency
departments used National Centers of Health
Statistics’ (NCHS) National Hospital Ambulatory
Medical Care Survey data and found an estimated 2.95 million emergency department visits
for dental-related complaints over a 4-year period (1997-2000).27 Those visits were similar in
number to those for “painful urination”. Patients
with dental complaints were significantly more
likely to have Medicaid or no health insurance
(self-pay) in comparison to patients without dental complaints. Care provided typically consisted
of prescribing antibiotics and analgesics along
with referrals to others for follow-up.
In 2007, dental complaints were the 6th
leading reason for emergency department visits
in Kansas City. An analysis of data from 20012006 found Kansas Citians made 19,316 visits
to emergency departments for dental complaints
(1.7% of all emergency department visits).There
was a very significant increasing trend in such
visits over the 6-year period, while the trend for
all other emergency department visits was stable. The nature of complaints were as follows:
dental caries 3,935, pulpitis or periapical abscess 2,862, cheek, lip, jaw injury or broken
tooth 1,672, temporomandibular joint disorders
287, and all other dental diseases 10,540.
Total emergency department charges for
these dental complaint visits were approximately
$6.9 million. Average charges were highest for
temporomandibular joint disorders $747, followed by check, lip, jaw injury or broken tooth
$549, dental caries $432, pulpitis or periapical
abscess $421, and all other dental diseases
$277. Self-pay and Medicaid constituted 70.6%
(38.3% self-pay; 32.3% Medicaid) of the payment sources compared to 51% for all other
types of emergency department visits.
Women made more than half (53.9%) of
the emergency department visits for dental
complaints as they did for other emergency department visits (54.8%). Significantly more
blacks used the emergency department for dental complaints than visited the emergency department for other complaints. And, half (50.8%)
of the dental visits were made by persons 19-35
years of age; this age-group made 32.2% of the
visits for other complaints.
Children
Healthy People 2010’s target for the
prevalence of untreated dental decay in children
ages 6-8 years old is 21%. There are two differDENTAL HEALTH
Page 228 of 294
ent local initiatives that provide information related to dental health in children, Score 1 for
Health and the Oral Health Surveillance Project.
Score 1 for Health
Score 1 for Health is a collaboration between the Kansas City University of Medicine
and Biosciences, University of Missouri School
of Dentistry and the Deron Cherry Foundation.
For 2006-2007, Score 1 for Health reported the
rate of untreated dental decay was 37.7%
among children in participating schools in the
Kansas City area.28 Rates for students varied
from 8% to 58% between schools. Using the
percent of children in a school who were eligible
for the Free and Reduced Lunch (FRL) Program
as a proxy indicator of children living in poverty
or among working poor families, the collaboration found lower socioeconomic status schools
had rates 1.7 times higher than those of higher
socioeconomic status schools. The dental need
was 1.2 times higher among blacks and Hispanics than whites. Children 8-10 years old had the
highest rates of need (40-41%). Of children referred for dental care, Hispanic families were the
least likely to see a dentist (38%) compared to
black (53%) and white (60%) families. Commonly identified barriers included a lack of insurance,
a lack of available providers, and a lack of timely
appointments.
Oral Health Surveillance Project
ren’s oral health status in a six-county bi-state
region, which included Cass, Jackson, and Lafayette counties in Missouri, and Allen, Wyandotte, and Johnson counties in Kansas. The
survey examined preschool children 2-4 years of
age, elementary school children who were 8
years old, and middle-school children 12 years
old. The project collected clinical and behavioral
data utilizing dental screening examinations and
survey questionnaires.
Liang Hong, DDS, MS, PhD and Michael McCunniff, DDS, MS provided the following information on 547 children from the Jackson
County portion of the study.
Of the participants, there were approximately equal numbers of boys and girls. Fiftyfive percent were non-Hispanic white, 31% nonHispanic black and 10% Hispanic. About half of
the children were eligible for FRL. In addition,
48% came from families with an annual income
<$40,000. Sixty-two percent of parents did not
have a college degree and 89% had some kind
of medical insurance.
The dental examination indicated that overall 18% of the children had developmental enamel defects, 15% had dental fluorosis in permanent maxillary central incisors, and 3% had dental fluorosis in primary second molars. Boys and
girls were equally likely to have dental caries
(40% vs 39%). Age was significantly associated
with caries experience with 8 year olds more
likely to have caries (Table 18-1); twelve year
olds had less caries experience because their
primary teeth had been lost and were not avail-
The Oral Health Surveillance Project
2007-2008 conducted by the University of Missouri Department of Dental
Table 18-1 Oral Health Surveillance Project 2007-2008 findings by age group, Jackson
Public Health,
County, Mo
with support
Age group
Dental
condition
2-4
years
8 years
12 years
from the
Dental plaque (bacterial film on tooth surface)
78%
70%
72%
REACH
Calculus
16%
24%
24%
Gingivitis (gum inflammation)
26%
35%
35%
Healthcare
Dental caries experience
19%
63%
52%
Foundation,
Untreated cavity
14%
57%
42%
was a yearAverage number of decayed, missing, or filled teeth
0.70
2.54
2.02
Average number of decayed or filled surfaces
1.26
3.86
2.88
long assessDental sealant
0.3%
12%
18%
ment of childDental erosion of maxillary incisors
20%
7%
10%
DENTAL HEALTH
Page 229 of 294
able for assessment. Non-Hispanic black children had the highest caries rate (44%) and nonHispanic white children the lowest (23%). While
sex was not a significant factor for untreated
caries, race/ethnicity was with non-Hispanic
black children (44%) being about three times
more likely to have untreated caries than nonHispanic white children (16%). Socioeconomic
status as measured by participation in the FRL
program and family income level, as well as
parents’ education level were significantly related to children’s caries experience (Tables 182 and 18-3).
Considering the severity of dental caries using the measure of number of decayed and filled
surfaces (DFS), there was no significant difference between boys and girls. Older children,
non-white children, children eligible for the FRL
program, those whose parents had less education, and those from low income families had
significantly more DFS.
The rate of sealant use, which is an effective
preventive measure for dental caries, was very
low. Overall, only 7% of children had dental sea-
lant in at least one tooth surface. This rate was
below the Healthy People 2010 objective that
50% of children receive dental sealant. Factors
such sex, race, eligibility for the FRL program,
parents’ education level, and family income,
were not related to dental sealant use.
Only 1.5% children had dental trauma suggesting that it is not a serious problem.
Twelve percent of children had dental erosion of the maxillary incisors with Hispanic children having the highest rate (36%), followed by
non-Hispanic white children (11%) and nonHispanic black children (7%). Children from low
income families were more likely to have dental
erosion of the maxillary incisors.
Among 12 year olds the mean orthodontic
treatment score was 5.36 (SD+2.92). Forty-four
percent of these children had no orthodontic
need (score 0-4), while 26% were considered as
having orthodontic treatment concern (score 57), and 30% had a definite orthodontic treatment
need (score 8-10). None of socioeconomic factors were significantly related to definite orthodontic treatment need.
Table 18-2 Oral Health Surveillance Project 2007-2008 findings by income status, Jackson County, Mo
Free/reduced lunch
participants
Family income
Dental condition
Yes
No
<$20,000
$20-59,999
>$60,000
Caries experience
Untreated caries
Average number of decayed, missing, or
filled teeth
Average number of decayed or filled
surfaces
Dental erosion of maxillary incisors
Urgent dental care
a
SD = standard deviation
46%
40%
1.89
a
(SD+2.77)
2.95
(SD+4.74)
12%
9%
17%
11%
0.56
(SD+1.63)
0.89
(SD+3.02)
6%
0%
49%
43%
2.03
(SD+2.74)
3.37
(SD+5.15)
14%
9%
29%
23%
1.01
(SD+2.09)
1.98
(SD+4.24)
12%
3%
17%
11%
0.64
(SD+1.92)
0.71
(SD+2.07)
6%
1%
Table 18-3 Oral Health Surveillance Project 2007-2008 findings by parents’ educational attainment
level, Jackson County, Mo
Parents’ education level
Dental condition
<High school
Some college
>College
Caries
Untreated caries
Average number of decayed, missing, or
filled teeth
Average number of decayed or filled surfaces
Dental erosion of maxillary incisors
Urgent dental care
a
SD = standard deviation
42%
36%
a
1.75 (SD+2.68)
33%
28%
1.31 (SD+2.56)
17%
12%
0.50 (SD+1.42)
2.87 (SD+4.89)
12%
8%
1.98 (SD+4.25)
7%
3%
0.71 (SD+2.07)
11%
0.5%
DENTAL HEALTH
Page 230 of 294
When it came to urgency of needed dental
care, 71% of the children had no obvious dental
problem, 24% needed early dental care, and 5%
needed urgent dental care. The elementary
school students had the highest percentage of
those who needed urgent dental care, probably
because vast majority of primary teeth still remained. Nine percent of non-Hispanic black
children had urgent dental care need, compared
to only 3% of non-Hispanic white and 1% of Hispanic children. Family income was a significant
factor with children from low income families
more likely to have urgent dental care need.
Out of the 547 children, only two did not
brush their teeth; 36% brushed their teeth once
daily, 53% twice daily, and about 11% 3 times or
more daily. Twenty-two percent of children
flossed including 17% who flossed once daily,
4% who flossed twice daily, and 1% who flossed
three times or more daily. Race/ethnicity, parents’ education, and family income were not significantly associated with dental flossing behavior, while girls, older children, and those not
eligible for the FRL program were significantly
more likely to floss. Overall, 62% of children did
not use mouth rinse. Older children, nonHispanic black children, those not eligible for the
FRL program, children whose parents had a low
education attainment level, and children from
low income families were significantly more likely to use mouth rinse. Disadvantaged children
may be more likely to use mouth rinse because
of public health programs that target them, not
necessarily because their parents purchase
these products.
Among those parents who returned a questionnaire survey, the primary source of drinking
water for their family was unfiltered city tap water (46%), filtered city tap water (36%), bottled
water (17%) and private well water (0.8%); collectively 82% used city tap water as their primary drinking water sources. Primary drinking water sources were significantly associated to any
caries experience, untreated caries, or decayed
and filled surfaces (DFS), with children drinking
DENTAL HEALTH
primarily city tap water having the lowest caries
experience.
About 43% of children were not breastfed as
an infant while 35% had been breast-fed for 1-6
months, 17% for 7-12 months, and 5% for >12
months. Breastfeeding had a significant effect
on children’s caries experiences with those who
were breast-fed longer having less caries experience.
Only about 11% of children did not drink fruit
juice, whereas 60% drank fruit juice 1-6 times
per week, and 29% drank fruit juice 1 or more
times per day. Fruit juice drinks were significantly related to the caries experience with children
who consumed more fruit juice having more caries experience. Similarly, about 33% of children
did not drink soda pop regularly, 54% drank it 16 times per week, while 12% consumed soda
pop at least 1 time per day. Children who drank
more soda pop had a significantly higher caries
experience.
Seventeen percent of parents reported their
children’s oral health in very good condition,
48% reported good oral health, 25% reported
fair oral health, and 4% reported poor oral
health. When parents were asked what specific
problems their children had with their teeth, 28%
reported tooth cavities, 20% reported crooked
teeth or need for braces, 9% reported tooth discoloration, 5% reported gum problems, and 1%
reported tooth pain. Sixty-four percent reported
that their children had a regular family dentist
and 80% had dental insurance. Fifty-eight percent reported that their children had a dental
visit in past year, 19% had a dental visit more
than one year ago; while 22% has never had a
dental visit. When parents were asked for reasons for the last dental visit, 69% reported it was
a routine checkup/examination or cleaning, and
5% reported their child’s teeth were bothering or
hurting.
Thirteen percent reported that they could not
get needed dental care for their children. When
parents were asked for main reason for not being able to get needed dental care for their child-
Page 231 of 294
ren, the primary reason was affordability (33%),
followed by no insurance (15%) difficulty getting
an appointment (15%), the dentist did not take
Medicaid insurance (8%), transportation problems (5%), did not know where to go (4%).
Children who were older, not black, not eligible
for the FRL program, from high income families,
and whose parents’ education attainment level
was high were more likely to have visited a dentist in the past year. Children who had dental insurance coverage were significantly more likely
to have had a dental visit in the past year (63%
vs 45%).
educate children and families about oral health
habits that should begin early in a child’s life.
The project encourages dentists to accept at
least 5 Project Ready Smile participants over the
course of a year.
Literature cited
1
National Institute of Dental and Craniofacial Research. Oral
Health in America: a Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. www.surgeongeneral.gov
2
Pediatric dental services
Only 1% of the 2,700 dentists in Missouri were enrolled in Medicaid and the Missouri
Children Health Insurance Program. These low
percentages have resulted in a shortage of dentists in the Kansas City region willing to accept
children on MC+/Medicaid (now known as Missouri Health Net).
In 2003, Citizens for Missouri’s Children
released a report, Dental Care Counts, Decay in
the Heartland: A Crisis for Kansas City Children.
According to that report, only 15% of dentists in
the region accepted children with MC+/Medicaid.
This translated into 1 dentist for every 923 children enrolled in MC+/Medicaid. As a result, less
than one-third of eligible children were screened
for dental problems. The report also stated that
the health care maintenance organizations under contract with the state of Missouri also had
low dental screening rates.
In 2007, the REACH Healthcare Foundation and the Health Care Foundation of
Greater Kansas City joined together to fund a 3year project known as Project Ready Smile with
the aim of having young children arrive at kindergarten with healthy teeth and mouths. This
goal is to be accomplished by 1) expanding the
pool of dentists willing to treat young children, 2)
encourage families to establish a dental home
for themselves and their young child, and 3)
Institute of Medicine. The Future of the Public’s Health in
st
the 21 Century. Washington DC:National Academies Press,
2002.
3
Padiha DM et al. Number of teeth and mortality risk in the
Baltimore Longitudinal Study of Aging. J Gerontol A Biol Sci
Med Sci 2008;63:739-744.
4
Hujoel P. Dietary carbohydrates and dental-systemic diseases. J Dental Res 2009;88:490-502.
5
Wu B et al. Cognitive function and oral health among community dwelling older adults. J Gerontol A Biol Sci Med Sci
2008;63:495-500.
6
Stein PS et al. Tooth loss, dementia and neuropathology in
the Nun study. J Am Dent Ass 2007;138:1314-1322, 13811382.
7
Beltran-Aguilar ED, Beltran-Neira RJ. Oral diseases and
conditions throughout the lifespan. II systemic diseases. Gen
Dent 2004;52:107-114.
8
Nicopoulou-Karayianni K et al. Tooth loss and osteoporosis: the osteodent study. J Clin Periodontol 2009;35:190197.
9
Alkhatib MN et al. Smoking and tooth discolouration: findings from a national cross-sectional study. BMC Public
Health 2005;5:27.
10
Marcus MB. Many Americans say they forgo routine dental
care. Job loss and hard times compound the problem. USA
Today 3/ll/09. www.usatoday.com
11
Marshall S et al. Eldersmile: a comprehensive approach to
improving oral health for seniors. Am J Public Health
2009;99:595-599.
12
Borrell LN et al. Socioeconomic disadvantage and periodontal disease: the Dental Atherosclerosis Risk in Communities Study. Am J Public Health 2006;96:332-339.
13
Kressin NR et al. A new brief measure of oral quality of
life. Prev Chronic Dis Public Health Res Pract Policy
2008;5(2).
DENTAL HEALTH
Page 232 of 294
14
Dye BA et al. Trends in oral health status: United States,
1988–1994 and 1999–2004. Vital Health Stat 2007;11:248.
www.cdc.gov/nchs.
15
Centers of Disease Control and Prevention. Oral health.
Preventing cavities, gum disease, and tooth loss, 2005.
www.cdc.gov/nccdphp.
16
Bailey W et al. Populations receiving optimally fluoridated
public drinking water – United States, 1992-2006. MMWR
17
for U.S. adults: National Health Interview Survey, 2006.
18
Brown DW. Complete edentulism prior to the age of 65
years is associated with all-cause mortality. J Public Health
Dent 2009;April 24 [epub ahead of print]
19
Centers for Disease Control and Prevention. Retention of
natural teeth among adults – United States, 2002. MMWR
20
21
Russell SL et al. Exploring potential pathways between
parity and tooth loss among American women. Am J Public
Health 2008;98:1263-1270.
22
Bloom B et al. Summary health statistics for US children:
National Health Interview Survey, 2005. NCHS Vital Health
Stat 2006;10(231). www.cdc.gov/nchs.
23
Brickhouse TH et al. Effects of enrollment in Medicaid
versus the State Children’s Health Insurance Program on
kindergarten children’s untreated dental caries. Am J Public
Health 2008;98:876-881.
24
Wall TP, Brown LJ. Public dental expenditures and dental
visits among children in the US, 1996-2004. Public Health
Rep 2008;123:636-645.
25
Eke PI et al. 2005. Dental visits among dentate adults with
diabetes – United States, 1999 and 2004. MMWR Morb
Mortal Wkly Rep 54:1181-1183.
26
Edelstein BL. Public and clinical policy considerations in
maximizing children’s oral health. Pediatr Clin North Am
2000;47:1177-1189.
27
Lewis C et al. Dental complaints in emergency departments: a national perspective. Ann Emerg Med 2003;42:9399.
28
Campbell A, Stering TK. Score 1 for Health. 2008 Community Report. www.Score 1 for Health.org
DENTAL HEALTH
Page 233 of 294
19. Tobacco Use
Worldwide, smoking will kill nearly 6.4
million people a year by 2015, 50% more than
HIV.1 By 2030, global annual smoking deaths
are expected to be between 8.3 and 10 million.2
Men are more than 3 times as likely to die as
women;3 however, the gap in tobacco use by
males and females is narrowing which would
then increase the overall impact of tobacco on
mortality.4 5
Although cigarette consumption in the
US has fallen to its lowest point, nicotinedependency (see Table 19-1) has not decreased
and may, in younger birth cohorts, being increasing particularly among women.6 Further,
tobacco use remains the number one actual
cause of death in the US.7 8 In 2007, an estimated 19.8% of population smoked cigarettes; a
significant reduction from the rate in 2006.9 Former smokers constituted another 21% of the
population.10 11 Reductions in cigarette smoking
may adversely affect the US Social Security system as a result of declines in smokingattributable mortality.12
In 2004 and 2006, US Surgeon General
Richard Carmona issued reports that summarized the health consequences of smoking (TaTable 19-1 Nicotine dependency is based
ble 19-2)13 and the health effects of involuntary
on 3 or more of the following criteria
exposure to tobacco smoke (Table 19-3).14
(source: Diagnostic and Statistical Manual of Mental
th
Disorders, 4 edition. Washington DC: American
Among both men and women, persons who
Psychiatric Association, 1994)
never smoked had much better survival rates
Criteria
than smokers in all socioeconomic levels; smokNeeding more nicotine to achieve desired
1
ing is a greater source of health inequity than
results
socioeconomic position and nullifies women’s
2 Experiencing nicotine withdrawal syndrome
survival advantage over men.15
3 Using cigarettes more than intended
In general, smoking rates in the nation
Experiencing a persistent desire or unsuc4
cessful efforts to cut down on nicotine use
are highest among persons with 9 to 11 years of
5 Spending a great deal of time using cigarettes
education and lowest among those with >16
6 Giving up activities in favor of nicotine use
years of education.16 Those living below the poContinuing to use cigarettes despite recurrent
verty level have a higher prevalence of smoking
7 physical or psychological problems likely to
than persons above the poverty level. The prehave been caused by nicotine use
valence of smoking may be influenced by
the amount of sleep a person gets each
night; <6 hours and >9 hours are assoTable 19-2 Major conclusions of the Surgeon Genciated with higher smoking rates.17
eral’s 2004 report on the health consequences of
smoking
It is estimated that 8.6 million
Conclusions
people have at least one serious illness
Smoking harms nearly every organ of the body, causing many
1
caused by smoking, and exposure to todiseases and reducing the health of smokers in general.
Quitting smoking has immediate as well as long-term benefits,
bacco smoke is projected to contribute to
2 reducing risks for diseases caused by smoking and improving
some 440,000 deaths each year.18 Among
health in general.
current smokers, chronic lung disease acSmoking cigarettes with lower machine measured yields of tar
3
and nicotine provides no clear benefit to health.
counts for 73% of smoking-related condiThe list of diseases caused by smoking has been expanded to
tions and, among former smokers, 50% of
include abdominal aortic aneurysm, acute myeloid leukemia,
4
cataract, cervical cancer, kidney cancer, pancreatic cancer,
smoking-related conditions. High rates of
pneumonia, periodontitis, and stomach cancer
tobacco-related cancer are found among
TOBACCO USE
Page 234 of 294
Table 19-3 Major conclusions of the Surgeon General’s 2006 report on the health consequences of involuntary exposure to tobacco smoke
Conclusions
1
2
3
4
5
6
Secondhand smoke causes premature death and disease in children and in adults who do not smoke.
Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung
growth in their children.
Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer .
The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke
Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control.
Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers
from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand
smoke.
men, blacks, non-Hispanics, and older adults.19
Recent data suggest that cigarette
smoke interferes with the production of the
FANCD2 protein in the lungs; this protein plays
a key role in repairing damage to DNA and for
causing apoptosis (death) of damaged cells.20
Loss of this protein puts the epithelial cells in the
airways at greater risk of becoming cancerous.
Of the four major smoking-related diseases
(lung cancer, chronic obstructive pulmonary disease (COPD), ischemic heart disease, and cerebrovascular disease, lung cancer is the most
expensive condition to treat while ischemic heart
disease was the least expensive.21 COPD is the
2nd most expensive condition to treat.
Smoking shortens a person’s life by 5 to
10 years22 while smoking cessation lowers
smoking -related death rates.23 24 Heavy smokers cannot simply reduce the number of cigarettes they smoke if they want to minimize their
risk of early death, they must stop completely.25
Among former smokers, it takes approximately
10 years for their arteries to return to the level of
stiffness seen in non-smokers.26 Because of genetics, some former smokers remain at a higher
risk for developing lung cancer than persons
who never smoked.27 The probability that a
smoker will cease smoking is influenced by the
dynamics of their social network.28
It is felt there are two basic approaches
to reducing the prevalence of smoking. One is to
discourage youth from adopting tobacco
TOBACCO USE
usage.29 This can be accomplished via a mix of
educational and monetary approaches. For example, studies have shown that a 10% increase
in the price of cigarettes reduces smoking by 7%
for youth and consumption by 4% for adults, although the effectiveness of this approach recently has been questioned.30 Only South Carolina had a lower cigarette tax than Missouri
(www.taxadmin.org/FTA/rate/cigarett.html). The
second approach is to get current smokers to
stop smoking. While most smoking cessation
costs are borne by the smoker, some states, but
not Missouri, offer assistance through Medicaid.31
In 2007, an estimated 19.8% of adults
were current smokers (males 21.3%; females
18.4%).32 Rates varied by race/ethnicity with
22.1% of non-Hispanic whites, 19.4% of nonHispanic blacks, and 12.7% of Hispanics being
smokers. 33 Between 1998 and 2007, the median
smoking rate among adults declined from 22.9%
to 19.8%. In Missouri, the rate declined from
declined significantly from 26.3% to 24.6%.
Among adolescents, 13% are current smokers.34
According to the Substance Abuse and
Mental Health Administration, 3.0-3.3% of persons >12 years of age use smokeless tobacco
products (6.2% of males versus 0.4% of females) and the rate is increasing among adolescents.35 36
Page 235 of 294
Missouri
The health and economic burden of tobacco smoking in Missouri is not inconsequential. Annually, some 9,600 Missourians die from
smoking-attributable causes (17% of all deaths),
132,103 years of potential life are lost, and $2.4
billion in economic productivity is lost.37 Smoking
attributable illness annually cost Missouri’s Medicaid program some $514 million.38
According to 2007 Behavioral Risk Factor Surveillance System data, 24.5% of Missouri
adults smoke cigarettes (25.9% of males; 23.2%
of females.39 The 2007 Missouri County-Level
Survey of Adult Tobacco Use and Related
Chronic Conditions and Practices found that
23.3% of adult Missourians were current cigarette smokers, 3.9% used smokeless tobacco
products, and 6.1% used other forms of tobacco
(www.dhss.mo.gov/CommunityDataProfiles). By
county, Clay had a current cigarette smoking
prevalence of 17.4%, smokeless tobacco prevalence of 3.0%, and other tobacco use prevalence of 6.0%; for Jackson and Platte counties
the respective prevalence rates were 25.8%,
3.3%, 8.3%, and 19.3%, 3.3%, 6.1%. None of
the county level prevalence rates were statistically different from the statewide rates. Half of
the smokers interviewed expressed a desire to
quit smoking.
The American Lung Association (ALA)
estimated that the economic costs due to smoking were $3,841,000,000 in Missouri. The ALA
gave Missouri a grade of “F” for tobacco prevention and control spending, smoke free air, and
cigarette tax, as well as a grade of “B” for youth
access to tobacco products.
In December 2008, the Health Care
Foundation of Greater Kansas City released a
report regarding policy options to reduce the
burden of tobacco in Missouri and Kansas.40
That report considered increased cigarette taxes
and clean indoor air laws. Federal cigarette taxes increased significantly in 2009 as part of the
financing for the federal State Children's Health
Insurance Program.41
As of 1/1/08, Missouri's tax rate was
$0.17 per pack and Arkansas’ was $0.59 (the
rate in other states bordering Missouri were
higher). In Missouri during FY 07/08,
534,438,741 packs of cigarettes were sold and
$90,854,586 in taxes collected.42 If the tax rate
had been equivalent to that of Arkansas, the
state would have taken in $315,318,857 or an
additional $224,464,271. Cigarette tax revenues
in Missouri were up 0.2% in FY 07/08 compared
to the prior year. None of this includes the
$12,214,822 collected on other tobacco products and which is folded into the overall rubric of
cigarette tax revenue, nor does it include the
additional $0.05 cigarette tax per pack collected
for Jackson County and for St Louis County.
Based on those fees, 52,706,220 packs of cigarettes were sold in Jackson County in FY 07/08,
a 5% decrease from the prior year.
Kansas City
A 2006 telephone survey of Kansas City
residents found that 20.3% reported they were a
smoker. And, a 2007 telephone survey conducted by the Missouri Department of Health
and Senior Services found a 21.8% rate. A
comparison of the 2006 and 2007 surveys by
city Councilmatic District is shown in Table 19-5;
the 2007 data is also shown by Kansas City
Health Zone.
In 2006, 18.2% of the telephone survey
respondents lived with someone who smoked
and they were asked whether they believed
smoking or breathing in some else’s tobacco
smoke can cause various health problems. Their
responses are summarized in Table 19-4.43
Prevention has a statistical package known as
Smoking-Attributable Mortality, Morbidity and
Economic Costs or SAMMEC.44 Using that program and the smoking rate for 2006-2007, the
Kansas City Health Department calculated the
estimated smoking-attributable mortality in the
community for the period 2003-2007.
TOBACCO USE
Page 236 of 294
8.5% of the estimated deaths for Missouri as a
whole; if proportionate, Kansas City would experience ~815 annual deaths. This discrepancy is
Don’t
most likely due to the lower smoking-rate in
Yes
No
know
Kansas City compared to the rest of Missouri.
Do you believe that smoking is the cause of
SAMMEC also provides estimates of
Heart disease
78.4%
9.7%
11.8%
Lung cancer
90.4%
4.3%
5.3%
smoking-attributable productivity losses and
Stroke
72.4%
10.2%
17.4%
smoking-attributable years of potential life lost
Low birthweight
72.0%
7.3%
20.7%
(YPLL). Those results are presented in Table
Impotence in men
41.8%
10.6%
47.6%
Do you believe that breathing in someone
19-7.
else’s tobacco smoke can cause
Work by the Kansas City Health DeHeart disease
67.8%
13.8%
18.4%
partment
and its community partners at the KanLung cancer
79.4%
9.7%
10.9%
Respiratory problems in
85.1%
5.9%
8.9%
sas City University of Medicine and Biosciences
children
and Children’s Mercy Hospital has examined
Sudden infant death
45.9%
13.3%
40.8%
syndrome
various issues related to pregnancy-smoking.
Those efforts demonstrated that smoking alone
or in combination with alcohol and/or drug use
Based on SAMMEC, 2,984 deaths
was associated with low birthweight for term46
among persons >35 years old were considered
and preterm infants47 as well as infants who
to be smoking related (Table 19-6). Those
were small for their gestational age.48 49Dependdeaths represented 17.0% of the 17,554 deaths
ing on the combination of smoking, alcohol, and
among persons >35 years old. Those deaths do
drugs, these health compromising behaviors
not include the approximately 400 deaths that
were associated with 11.8-31.4% of preterm
would have been attributed to secondhand
births and 5.5-18.5% of low birthweight term
smoke. Directly and indirectly, then, cigarette
births. Among women who had two pregnancies,
smoking contributed to an estimated 18.5% of all
24.9% of those who smoked during their first
deaths in Kansas City. The estimated deaths
pregnancy did not smoke during their second
were for a 5-year period, which translates to an
pregnancy, while only 4.8% of the women who
estimated 675 Kansas City residents dying each
did not smoke during the first pregnancy did so
year from smoking-attributable causes. In Misin the second pregnancy.50 The pregnancysouri, an estimated 9,585 persons die annually
smoking prevalence, however, increased with
from smoking-attributable causes.45 At ~8.5% of
the number of prior births to the women. During
Missouri’s population, the estimated 600 per2001-2005, 13% of pregnant women who had a
sons dying annually in Kansas City is less than
live birth
smoked
during
Table 19-5 Percent of smokers as elicited by telephone surveys, Kansas City, Mo
pregnancy
2006
2007
2007
(1,234 respondents)
(1,278 respondents)
(1,278 respondents)
and infants
Councilmatic
born to
District
Smokers
Smokers
Health Zone
Smokers
smokers
1
21.3%
21.6%
Platte
17.8%
2
17.0%
18.8%
Clay01
10.9%
had a risk
3
23.0%
30.2%
Clay02
23.4%
of dying
4
19.0%
20.5%
Jackson01
17.6%
5
22.7%
29.4%
Jackson02
31.8%
that was
6
17.8%
20.1%
Jackson03
27.7%
76% highTotal
20.3%
21.8%
Jackson04
19.9%
er than for
Total
21.8%
Table 19-4 Responses of 1,234 Kansas City,
Mo, residents to questions on tobacco
smoke and health
TOBACCO USE
Page 237 of 294
Table 19-6 Smoking-Attributable Mortality, Kansas City, Mo, 2003-2007
(adults age 35 years and old-
er; does not include burn or second hand smoke deaths)
Males
Disease category
Deaths
Females
Rate1
Deaths
Malignant neoplasms
Lip, oral cavity, pharynx
27
6.3
11
Esophagus
49
11.6
18
Stomach
13
3.2
2
Pancreas
25
5.9
27
Larynx
19
4.5
7
Trachea, lung, bronchus
654
155.5
419
Cervix uteri
0
0.0
1
Kidney & renal pelvis
20
4.8
0
Urinary bladder
35
9.1
12
Acute myeloid leukemia
5
1.2
2
Sub-total
847
202.1
499
Ischemic heart disease
285
68.0
168
Other heart disease
98
25.7
84
Cerebrovascular disease
54
12.7
65
Atherosclerosis
31
9.5
16
Aortic aneurysm
28
6.9
18
Other arterial disease
3
0.9
8
Sub-total
499
123.7
359
Pneumonia, influenza
31
9.0
26
Bronchitis, emphysema
29
7.4
30
Chronic airway obstruction
322
85.1
342
Sub-total
382
101.5
398
Total
1,728
427.3
1,256
1
Average annual age-adjusted death rate ; US 2000 standard population
those born to non-smokers.51
In addition to the smoking itself, there is
the related issue of protecting individuals from
the effects of environmental (second-hand)
smoke, whether at home, in the work place, or at
other venues in the community.52 For example,
exposure to second-hand smoke has been associated with cognitive impairments among nonsmokers.53 Also, second-hand smoke in the
home is estimated to add $415 million to the
annual health care expenditures of children as
they have twice the risk of having emergency
department visits and three times the risk of
hospitalization for respiratory conditions.54 Nationally, the prevalence of second-hand smoke
exposure is highest among non-Hispanic blacks
and persons with lower income.55 For Minnesota, the estimated annual cost of treatment for
conditions causally linked with second-hand
smoke was equivalent to $44.58 per state resi-
Total
Rate
Deaths
Rate
1.8
2.9
0.3
4.3
1.2
69.2
0.2
0.0
1.9
0.3
82.1
38
67
15
52
26
1,073
1
20
47
7
1,346
3.7
6.5
1.5
5.0
2.5
103.2
0.1
1.9
4.5
0.7
129.6
26.4
12.4
10.8
2.2
2.8
1.3
56.2
453
182
119
47
46
11
858
43.7
17.5
11.5
4.6
4.5
1.1
82.9
3.8
4.7
53.0
61.5
199.8
57
59
664
780
2,984
5.5
5.7
64.0
75.2
287.7
dent.56
Of 1,234 Kansas Citians surveyed in
2006, 70.2% said smoking was not permitted in
the home which was higher than the 64.0% reported statewide in Missouri in 200357 and similar to the national median (73.7%) for homes
where smoking is prohibited. Of those who allow
smoking in the home, 36.2% permitted it only in
designated rooms. Smoking was permitted in
designated areas outside of the home by 76.3%
of respondents, although 9% of these individuals
indicated that permission was conditional. Of the
respondents, 74.1% did not permit smoking in
their car, van, or truck, while 20.3% indicated
that in the prior week they had been a passenger in a vehicle with a person who was smoking.
In June 2008, existing restrictions on
smoking in the workplace in Kansas City, including restaurants and bars, were replaced by more
comprehensive bans that were passed by a vote
TOBACCO USE
Page 238 of 294
Table 19-7 Smoking-attributable productivity losses and years of potential life lost, Kansas
City, Mo, 2003-2007 (adults age 35 years and older; does not include burn or second hand smoke deaths)
Productivity losses
(millions of dollars)
Disease category
Malignant neoplasms
Lip, oral cavity, pharynx
Esophagus
Stomach
Pancreas
Larynx
Trachea, lung, bronchus
Cervix uteri
Kidney & renal pelvis
Urinary bladder
Acute myeloid leukemia
Sub-total
Ischemic heart disease
Other heart disease
Cerebrovascular disease
Atherosclerosis
Aortic aneurysm
Other arterial disease
Sub-total
Pneumonia, influenza
Bronchitis, emphysema
Chronic airway obstruction
Sub-total
Total
Years of potential life lost
Males
Females
Total
Males
Females
Total
12,918
15,288
4,041
8,856
6,212
195,599
0
6,799
7,111
973
$257,797
3,219
4,296
0
6,756
2,711
119,185
408
0
1,999
301
$138,875
16,137
19,584
4,041
15,612
8,923
314,784
408
6,799
9,110
1,274
$396,672
512
737
194
401
285
9,573
0
309
417
62
12,490
182
274
15
412
137
6,995
22
0
155
25
8,217
694
1,011
209
813
422
16,568
22
309
572
87
20,707
120,366
29,806
24,623
2,445
9,339
120
$186,699
43,747
14,830
28,025
301
3,042
1,317
$91,262
164,113
44,636
52,648
2,746
12,381
1,437
$277,961
5,000
1,398
992
262
433
22
8,107
2,592
1,076
1,323
126
237
104
5,458
7,592
2,474
2,315
388
670
126
13,565
5,405
7,134
49,304
$61,843
$506,339
4,372
4,308
51,627
$60,307
$290,444
9,777
11,442
100,931
$122,150
$796,783
336
374
3,465
4,175
24,772
317
375
4,284
4,976
18,651
653
749
7,749
9,151
43,423
of the citizens. Although, casino gaming floors
were exempted from the restrictions, essentially
all other workplaces were made smoke free.
Reviews of national data show that smoking
bans in public places and workplaces are significantly associated with a reduction in heart attacks.58 59
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Bombard J et al. State-specific prevalence of current cigarette smoking among adults – United States, 2003. MMWR
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Stewart SL et al. Surveillance for cancers associated with
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Anthonisen NR et al. The effect of a smoking cessation
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Tverdal A, Bjartveit K. Health consequences of reduced
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26
Jatoi NA et al. Impact of smoking and smoking cessation
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Chari R et al. Effect of active smoking on the human
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Christakis NA, Fowler HJ. The collective dynamics of
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Tauras JA et al. State tobacco control spending and youth
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Franks P. et al. Cigarette prices, smoking, and the poor:
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Halpin HA et al. State medicaid coverage for tobaccodependence treatments – United States, 2005. MMWR Morb
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Boffetta P et al. Smokeless tobacco and cancer. Lancet
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Adhikari B et al. State-specific smoking-attributable mortality and years of potential life lost – United States, 20002004. MMWR Morb Mortal Wkly Rep 2009;58:29-33.
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Fitzgerald K et al. Clinical manifestation of small-forgestational-age risk pregnancy from smoking is gestational
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Page 241 of 294
20. Alcohol Use
Alcoholic beverages have been used in
human societies since the beginning of recorded
history. Alcohol remains socially and legally acceptable in most of the Western world. For most
people who drink, alcohol is a pleasant accompaniment to social activities. When alcohol is
consumed while smoking tobacco it is undoubtedly the most common drug combination used
in the US.1 Moderate alcohol use (up to two
drinks per day for men and one drink per day for
women and older people) is not harmful for most
adults. Nonetheless, a large number of people
get into serious trouble because of their drinking.
Nearly a third of Americans abuse or become
dependent on alcohol over the course of their
lives and only 24% are ever treated for it.2 A history of heavy drinking reduces life span by up to
25 years across all major chronic diseases, according to the National Institute of Alcohol
Abuse, and Alcoholism (NIAAA). During 20012005, an estimated annual 79,646 alcoholattributable deaths and 2.3 million years of potential life lost were attributed to the harmful effects of excessive alcohol use.3
Conversely, abstaining from alcohol use
or using it at a low frequency may lead to increased risk for anxiety and depression.4
Accompanying the near ubiquity of alcoholic beverages in human history has been an
appreciation of the social and health problem
caused by drinking.5 Alcohol has been shown to
be causally related to >60 different medical conditions, in most, but not all cases, detrimentally.6
For most diseases there is a dose-response relation to the volume of alcohol consumption, with
the risk of the disease increasing with higher
intake levels. The exceptions are in the area of
cardiovascular diseases, especially coronary
heart disease and stroke, diabetes, and injuries,
where other dimensions of consumption than
average volume play a crucial role in determining outcome. Drinking of alcohol during preg-
nancy has been reported to raise the risk of
premature births, low birthweight infants, and
infections in babies after birth.7 8 9 At the extreme, prenatal exposure to alcohol can result
fetal alcohol spectrum disorder and its various
component disorders, ie, fetal alcohol syndrome,
alcohol-related birth defects, fetal alcohol effects, and alcohol-related neurological disorders.10
According to the National Institutes of
Health, early alcohol use, independent of other
risk factors, may contribute to the risk of developing future alcohol problems.11 In 2000, alcohol
consumption was the 3rd leading actual cause of
death in this country.12 In purely economic
terms, alcohol-related problems cost society approximately $185 billion per year. Of these
costs, >70% are due to productivity losses and
illnesses attributed to alcohol, while <10% are
for medical treatment of alcoholism and alcohol
abuse.
Alcohol abuse and alcohol dependency
are two negative outcomes resulting from alcohol consumption. Alcohol abuse is defined by
the NIAAA as causing a failure to fulfill major
role obligations at work, school, or home; interpersonal social and legal problems; and/or drinking in hazardous situations, such as driving. Alcohol dependence (alcoholism) is characterized
by impaired control over drinking, compulsive
drinking, preoccupation with drinking, tolerance
to alcohol and/or withdrawal symptoms. The
brain pathology induced by a history of dependence has three key features: 1) a history of dependence established through repeated cycles
of excessive alcohol intake and withdrawal leads
to long lasting, perhaps lifelong pattern of excessive alcohol intake; 2) an equally persistent
increase in responses to fear and stress; and, 3)
while stress does not affect voluntary alcohol
intake, it does so potently in individuals with a
history of dependence.13
ALCOHOL USE
Page 242 of 294
Alcohol dependence contributes to other
health problems and thereby increases the use
of health care services. Between 15-30% of patients in acute care hospitals have alcohol problems, regardless of their admitted diagnosis.
Unfortunately, only a fraction of these alcohol
diagnoses are reflected in discharge diagnoses.
In addition, the families of alcoholics consume
more health care services than do those of nonalcoholics.
Workplace alcohol use and impairment
directly affect an estimated 15% of the US workforce (19.2 million workers).14 Specifically, an
estimated 1.83% (2.3 million workers) drink before work, 7.06% (8.9 million workers) drink during the workday, 1.68% (2.1 million workers)
work under the influence of alcohol, and 9.23%
(11.6 million workers) work with a hangover.
Drinking on the job, being under the influence or
working with a hangover is more prevalent
among men, younger workers, and unmarried
workers. The highest level of alcohol use and
impairment are found in management, sales,
catering, and construction.
Alcohol and drugs were ranked by Kansas Citians as the 2nd leading community concern in a survey conducted in 2003 by the Kansas City Health Commission; health care providers ranked this as the leading community concern.15
Prevalence
National 2004 data showed that about
47% of adult >18 years old regularly drink alcohol, 13% are infrequent drinkers, and 25% are
lifetime abstainers.16 For 2008, the Substance
Abuse and Mental Health Services Administration (SAMHSA) reported that 51.6% of person
>12 years of age were current consumers of
alcohol.17
Men are about 1.5 times more likely to
be a regular drinker than women and the prevalence of drinking declines with increasing age,
although the gap between men and women is
ALCOHOL USE
decreasing.18 19 Non-Hispanic whites are more
likely to be a current drinker and Asians are the
most likely to be lifetime abstainers. Hispanics
and non-Hispanic blacks are twice as likely to be
lifetime abstainers as non-Hispanic whites. The
Missouri Behavioral Risk Factor Surveillance
System (BRFSS) 2007 annual report found that
adults in the Kansas City area were less likely to
drink alcohol than residents in the St Louis area.
Recent data from the Framington Heart
Study found that the proportion of abstinence
increased and average consumption among
drinkers declined with age.20 Further, the proportion of moderate use was higher, but heavy use
was lower, among younger adults than older
adults. Also, beer consumption has been decreasing over the last 50 years while drinking
wine has increased. Despite these findings, the
cumulative incidence of alcohol use disorders
did not decrease.
According to the National Center for
Health Statistics’ 2007 National Health Interview
Survey (www.cdc.gov/nchs) 20.3% of adults had
>5 drinks in 1 day at least once in the past year.
For both men and women, younger adults were
more like to behave in this manner, with men
considerably more likely to do so than women.
Non-Hispanic white adults had an age-adjusted
rate of 24.0%, Hispanic adults 16.7%, and nonHispanic black adults 11.6%. The prevalence of
this behavior also seems to correlate with sleep
deprivation with persons who got less sleep having higher rates and is most notable among men
and younger adults.
Nearly 16 million Americans >12 years
old meet the criteria of the American Psychiatric
Association for alcohol abuse and dependence.
Dependency often begins prior to 18 years of
age.21 Several million more adults engage in
risky drinking that could lead to alcohol problems. These patterns include binge drinking and
heavy drinking on a regular basis. In addition,
more than half of adults report that one or more
of their close relatives have a drinking problem.
Nearly 4% of Missourians >12 years of age are
Page 243 of 294
dependent upon alcohol.22 In a 2004 telephone
survey commissioned by the Kansas City Health
Department, 1.6% of respondents reported that
they abused alcohol.23
Underage drinking
Although there are legal age limits for alcohol purchase and consumption, it is clear that
many persons become current drinkers at earlier
ages. Between 40% and 50% of high school
students in Missouri and Kansas City claim to be
current drinkers of alcohol,24 with little difference
between males and females (Table 20-1). Most
had their first drink when 12-14 years old, although 25% of boys claim they were <11 years
of age. Among students who did not drink, the
overwhelming reason for not drinking was that
they did not want to drink, followed by the idea it
is wrong; religious beliefs was the least mentioned reason for abstaining.
Boys report drinking more to get drunk
and girls drink more for social reasons; almost
half of the students report frequently being
around drunken peers. And, binge drinking is the
most common pattern of alcohol consumption
among high school youth with no difference by
sex.25 26 About 30% of high school students
binge drink.27
According to Columbia University’s National Center of Addiction and Substance Abuse,
underage drinkers and adult excessive drinkers
are responsible for 50.1% of the alcohol con-
sumption in this country and 48.9% of the money spent on alcohol. In 1999, underage drinkers
consumed 19.7% of the alcohol nationally or
$22.5 billion worth of alcohol. “Excessive” drinking by adults (consumption of >2 drinks daily)
accounted for 30.4% of the alcohol consumed or
$34.4 billion worth of alcohol expenditures.
While there have been calls to lower the
legal drinking age from 21 years, there are data
showing that in states which historically had
lower drinking ages there is an association with
pregnancy complications.28 A drinking age of 18
was associated with higher incidences of unplanned pregnancies, low birthweight, and premature birth.
Binge drinking
Binge drinking is defined as >5 drinks on
the same occasion at least once in the prior
month and it is estimated that about 23% of
drinkers binge (www.samhsa.gov) and is growing at a faster rate among underage girls than
boys.29 Binge drinking is not confined to young
drinkers. Data from the National Survey on Drug
Use and Health show that 22% of men and 9%
of women ages 50-64 years old engage in binge
drinking.30 Among women in their 20s, binging is
more common among higher educated women,
but by age 40 less-educated women are more
likely to be drinking too much.31 Binge drinking
among women has been reported to double their
risk of breast cancer.32 And, binge drinking has
been strongly associated
with alcohol-impaired driving.33 Adult binge drinkers
Table 20-1 Consumption of at least part of one drink by students
tend to prefer beer, while
in the Kansas City metropolitan area
youth binge drinkers tend
Frequency
8th grade
10th grade
12th grade
to use hard liquor.34
Lifetime
59%
75%
85%
Approximately a
30 day
47%
59%
68%
7 day
23%
32%
41%
quarter of drinkers in MisMale
Female
Male
Female
Male
Female
souri binge drink with the
30 day
46%
49%
61%
56%
70%
66%
highest prevalence being
7 day
23%
22%
37%
28%
46%
36%
Source: Partnership for Children. 2006. Kauffman Teen Survey Community Report, 2004-2005
among those 18-25 years
Results. www.pfc.org
old (~47%)
ALCOHOL USE
Page 244 of 294
(www.oas.samhsa.org). In 2001, the number of
binge drinking episodes per person per year was
between 7.9 and 12.3,35 placing Missouri among
the highest states for this behavior. According to
the 2007 BRFSS report for Missouri, the prevalence of adult binge drinking was 16.2% (20.5%
for males; 12.2% for females), while in the Kansas City region the prevalence rates were 22.9%
and 10.9%, respectively. The national youth risk
behavior surveillance program reported that
30.5% of Missouri high school student periodically binge drink.
In addition to binge drinking, there is
heavy drinking which is defined as an average of
>2 drinks/day during the preceding month for
men and an average of >1 drink per day during
the preceding month for women. The prevalence
of heavy drinking among men in the Kansas City
BRFSS region was 5.2% and among women it
was 6.0%. Heavy drinking has been associated
with causing high blood pressure, stiff arteries,
and rigid heart muscles in men and enlarged
hearts in women, boosting their risk of heart attack and/or stroke.
Smoking, while drinking, may encourage
individuals to drink more.36 In rats, the level of
alcohol in the bloodstream falls as nicotine levels increase. It is hypothesized that somehow
the presence of nicotine delays the release of
alcohol from the stomach to the intestines. This
delay allows the alcohol molecules to be metabolized, leaving less alcohol to be absorbed by
the intestines into the bloodstream. Thus, in
people nicotine would diminish the desired effect
of the alcohol and would encourage drinkers to
drink more to achieve the pleasurable desired
effect, particularly among heavy and binge
drinkers.
Health consequences
In Kansas City, during 2007, there were
604 emergency department visits and 413 hospitalizations for alcoholism, plus 36 emergency
department visits and 261 hospitalizations for
ALCOHOL USE
Figure 20-1 Age-adjusted rates per
100,000 population for hospitalization due
to alcoholism, Kansas City, Mo
324.7
238.4
174.9
117.5 115.6 114.7
88.3
94.3
2000 2001 2002 2003 2004 2005 2006 2007
alcoholic cirrhosis. The age-adjusted hospitalization rates due to alcoholism decreased 71.0%
between 2000 and 2007 (Figure 20-1) and the
age-adjusted deaths rates fluctuate with no clear
trend (Figure 20-2). The proportion of alcohol
Figure 20-2 Age-adjusted alcohol related
death rates per 100,000 population, Kansas City, Mo
15
16
15
14
12
15
11
11
Year 2010 objective is 4 alcohol-related deaths per 100,000
population
2000
2001
2002
2003
2004
2005
2006
2007
related deaths is highest persons 45-64 years
old (Figure 20-3).
Injury is the leading cause of visits to
emergency departments in Kansas City and it
well established that there is a relationship between drinking and injuries. A recent study suggested that 2-6% of all injuries that are seen in
emergency departments can be attributed to
drinking alcohol prior to incurring the injury.37 For
violence related injuries, 43% were attributed to
Page 245 of 294
Figure 20-3 Age-distribution of alcohol
related deaths, Kansas City, Mo, 2007
16
11
12
6
0
0
15-24
25-34
0
35-44
45-54
55-64
65-74
75-84
drinking before the injury.
Driving under the influence
category of drivers to show an increase; the age
groups with the highest rates of alcohol involvement were those 30-39 and 40-49 years old.
Three-fourths (75%) of drivers with alcohol in
fatal crashes had blood alcohol concentration
(BAC) levels of 0.10 or 0.11 which is greater
than the legal limit in all States and the District of
Columbia. Without respect to age, motorcycle
operators with alcohol in fatal crashes had a
lower median BAC level than other vehicle type
operators.
According to the NIAAA, the prevalence
of driving after drinking has been declining, most
significantly among persons 18-29 years old,
although 22 and 23 year olds still had the highest prevalences of 11.5% and 10.4%, respectively. Overall, 11.9% of binge drinkers nationwide drive within 2 hours of their binge drinking
episode.40 There was no decline in this behavior
among females and among college students.41
SAMHSA reported that 21% of drivers
<21 years old had driven in the past year while
under the influence of alcohol or illicit drugs.42
Non-Hispanic whites and Native Americans
were more likely to report this behavior, as were
males. In addition, 44% of 16-20 years olds had
used alcohol in prior month, 30% were binge
drinkers, and 10% were heavy drinkers. The
prevalence of DUI in this age group was highest
in the Midwest (approximately 25% of drivers
Driving under the influence (DUI) of alcohol is both a safety and public health problem;
about 12% of adults in the US drove DUI during
the past year.38 Over 80% of the people involved
in DUI episodes had been binge drinking. Binge
drinkers were >13 times more likely to DUI than
people who drank alcohol but did not binge
drink. Over half of DUI episodes involve moderate drinkers. In 2008, the Kansas City Police
Department issued 1,639 violations for DUI.39
Males comprised 79.3% of the violators and the
age distribution of all the violators is shown in
Figure 20-4.
The National Highway TrafFigure 20-4 Age distribution of 1,639 driving while under
fic Safety Administration
the influence of alcohol violators, Kansas City, Mo, 2008
(www.nhtsa.dot.gov) reports that in
(source: Kansas City Police Department )
2007, an estimated 12,998 people
618
were killed in alcohol-impaired driving crashes – a decline of 3.7%
from the 13,491 fatalities in 2006.
352
Persons in the 20-29 and 30-39
314
year age groups are those with the
213
highest rates of alcohol involvement
for drivers of passenger cars, SUVs,
64
51
12
12
pickups, and vans. However alco3
0
hol-impaired motorcycle riders in=<15 16-17 18-19 20-24 25-34 35-44 45-54 55-64 65-74 =>75
creased by 10% in 2007 – the only
ALCOHOL USE
Page 246 of 294
Table 20-2 Motor vehicle accidents in
which alcohol was involved, Kansas City,
Mo, by county, 20061
Portion of Kansas City
Crashes
Fatalities
Injuries
1
Total
crashes
Clay
Jackson
Platte
601
18
238
114
2
44
440
15
177
47
1
17
From Missouri State Highway Patrol, 2006 Missouri Traffic
Safety Compendium
<21 years of age).
The 2003 Youth BRFSS report showed
that 14.9% of Missouri high school students had
driven after drinking alcohol and that 31.7% had
ridden with a driver who had been drinking.
Missouri does not have an open container law. Currently, only the driver of a vehicle
is prohibited from drinking alcoholic beverages
in a moving vehicle. Missouri’s permissible blood
alcohol level for drivers is 0.08%. During 2008,
4.9% of all traffic accidents in Missouri and
28.6% of all fatal crashes were alcohol related.43
In addition to the 262 persons killed, another
4,511 were injured in alcohol-related accidents.
Among Missouri counties in 2006, Jackson ranked 2nd in alcohol related crashes, with
Clay tied at 6th and Platte ranked 13th. Kansas
City ranked 1st in alcohol related crashes among
municipalities. Table 20-2 summarizes alcohol
related motor vehicle crashes in Kansas City
during 2006.
4
Skogen JC et al. Anxiety and depression among abstainers
and low-level alcohol consumers. The Nord-Trøndelag
Health Study. Addiction 2009;104:1519-1529.
5
Room R et al. Alcohol and public health. Lancet
2005;365:519-530.
6
Rehm J et al. The relationship of average volume of alcohol
consumption and patterns of drinking to burden of disease.
Addiction 2003;98:1209-1228.
7
Dew PC et al. The effect of health compromising behaviors
on preterm births. Matern Child Health J 2007;11:227-233.
8
Okah FA et al. Term gestation low birth weight and health
compromising behaviors during pregnancy. Obstet Gynecol
2005;105:543-550.
9
Gauthier TW et al. Maternal alcohol abuse and neonatal
infection. Alcoholism Clin Exper Res 2005;29:1035-1043.
10
Wattendorf DJ et al. Fetal alcohol spectrum disorders. Am
Fam Pract 2005;72:279-282, 285.
11
Hingston RW et al. Age at drinking onset and alcohol
dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med 2006;160:739-746.
12
Mokdad A et al. Actual causes of death in the United
States, 2000. J Am Med Ass 2004;291:1238-1245.
13
Heilig M. Triggering addiction. The Scientist
2008;22(12):30.
14
Frone M. Prevention and distribution of alcohol use and
impairment in the workplace: a US national survey. J Studies
Alcohol 2006;67:147-156.
15
Kansas City Health Department. Mobilizing for Action
through Planning and Partnerships: Kansas City Community
Health Assessment. 2004. www.kcmo.org/health.
16
National Center for Health Statistics. Summary health
statistics for US adults: National Health Interview Survey,
2004. Vital Health Stat Series 2006;10(228).
www.cdc.gov/nchs
17
Literature cited
Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use
and Health: National Findings. www.oas.samhsa.gov
1
Martin CS. Timing of alcohol and other drug use. Alcohol
Res Health 2008;31:96-99.
2
Hasin DS et al. Prevalence, correlates, disability, and comorbidity of DSM-IV Alcohol Abuse and Dependence in the
United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64:830-842.
3
Centers for Disease Control and Prevention. Alcoholrelated disease impact (ARDI). 2008.
www.cdc.gov/alcohol/ardi.htm
ALCOHOL USE
18
Schoenborn CA et al. Health behaviors of adults: United
States 1999-2001. National Center for Health Statistics, Vital
Health Stat Series 2004;10(219). www.cdc.gov/nchs
19
Grucza RA et al. Secular trends in lifetime prevalence of
alcohol dependence in the United States: a re-evaluation.
Alcohol Clin Exper Res 2008;32:763-770.
20
Zhang Y et al. Secular trends in alcohol consumption over
50 years: the Framingham Study. Am J Med 2008;121:695701.
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21
Hingston RW et al. Age of alcohol-dependence onset:
associations with severity of dependence and seeking treatment. Pediatrics 2006;118:e755-e763.
22
Wright D, Sathe N.. State estimates of substance use from
the 2003-2004 National Surveys on Drug Use and Health.
Substance Abuse and Mental Health Services Administration. 2006. www.oas.samhsa.org
23
Survey. www.kcmo.org/health
24
37
Cherpitel CJ et al. Attributable risk of injury associated with
alcohol use: cross-national data from the Emergency Room
Collaborative Alcohol Analysis Project. Am J Public Health
2005;95:266-272.
38
Substance Abuse and Mental Health Services Administration. Results from the 2008
National Survey on Drug Use and Health: National Findings.
http://oas.samhsa.gov
39
Kansas City, Missouri, Police Department. Annual Report
2008. www.kcmo.org
Grunbaume JA et al. Youth risk behavior surveillance –
United States, 2003. MMWR Morb Mortal Surveil Summ
2004;53:SS-2.
Naimi TS et al. Driving after binge drinking. Am J Prev
Med 2009;37:314-320.
25
41
Miller JW et al. Binge drinking and associated health risk
behaviors among high school students. Pediatrics
2007;119:76-85.
26
reported by adolescents aged 12-17 years; United States,
www.cdc.gov/nchs
27
Roeber J et al. Types of alcoholic beverages usually conth
th
sumed by students in 9 -12 grades – four states, 2005.
40
Hingson R et al. 2005. Magnitude of alcohol-related mortality and morbidity among US college students ages 18-24:
changes from 1998 to 2001. Annual Rev Public Health
26:259-279.
42
Substance Abuse and Mental Health Services Administration. Driving under the influence (DUI) among young persons. The NSDUH Report 12/3/04. www.oas.samhsa.gov.
43
Missouri State Highway Patrol. Missouri Traffic Crashes,
2009 edition. www.mshp.dps.missouri.gov
28
Fertig AR, Watson T. Minimum drinking age laws and
infant health outcomes. J Health Econ 2009;28:737-747.
29
Center on Alcohol Marketing and Youth. Underage Age
Drinking in the United States, 2005: a Status Report. Georgetown University. 2006. www.camy.org
30
Blazer DG, Wu LT. The epidemiology of at-risk and binge
drinking among middle-aged and elderly community adults:
National Survey on Drug Use and Health. Am J Psychiatry
2009;17 August [epub ahead of print].
31
Jefferis B et al. Social gradients in binge drinking and
abstaining trends in a cohort of British adults. J Epidemiol
Community Health 2007;61:150-153.
32
Morch L et al. Drinking patterns and mortality among Danish nurses. Eur J Clin Nutr 2008;62:817-822.
33
Naimi TS et al. Binge drinking among US adults. J Am
Med Assoc 2003;289:70-75.
34
Naimi TS et al. What do binge drinkers drink? Implications
for alcohol control policy. Am J Prev Med 2007;33:188-193.
35
Nelson DE et al. Metropolitan-area estimates of binge
drinking in the United States. Am J Public Health
2004;94:663-671.
36
Parnell SE et al. Nicotine decreases blood alcohol concentrations in adult rats: a phenomenon potentially related to
gastric function. Alcoholism: Clin Exper Res
2006;30:1408-1413.
ALCOHOL USE
Page 249 of 294
21. Drug Use
According to the National Drug Intelligence Center, the Kansas City metropolitan
area is a significant consumer market for illicit
drugs with excellent transportation resources.1 It
serves as a major shipping point for drugs and
money to narcotics markets throughout the nation. Employer drug testing programs reveal that
Kansas City has a higher positivity rate for amphetamines (80%), cocaine (30%), marijuana
(60%), opiates (20%), and PCP (900%) than
national averages (Kansas City Star 7/20/08
A1).
Prevention lists illicit drug use as the 10th leading
actual cause of death in the US and the 2nd leading cause of accidental deaths. In 2008, an estimated 8.0% of the population >12 years of age
were current illicit drug users.2
Surveys by the Substance Abuse and
Mental Health Services Administration (SAMHSA) indicate that marijuana was the most commonly used illicit drug (75.7%). An estimated
19.6% of unemployed adults >18 years old were
current illicit drug users compared to 8.0% of
full-time and 10.2% of part-time workers. Overall, most illicit drug users (72.7%) were employed. Rates of drug use are associated with
age. The rates of current illicit drug use among
youth and young adults increased with age being the highest among persons aged 18 to 20
and then declined among adults with increasing
age. Males were about twice as likely to use marijuana as females, although among adolescents
the percentages are fairly similar.3 In addition,
SAMHSA reported that 12.3% of current drivers
18 to 25 years of age, in the past year, drove
while under the influence of illicit drugs.
In recent years, the trends in drug use
have become more complex, and thus more difficult to describe.4 A major reason for this increased complexity is that cohort effects have
emerged, beginning with the increases in drug
use that occurred during the early 1990s. “Cohort effects” refer to lasting differences between
class cohorts that stay with them as they advance through school and beyond. These effects
result in the various grades reaching peaks or
valleys in different years, and thus the various
age groups are sometimes moving in different
directions at a given point in history.
Because drug use usually begins during
adolescence, the National Institute on Drug
Abuse sponsors a program known as Monitoring
the Future which is based on a series of surveys
examining the behaviors, attitudes, and values
of secondary school students, college students,
and young adults up to age 45 years old towards
drugs and their use. At the core of Monitoring
the Future is a series of annual surveys of adolescents. In the Kansas City area, similar surveys of adolescents are no longer conducted.
According to Monitoring the Future,
males to have somewhat higher rates of illicit
drug use than females (particularly, higher rates
of frequent use), and much higher rates of steroid use. These differences appear to emerge as
students grow older. In 8th grade, females actually have higher rates of use for some drugs.
Contrary to popular assumption, at all grade levels, black students have substantially lower
rates of use of most licit and illicit drugs than do
whites.
In Missouri, the prevalence of the use of
illicit drugs in the prior month is approximately
8%, with 1.9% of the population >12 years of
age being illicit drug dependent and 3% being
dependent or an abuser.5 Each year, about 2%
of Missourians >12 years of age try marijuana
for the first time. For the period 1999-2001, the
northwestern counties of Missouri were reported
to have an estimated 5% of the population being
current marijuana users and to have an average
DRUG USE
Page 250 of 294
annual rate of 1.5% for first use of
Table 21-1 Percentage of drug-related emergency departmarijuana.6 For the counties emment visits nationally, based on DAWN, 2006
bracing the Kansas side of the
Drug
Percentage
Illicit drug only
31%
Kansas City metropolitan area, the
Pharmaceuticals only
28%
current usage rate was estimated
Alcohol only
7%
at 4.7% and 2% for first use. A
Alcohol plus pharmaceuticals
10%
Illicit drug plus alcohol
13%
telephone survey in 2004 commisIllicit drug plus pharmaceuticals
8%
sioned by the Kansas City Health
Illicit drug plus pharmaceuticals plus alcohol
3%
Department had 1.1% of respondents reporting use of illicit drugs.7
In 2007, the Kansas City Police
Figure 21-1 Rates per 10,000 population of
Department made 5,431 arrests for narcotics.
emergency department visits and hospitalizations that were drug-related, Kansas City, Mo
and hospitalization
SAMHSA’s Drug Abuse Warning Network (DAWN) 2006 data estimated that, nationally, over 1.7 million emergency department
visits were drug-related visits and that 56% were
associated with use of one or more illicit drugs
(Table 21-1).8 Cocaine was involved in 57% of
illicit drug related emergency department visits;
marijuana was the next most common reason
(30%). A DAWN case is defined as any emergency department visit related to recent drug
use, including use of drugs plus alcohol, or alcohol alone in persons <21 years of age.
In Kansas City, the rate of emergency
department visits due to drug abuse remained
stable between 2000 and 2007, while the rate of
hospitalization decreased 84.3% (Figure 21-1).
The rates for emergency department visits for
both non-Hispanic whites and non-Hispanic
blacks varied over the 7 year period (Figure 212). And, although non-Hispanic blacks had a
hospitalization rate 2.1 times higher than nonHispanic whites in 2000, their rates both declined and that for non-Hispanic blacks was only
23% higher in 2007 (Figure 21-3).
DRUG USE
Emergency Dept
14.2
11.1
9.6
10.8
8.8
2000
2001
Hospital
13.0
10.7
11.1
3.3
3.1
2004
2005
11.5
13.0
8.0
5.1
2002
2003
2.3
1.7
2006
2007
emergency department visits by race/ethnicity
that were drug-related, Kansas City, Mo
White, non-Hispanic
29.0
21.9
Black, non-Hispanic
27.8
18.5
16.7
17.4
21.1
22.3
6.6
5.6
7.1
8.5
8.8
7.9
9.4
5.0
2000
2001
2002
2003
2004
2005
2006
2007
Page 251 of 294
hospitalizations by race/ethnicity that were
drug-related, Kansas City, Mo
White, non-Hispanic
Figure 21-5 Age distribution of drug related deaths, Kansas City, Mo, 2007
16
Black, non-Hispanic
17.8
9
13.5
7
6
3
5.3
4.2
4.3
3.2
3.0
2002
2003
8.4
3.3
2.4
2.1
3.0
3.3
2004
2005
2.4
2006
1.7
2007
0
5.9
2000
2001
15-24
Figure 21-4 Age-adjusted drug-related death
rates per 100,000 population, Kansas City, Mo
25-34
35-44
45-54
55-64
=>65
Age (years)
Literature cited
1
National Drug Intelligence Center. Drug Market Analysis
2008: Midwest, High Intensity Drug Trafficking Area.
www.usdoj.gov/ndic
8
9
8
8
9
9
7
5
2
Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use
and Health: National Findings. www.oas.samhsa.gov
3
Healthy People 2010 objective is 1 death per 100,000 population
reported by adolescents aged 12-17 years: United States,
www.cdc.gov/nchs
4
2000
2001
2002
2003
2004
2005
2006
2007
Johnston LD et al. 2006. Monitoring the Future national
results on adolescent drug use; overview of key findings,
2007. National Institute of Drug Abuse.
www.monitoringthefuture.org
5
Deaths
Between 2000 and 2007, the ageadjusted drug-related death rate among Kansas
City residents has remained relatively stable
and, on average, 7.7 times higher than the
Healthy People 2010 objective (Figure 21-4).
Over the years, non-Hispanic blacks were 50%
more likely to have a drug-related death than
non-Hispanic whites. The age distribution of
deaths in 2007 is shown in Figure 21-5.
Wright D, Sathe N. State estimates of substance use from
the 2003-2004 National Surveys on Drug Use and Health.
Substance Abuse and Mental Health Services Administration. www.oas.samhsa.org
6
Substance Abuse and Mental Health Services Administration. Substate estimates from the 1999-2001 national surveys on drug use and health. www.oas.samhsa.gov
7
Survey. www.kcmo.org/health
8
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network 2006: national estimates
of drug-related emergency department visits.
http://DAWNinfo.samhsa.gov .
DRUG USE
Page 253 of 294
22. Suicide
Suicide is defined as a death resulting
from the use of force against oneself when a
preponderance of the evidence indicates that
the use of force was intentional.1 This category
includes deaths of person who intended only to
injure rather than kill themselves, cases of socall “Russian roulette,” and suicides involving
only passive assistance to the decedent (eg
supplying the means or information needed to
complete the act). The category does not included deaths caused by chronic or acute substance abuse without the intent to die or deaths
attributed to autoerotic behavior (eg selfstrangulation during sexual activity). Nearly half
of the suicide-related internet websites provide
advice on “how to” take one’s own life.2
National
Suicide rates in the United States have
declined in recent years, reversing earlier
trends, although there has been an increase in
suicides among whites 40-64 years of age.3 4 In
2007, suicide was the 11th leading cause of
death with 33,185 deaths or 1.4% of all deaths
that year.5 More males committed suicide than
females and the percent of white deaths attributed to suicide was twice that for blacks. Sui-
Figure 22-1 Age-adjusted suicide death
rates per 100,000 population, US, 2005
cides are more likely to occur on Wednesdays
than any other day of the week and are more
likely during summer months than the winter.6
Using national data from 2005,7 the ageadjusted mortality rates are shown in Figure 221. White males had a rate 3.9 times that of white
females (19.7 and 5.0, respectively) while black
males had a rate 4.8 times that of black females
(8.7 and 1.8, respectively). Firearms were used
in 52.1% of suicides, suffocation/hanging in
22.2%, poison in 17.6%, cutting/piercing in 1.8%
drowning in 1.1%, and other methods in 5.2%.
Although suicide rates have been declining, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts during the 1990s despite a dramatic increase in
treatment.8 Among young adults there are significant differences between males and females in
the risk factors for attempted suicide.9 The ageadjusted suicide mortality rate for men has
changed very little over the past 3 decades while
declining fairly consistently among women.
Why people kill themselves is a complex
issue (Figure 22-2), yet, in many cases, it often
can be prevented by early recognition and
treatment of mental disorders; it is often per-
Figure 22-2 Percentage of suicides by selected circumstances (adapted from National
Violent Death Reporting System, 2006).
41.9%
Mental health problem
43.6%
Current depressed mood
10.0
12.4
14.9
16.5
16.9
13.9
16.9
12.6
Physical health problems
0.7
History of suicide attempts
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-74 =>85
31.5%
Intimate partner conflict
Alcohol dependence
22.0%
19.5%
18.0%
Age (years)
SUICIDE
Page 254 of 294
Figure 22-3 Age-adjusted suicide death rates per 100,000 population, Missouri, 1998-2007
Total
20.9
21.4
21.4
22.3
12.5
12.5
12.4
13.0
12.1
5.1
4.8
4.5
4.6
3.9
1998
1999
2000
2001
2002
21.1
ceived as the solution for a one’s depression.10
More than 90% of decedents are reported to
have had a mental or substance abuse disorder,
or a combination of disorders.11 Toxicological
testing indicates that a substantial percentage of
suicide decedents test positive for alcohol or
other drugs, with alcohol being detected in a
third of cases.12 Yet, there is evidence to suggest that non-Hispanic black suicide decedents
are less likely to have had depression than nonHispanic whites13 and that suicide attempts
among blacks are more common than previously
thought.14
In addition to mental and substance
abuse disorders, risk factors include prior suicide attempt, stressful life events and access to
lethal suicide methods. The rate of suicide for
people who had a prior suicide attempt is 100
times higher in the year following the episode
than for the general population. Long term studies show that this increased rate of suicide
persists. In Jackson County, Mo, suicide victims
were 1) more likely to live in houses than were
controls rather than in apartments or trailers, 2)
more likely to live in more expensive homes than
controls, 3) more likely to kill themselves because of factors other than financial strain, and
4) if financial strain was a factor, more likely to
kill themselves after becoming accustomed to a
more affluent lifestyle.15
SUICIDE
Male
Female
22.3
22.5
12.6
13.5
13.5
5.4
4.7
5.6
5.4
2004
2005
2006
2007
19.6
20.7
21.0
12.0
12.6
5.1
2003
Missouri
In 2007, 810 Missourians killed themselves. This was the highest number in the past
10 years (Figure 22-3); males had an ageadjusted death rate 4.4 times higher than females. Firearms were used in 58.6% of suicides,
including 64.1% of those by men and 36.5% of
those by women.
Kansas City
The number of Kansas City residents
who commit suicide is variable year-to-year and
the age-adjusted death rate is typically 2-3 times
higher than the Healthy People 2010 objective of
5.0 deaths per 100,000 population (Figure 22-4).
The age-specific annualized death rates for suicide are shown in Figure 22-5. Tables 22-1 and
22-2 provide the ages of decedents and methods of suicide. The choice of methods is similar to what has been reported nationally and in
Missouri, namely men chose firearms while
women utilized other methods. Non-Hispanic
white males were 60% of suicide decedents between 2003 and 2007 (Figure 22-6).
Page 255 of 294
Figure 22-4 Suicide deaths and age-adjusted death rates per 100,000 population, Kansas City,
Mo
Suicides
Rate
79
69
69
61
53
49
11.1
1998
53
47
64
49
17.4
16.8
14.2
11.8
10.2
12.4
10.4
1999
2000
2001
2002
2003
2004
2005
15.7
14.5
2006
2007
Figure 22-5 Age-specific death rates per 100,000 population by
age group for suicide, Kansas City, Mo, 2003-2007
19.3
20.5
19.2
16.7
15.3
13.3
13.2
11.0
1.9
10-14 y
15-24 y
25-34 y
35-44 y
45-54 y
55-64 y
65-74 y
75-84 y
85+ y
Table 22-1 Suicides by age group and method, Kansas City, Mo, 2003-2007
Age Group
# Suicides
Method of Suicide
% of
Total
5-14 years
3
1.2
15-24 years
40
14.4
25-34 years
35-44 years
40
69
14.4
24.9
45-54 years
58
20.9
55-64 years
65-74 years
75-84 years
>85 years
Total
29
18
14
6
277
10.5
6.5
5.1
5.2
100.0
Frequency
Handgun
Rifle, shotgun &
larger firearm
Other firearms
Self-poisoning
Hanging, strangulation & suffocation
Jumping
All others
Total
% of
Total
76
27.4
45
16.2
15
64
5.4
23.1
50
18.1
10
17
277
3.6
6.1
100
SUICIDE
Page 256 of 294
Table 22-2 Method of suicide by sex and race, Kansas City, Mo, 2003-2007
Method
Handgun
Rifle, shotgun, & larger
firearm
Other firearms
Self-poisoning
Hanging, strangulation, &
suffocation
Jumping
All others
Total
Male
66
Female
10
White,
nonHispanic
54
Black,
nonHispanic
20
Hispanic
0
Asian
0
Native
American
0
Not
listed
2
44
1
36
7
2
0
0
0
13
39
2
25
12
53
2
7
1
2
0
0
0
2
0
0
42
8
35
9
4
1
1
0
10
12
226
0
5
51
4
14
208
6
3
54
0
0
9
0
0
1
0
0
3
0
0
2
Figure 22-6 Percent of suicide deaths by race/ethnicity, Kansas City, Mo, 2003-2007
Other female
Other male
Hispanic female
Hispanic male
Black female,
NH
Black male, NH
White female,
NH
White male, NH
SUICIDE
0.4%
1.8%
0.4%
2.9%
2.2%
17.3%
15.5%
59.6%
Page 257 of 294
Literature Cited
1
Karch DL et al. Surveillance for violent deaths – National
Violent Death Reporting System, 16 states, 2005. MMWR
Morb Mortal Surv Summ 2008;57:SS-3.
2
Biddle L et al. Suicide and the internet. Brit Med J 2008;
336:800-802.
3
Hu G et al. Mid-life suicide: an increasing problem in US
whites, 1999-2005. Am J Prev Med 2008;35:589-593.
4
McKeown RE, Cuffe SP, Schulz RM. US suicide rates by
age group, 1970-2002: an examination of recent trends. Am
J Public Health 2006;96:1744-1751
5
6
Kposowa A, D’Auria S. Association of temporal factors and
suicides in the United States, 2000-2004. Soc Psychiatry
Psychiatr Epidemiol 2009; June 09 [epub ahead of print].
7
Kung HC et al. Deaths: final data for 2005. Natl Vital Stat
8
Kessler RC et al. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 20012003. J Am Med Ass 2005;293:2487-2495.
9
Zhang J et al. Gender differences in risk factors for attempted suicide among young adults: findings from the Third
National Health and Nutrition Examination Survey. Ann Epidemiol 2005;15:167-174.
10
Kansas City Metropolitan Health Council. Depression in
Kansas City. What’s being done and what is needed. 2005.
35 p.
11
Surveil Sum 2009;58:SS-1.
12
Crosby AE, et al. Alcohol and suicide among racial/ethnic
populations --- 17 states, 2005--2006. MMWR Morb Mortal
Wkly Rep 2009;58:637-641.
13
Abe K et al. Characteristics of black and white suicide
decedents in Fulton County, Georgia, 1988-2002. Am J Public Health 2006;96:1794-1798.
14
Joe S et al. Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States. J Am Med
Ass 2006;296:2112-2123.
15
Young TW et al. The Richard Cory phenomenon: suicide
and socioeconomic status in Kansas City, Missouri. J Forensic Sci 2005;50:443-447.
SUICIDE
Page 259 of 294
23. Homicide
Homicide is defined as a death resulting
from the use of force or power, threatened or
actual, against another person, group, or community when a preponderance of evidence indicates that the use of force was intentional. The
National Center for Health Statistics also regards as homicide (a) arson with no intent to
injure a person and (b) a stabbing with intent
unspecified. Excluded are vehicular homicide
without intent to injure, unintentional firearm
deaths, combat deaths or acts of war, and
deaths of unborn fetuses. Homicides can originate from any number of circumstances as
shown by the National Violent Death Reporting
(crude rate of 6.1 deaths per 100,000 population) died as a result of homicide and firearms
were used in 12,352 (68.2%) of these deaths.
The homicide rate for males is more than 3.5
times higher than that for females. And, blacks
account for approximately half of the homicide
decedents.
Age-specific homicide rates are highest
for persons 20-24 years old. The rate for infants
<1 year of age is approximately 4 times that for
children 1-4 years old and similar to that for adolescents 15-19 years of age. Rates are lowest
among children 5-14 years and adults >55 years
old.
Figure 23-1 Percentage of homicides by selected circumstances, adapted from National Violent Death Reporting System, 2006
Other argument
39.3%
Precipitated by another crime
32.0%
Intimate partner conflict
20.1%
Drug involvement
16.0%
Argument over money/property
Jealousy
Brawl
Gang related
7.6%
4.5%
1.9%
4.5%
System (Figure 23-1).1 The majority of homicides are related to interpersonal conflicts.
National
Nationally, homicide is the 15th leading
cause of death overall in the US.2 It is the 2nd
leading cause of death for persons 15-24 years
of age, the 3rd leading cause for persons 25-34
years old, and the 4th leading cause for individuals 1-14 years old.3 In 2005, 18,124 persons
Homicide is the 15th leading cause of infant death in the US. Infants are at greatest risk
for homicide during the first week of infancy and
the first day of life; among homicides during the
first week of life, 83% occur on the day of birth.
The homicide rate on the first day of life is >10
times that during any other time of life. Among
homicides on the first day of life, 95% of victims
are not born in a hospital. The 2nd highest peak
in risk for infant homicide occurs during the 8th
week of life and may be due to a caregiver's
reaction to an infant's persistent crying; infant
HOMICIDE
Page 260 of 294
crying duration peaks at 6-8 weeks of age.
Among homicides during the first week of life,
89% of perpetrators are female, usually the
mother. Mothers who kill their infants are more
likely to be adolescents and have a history of
mental illness.
Figure 23-2 Total homicides recorded in
Kansas City, Mo (source: Kansas City, Mo, Police Department)
127
122 117
114
87
92
126
115
94
89
Missouri
During 2003-2007, 1,949 Missourians
(390 per year) died as a result of homicide. Over
two-thirds (67.9%) of the decedents were residents of just three jurisdictions: Jackson County512 deaths, St Louis City-457 deaths, and St
Louis County-354 deaths. The age-adjusted
death rate for St Louis City was 63% higher than
that for Jackson County which in turn was 52%
higher than that of St Louis County.
Seventy-eight percent of the homicide
decedents were male, with males having an
age-adjusted death rate 3.7 times that of females (10.8 vs 2.9, respectively). Non-Hispanic
blacks constituted 61.7% of the male deaths and
37.3% of the female deaths. Of the homicides
during 2003-2007, 67.5% were firearm related;
73.1% of male decedents were killed by firearms
as were 47.4% of female decedents.
Kansas City
Police statistics
According to the Kansas City Police Department’s 2008 Annual Report (www.kcpd.org)
there were 115 murders and 11 justifiable homicides in Kansas City (Figure 23-2). Of the 126
homicide victims, 88% were male and 75% were
black, 13.5% white, 10.3% Hispanic, 0.8%
Asian. Sixty percent of the victims were 17-34
years old. Firearms were used in 81% of incidents.
Health Department statistics
There is a difference in homicide numbers between those reported by the Police and
HOMICIDE
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Figure 23-3 Number of Kansas City, Mo,
residents who died as the result of homicide
129
110
99
107
99
74
83
82
97
80
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
those reported by the Health Department (Figure
23-3). The Police Department reports on total
homicides that occur within the city limits, while
the Health Department reports on homicides
among Kansas City residents irrespective of
where the homicide occurred. Table 23-1 displays the race/ethnicity breakdown of homicide
decedents during 2007. Of the homicide deaths,
79 occurred among residents of the Jackson
County portion of the City and one occurred in
the Clay County portion.
The age-adjusted death rates for homicide have fluctuated annually as is shown in
Figure 23-4. In 2007, the rate was 5.7 times
higher than the Healthy People 2010 national
objective. In 2007 the average age of death from
homicide was 34.0 years and the median age of
death was 32.0 years. The age distribution of
Page 261 of 294
For the period
2003-2007, homicide
Native
was the leading cause of
American
Total
death among non0
63
Hispanic black men 5-34
1
17
1
80
years of age, the 2nd
leading cause of death
among those 35-44
th
years old, and the 5 leading cause among 4554 year olds.
In 2007, homicide was the 3rd leading
cause of death for Hispanics, and for 20032007, it was the 4th leading cause of death. As
with non-Hispanic blacks, homicide was 1st or
2nd leading cause of death among Hispanic
males.
Among women, homicide was not
among the top 10 leading causes of death overall, either for 2007 or 2003-2007. However, during 2003-2007, it was the 2nd leading cause of
death for 15-24 year old non-Hispanic white
women and 4th leading cause of death for women 25-34 years of age. Among non-Hispanic
black women, homicide was the leading cause
of death among those 15-34 years of age and
the 9th leading cause among 45-54 year olds.
The annualized age-specific infant homimicide rate, for 2003-2007, was 3.1 per 100,000
population which was 62% lower than the rate of
8.3 reported nationally.4
Table 23-1 Homicide deaths among Kansas City, Mo, residents, 2007
White,
nonHispanic
Black,
nonHispanic
Hispanic
Asian
5
6
11
48
7
55
10
2
12
0
1
1
Male
Female
Total
100,000 population due to homicide, Kansas City, Mo
21.7
23.5
21.6
16.2
17.9
21.4
17.8
17.0
Yr 2010 objective is 3 homicides per 100,000 population
2000
2001
2002
2003
2004
2005
2006
2007
Figure 23-5 Distribution by age of 79 homicide deaths among Kansas City, Mo,
residents, 2007
24
19
12
11
6
4
1
0
<5
2
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84
Age (years)
Literature cited
1
Karch DL et al. Surveillance for violent deaths - National
Surveil Sum 2009;58:SS-1.
2
homicide deaths during 2007 is presented in
Figure 23-5.
In 2007, homicide was not among the
10 leading causes of death for Kansas City
dents, although it was the 7th leading cause of
death among males. Among non-Hispanic
blacks it was the 5th leading cause overall.
3
Surv Summ 2008;57:SS-3.
4
Paulozzi L, Sells M. Variation in homicide risk during infancy – United States, 1989-1998. MMWR Morb Mortal Wkly
Rep 2002;51:187-189.
HOMICIDE
Page 263 of 294
24. Intimate Partner Violence
Intimate partner violence (IPV) is a significant public health problem in the US. At some
time in their life, 23.6% of women and 11.5% of
men are victims of IPV.1 Women who suffer from
IPV during their adult lives and their children
seek more mental and other health care than
non-abused women and their children; this includes children whose mothers were abused
before they were born.2 Sexually abused women
experience depression and physical symptoms
that often persist for years once the abuse has
ceased.3
Research indicates that IPV exists on a
continuum from episodic violence (a single or
occasional occurrence) to battering.4 Battering is
more frequent and intensive and involves one
partner who develops and maintains control over
the other. The costs of partner rape, physical
assault, and stalking exceed $5.8 billion each
year, nearly $4.1 billion of which is for direct
medical and mental health care services.5 The
total costs of IPV also include nearly $0.9 billion
in lost productivity from paid work and household chores for victims of nonfatal domestic violence and $0.9 billion in lifetime earnings lost
by victims of IPV homicide. The largest proportion of the costs is derived from physical assault
Figure 24-1 Reported cases of intimate
partner violence reported to the Police
Department, Kansas City, Mo
6,255
victimization because that type of IPV is the
most prevalent. The largest component of IPVrelated costs is health care, which accounts for
more than two-thirds of the total costs. Experiencing IPV is associated with a number of adverse health outcomes and behaviors.6 According to a report at the 2006 Academy of Management meeting, IPV affects the workplace
resulting in nearly $1.8 billion in lost productivity
each year. About 10% of victims experienced
violence within the prior year and, for most, this
led to lessen work productivity. Women who
were victims of IPV lost an average of 249 work
hours to distraction, 40% more than non-victims.
Among men, victims lost 244 hours to distraction, compared to 202 hours for non-victims.
Tardiness and/or absenteeism were 26 times
more likely in recent IPV cases compared to
non-victims.
Internationally, a study of violence
against dating partners among university students found a third were violent with their partner and that women are as likely to as men to be
the perpetrator (www.unh.edu/frl). The most
common pattern of dating violence involves both
partners hitting each other, followed by the female partner being the sole perpetrator, and
least commonly, only the male partner does the
hitting.
It has been reported that young men
who commit intimate partner violence more likely
to engage in more risky sexual behaviors, have
sex with other women, and have fathered 3 or
more children.7
4,897
4829 4933 4,724 4,546
4,254 4,065 4,255
Kansas City
2000 2001 2002 2003 2004 2005 2006 2007 2008
In 2008, there were 6,255 instances of
IPV, including 8 homicides (Figure 24-1).8 A single day survey (10/7/08) of IPV service providers
in the Kansas City metropolitan area, found, that
INTIMATE PARTNER VIOLENCE
Page 264 of 294
at a minimum, IPV services rendered were estimated to have cost the community $47,862 plus
an additional $10,000 for bed-nights.9 Seventyone percent of the services went to persons defined as IPV victims, 22% went to offenders, and
7% went to persons defined as neither victims
nor offenders.
The 2006 Annual Report of the Kansas
City Police Department provides the most recent
detailed information regarding IPV cases. That
year, more than a third of IPV incidents occurred
on a Saturday or Sunday. Almost half of all incidents occurred between 4 PM and 12 AM.
In 45.8% of the cases, the event was
not the first time that the offender committed IPV
against the victim; 0.4% of the victims had previously filed an order of protection against the
offender. Nearly 19% of the offenses were aggravated assault, 80% were non-aggravated
assault, 0.6% involved vandalism, and 1.1%
were robberies. Twenty homicides (0.5% of incidents) resulted, comprising 19.4% of the homicides recorded in the City in 2006. IPV homicide
methods reflect the motivation of the offender
and qualities of the victim-offender relationship.10
In 35% of incidents, the offender and
victim had resided together in the past. Individuals who were not married but living together,
were involved in 14.5% of incidents, while only
13.1% incidents involved spouses and 0.9%
former spouses. In 21.6% of the incidents there
was at least one child in common for the offender and victim. Thirteen percent (13.3%) of incidents occurred between individuals related by
blood and 0.8% by persons related by marriage.
In 2006, the Police recorded the involvement of alcohol and/or drugs for 65.3% and
46.9% of IPV incidents, respectively. For the
2,779 incidents in which information regarding
alcohol was available, 51.5% of reports indicated the absence of alcohol. When alcohol was
involved, 92.7% of offenders, 7.9% of victims,
and 58.3% both offenders and victims had been
drinking. For the 1,999 reports that had informaINTIMATE PARTNER VIOLENCE
tion regarding the presence of drugs, 84.6%
found no drug involvement. When drugs were
recorded, 84.7% had drug use by the offender,
4.2% had use by the victim, and 11.1% had both
parties using drugs.
Nationally, female-to-male IPV was
higher than male-to-female violence, 21% versus 14%, and this was consistent across racial
and ethnic groups.11 The PULSE survey12, conducted by the Kansas City Health Department
and the Lesbian and Gay Community Center of
Greater Kansas City, found a IPV rate of 12% in
the lesbian, gay, bisexual and transgendered
community. The rate was higher among lesbians
(15%) compared to gay men (11%). Among racial and ethnic groups, the percentage of lesbian
and gay victims of IPV was highest among Hispanics (24%), followed by non-Hispanic blacks
(17%), and non-Hispanic whites (11%). Fifty-six
percent of these victims reported multiple attacks in the prior 3 years.
Literature cited
1
Breiding MJ et al. Prevalence and risk factors of intimate
partner violence in eighteen US states/territories, 2005. Am J
Prev Med 2008;34:112-118.
2
Rivara FP et al. Intimate partner violence and health care
costs and utilization for children living in the home. Pediatrics
2007;120:1270-1277.
3
Bonomi AE et al. Health outcomes of women with physical
and sexual intimate partner violence. J Women’s Health
2007;16:987-997.
4
Johnson MP. Patriarchal terrorism and common couple
violence: two forms of violence of against women. J Marriage Family. 1995;57:283-294.
5
National Center for Injury Prevention and Control. Costs of
Intimate Partner Violence Against Women in the United
States. Atlanta (GA): Centers for Disease Control and Prevention; 2003. www.cdc.gov
6
Breiding MJ et al. Chronic disease and health risk behaviors associated with intimate partner violence – 18 US
states/territories, 2005. Ann Epidemiol 2008;18:538-544.
7
Raj A et al. Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men.
Am J Public Health 2006;96:1873-1878.
Page 265 of 294
8
Kansas City, Missouri, Police Department. 2006 Annual
Report. www.kcpd.org.
9
Radakovich R et al. Report on 2008 Domestic Violence
Point-in-Time Survey. April 10, 2009. Kansas City, Missouri,
Health Commission. www.kcmo.org/health
10
Mize KD, Shackelford TK. Intimate partner homicide in
heterosexual, gay, and lesbian relationships. Violence Vict
2008;23:98-114.
11
Caetano R, Cunradi C. Intimate partner violence and depression among whites, blacks, and Hispanics. Ann Epidemiol 2003;13:661-665.
12
Kansas City Health Department , Lesbian and Gay Community Center of Kansas City. The PULSE. A health assessment of the lesbian, gay, bisexual, & transgendered
(LGBT) community in the Kansas City, Missouri, bi-state
metropolitan area. 2004. www.kcmo.org/health.
INTIMATE PARTNER VIOLENCE
Page 267 of 294
25. Infectious and Communicable Disease
Infectious and communicable diseases
are the 6th leading cause of death among Kansas City residents. There is no good estimate of
the number of individuals who contract such diseases through the year or the number of days of
disability (eg, missed days of work or school).
And, the economic impact of communicable and
infectious diseases also is unknown in most
cases.
Since exposure to various communicable and infectious diseases is universal, it was
not surprising that Kansas City residents recognize the importance of protecting the community
against such diseases. The data in Table 25-1
shows the responses of residents to a survey
commissioned by the Kansas City Health Department.1
Table 25-1 Responses of 1,215 residents regarding the importance of various public
health services, Kansas City, Mo, 2003
Public health service
Preventing the spread of
infectious diseases
Protecting the public from
new health threats
Protecting against food
poisoning
Assessing and monitoring
diseases
Very
important
Somewhat
important
90.1%
8.6%
84.9%
11.9%
82.5%
13.7%
77.0%
17.7%
In 2006, the Kansas City Health Department again commissioned a survey of City
residents and inquired about satisfaction with its
services.2 From that survey 67.1% of 1,234 respondents were satisfied with how the Health
Department prevents the spread of infectious
diseases in the community and only 6.2% were
dissatisfied. And, 65% were satisfied with how
the Health Department protects the public from
new health threats; 9% were dissatisfied. When
asked which services should receive the most
emphasis, 80.6% ranked the prevention of infectious diseases as the service the most important
and 78.4% ranked the protection of the public as
the second most important service.
There is a list of reportable diseases
and conditions that legally mandates the reporting of selected diseases to the Division of Communicable Disease Prevention and Public
Health Preparedness of the Kansas City Health
Department. That list can be accessed on the
Health Department’s web site,
http://www.kcmo.org/health. Although physicians
and laboratories are required to file these reports, the completeness of reporting is highly
variable for each disease. In Kansas City, laboratory reporting is more complete and timely than
physician reporting.
Table 25-2 lists by year the number of
cases and the case rates per 100,000 population for a select number of reportable infectious
and communicable diseases in Kansas City for
the time period 2004-2008; a more comprehensive listing can be found in the Health Department’s annual report located on the web site
www.kcmo.org/health. The annual case counts
for most diseases listed in Table 25-2 represent
what is termed ‘endemic’ or normal levels for the
community. While some diseases have exhibited
a downward trend, eg gonorrhea, others have
remained relatively stable, eg Escherichia coli
O157:H7, and others have increases, eg hepatitis B. Many factors contribute to increases or
decreases in the number of cases in the community.
The Healthy People 2010 national objectives address some infectious and communicable diseases; these rates have more relevance at the state level than at the level of cities.
For some diseases, Kansas City is already below the national target level while for others,
such as gonorrhea, it is doubtful that the City
can ever reach the 2010 objective (Table 25-3).
INFECTIOUS & COMMUNICABLE DISEASES
Page 268 of 294
Table 25-2 Cases and rates per 100,000 population* for selected infectious and communicable diseases, Kansas City, Mo
2008
Disease
Campylobacter
Chlamydia
Cryptosporidium
Escherichia coli O157:H7
Gonorrhea
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Influenza
Meningitis, meningococcal
Pertussis
Salmonellosis
Shigellosis
Syphilis, P&S
Tuberculosis
West Nile
2007
Rate
Cases
Rate
Cases
Rate
50
4,735
16
2
2,065
3
54
405
132
2,323
3
6
42
8
62
18
1
11.3
1,071.7
3.6
0.5
467.4
0.7
12.2
91.7
29.9
525.8
0.7
1.4
9.5
1.8
14.0
4.1
0.2
40
4,279
21
5
2,264
1
41
311
139
1,009
2
6
47
1
102
20
9
9.1
968.5
4.8
1.1
512.4
0.2
9.2
69.5
31.5
228.4
0.5
1.4
10.6
0.2
23.1
4.5
2.0
36
4,057
38
0
2,366
6
33
348
148
1,227
2
24
51
28
81
24
5
8.1
918.8
8.6
0.0
535.8
1.4
5.4
78.3
33.5
277.9
0.5
5.4
11.6
6.3
18.3
5.4
1.1
Cases
Rate
Cases
Rate
36
4,215
6
2
2,420
3
39
279
117
820
5
29
46
349
61
24
1
8.2
954.6
1.4
0.4
548.1
0.7
8.8
63.2
26.5
185.7
1.1
6.6
10.4
79.0
13.8
5.4
0.2
32
4,385
7
2
2,567
1
15
223
122
141
1
40
34
11
23
21
8
7.2
993.1
1.6
0.4
581.4
0.2
3.4
50.5
27.6
31.9
0.2
9.0
7.7
2.5
5.2
4.7
1.8
2005
Disease
Campylobacter
Chlamydia
Cryptosporidium
Escherichia coli O157:H7
Gonorrhea
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Influenza
Pertussis
Salmonellosis
Shigellosis
Syphilis, P&S
Tuberculosis
West Nile
2006
Cases
2004
Sexually transmitted diseases
Among sexually transmitted diseases,
reported gonorrhea cases averaged 2,336 between 2004 and 2008 which is less than half the
5,000-7,000 cases per year reported through the
1980s. There were 2,065 cases among residents in 2008. In 2007, the last year for which
national statistics are available, Kansas City accounted for 61.5% of the gonorrhea reported in
the Kansas City MO-KS metropolitan statistical
area. Also, in 2007, Missouri ranked 8th in the
incidence of gonorrhea. The federal government
no longer provides a ranking by cities; instead it
lists gonorrhea by counties and independent
cities. Thus, in 2007, Jackson County was the
21st worst out of 69 jurisdictions for gonorrhea
while St Louis City was ranked 20th. In 2008,
59.4% of the reported gonorrhea cases in Missouri came from St Louis City and Kansas City.
Meanwhile, the increasing trend in reported cases of chlamydia infections appears to
have leveled off between 2004 and 2008, averaging 4,334 cases annually. As with gonorrhea,
Missouri ranked high among the states (16th)
being above the national average. Among counties and independent cities, Jackson County
ranked 39th out of 52 jurisdictions and St Louis
City ranked 50th. In 2007, Kansas City ac-
Page 269 of 294
recent transmission patterns.
Another important indicator related to
syphilis is the occurrence of cases of congenital
syphilis. Between 2004 and 2008, Kansas City
recorded no congenital cases of syphilis.
Table 25-3 Infection rates in Kansas City
and Healthy People 2010 national objectives
Disease
Campylobacter
Escherichia coli
O157:H7
Gonorrhea
Hepatitis A
Listeria
Salmonellosis
Syphilis, primary &
secondary
Tuberculosis
Ave Rate for
2002-2006
Yr 2010 Objective
7.7
12.3
0.7
1.0
542.3
1.1
0.09
19.0
4.5
0.25
0.5
1.0
9.6
6.8
12.8
0.2
5.2
1.0
HIV infections
The effectiveness of current therapies in
controlling the progression of HIV infection towards death and in reducing hospitalizations
from the disease is reflected in Figures 25-1
through 25-3. The distribution of cases among
males by race/ethnicity is shown in Figure 25-4.
HIV remains largely a disease of men-whohave-sex-with-men.
counted for 51.2% of the chlamydia reported in
the Kansas City MO-KS metropolitan statistical
area.
In 2007, Missouri ranked 14th among
states for reported cases of primary and secondary (P&S) syphilis with 239 cases of which
102 (42.7%) were among Kansas City residents.
Figure 25-1 Age-adjusted death rates per 100,000 population due to HIV, Kansas City, Mo
26.6
27.6
26.4
24.3
18.7
17.2
8.8
1991
1992
1993
1994
1995
1996
1997
9.3
1998
The two cities, Kansas City and St Louis City,
accounted for 54.7% of the P&S syphilis in the
state during 2008. Nationally, in 2007, among
counties and independent cities Jackson County
ranked 27th out of 61 jurisdictions and St Louis
City ranked 48th. While P&S syphilis cases do
not include all reported cases of syphilis in a
community, they represent the best indicator of
6.9
1999
8.4
2000
7.1
2001
9.1
8.9
5.5
4.1
2002
2003
2004
2005
5.4
6.0
2006
2007
Figure 25-2 HIV-related deaths by age,
12
6
4
2
1
1
15-24 y 25-34 y 35-44 y 45-54 y 55-64 y 65-74 y
Page 270 of 294
Of the infectious and communicable diseases, TB is the one most affected by the
changing demography of the community. Fortyfour percent of TB cases in Kansas City residents since 2004 were among the foreign-born
(Figure 25-6). Nationally, the percentage of cases of TB among the foreign-born has been steadily increasing over the past decade.3 In 2008,
the case-rate of TB among the foreign-born in
the US was 10 times higher than that of persons
born in this country.4
Figure 25-3 Age-adjusted hospitalization
rates for HIV, Kansas City, Mo
60.4
49.8
2000
2001
43.8
2002
41.8
2003
41.3
2004
36.4
33.6
34.9
2005
2006
2007
Figure 25-4 HIV diagnoses among men, Kansas City, Mo
100%
White Males
80%
Non-white Males
60%
40%
20%
0%
Tuberculosis
Tuberculosis (TB) control in the United
States is a public health success story (Figure
25-5 and Table 25-4). The Kansas City Tuberculosis Sanitarium, a 250 bed facility which opened
on Christmas Day 1915, was shut down in mid1964. That year there were 199 cases of active
TB among City residents and by 2008 there
were only 18 cases.
The fact that 11% of tuberculosis cases
occur among the homeless is not unexpected.
The communal nature of shelters, the limited
use of medical care, and other behaviors all contribute to the transmission of the bacteria that
cause tuberculosis, as well as the activation of
latent tuberculosis infections into clinical disease.
Figure 25-5 Tuberculosis cases among Kansas City, Mo, residents
400
350
300
250
200
150
100
50
0
50
60
70
80
90
00
08
Page 271 of 294
Table 25-4 Tuberculosis cases among
Kansas City, Mo, residents, 1950 to
present
Year
00
01
02
03
04
05
06
07
08
09
1950
357
262
252
293
265
270
288
250
254
259
1960
214
224
229
199
207
234
181
143
108
129
Decade
1970
1980
142
63
104
56
89
42
93
43
118
48
105
54
89
49
54
61
77
44
51
39
1990
37
34
21
40
40
43
51
39
39
42
Table 25-6 Animal bites per 100,000 Kansas City, Mo, residents
2000
43
32
28
26
21
24
24
20
18
Figure 25-6 Tuberculosis in Kansas City,
Mo, 2004-2008
Foreign-born
47, 44%
48, 45%
Homeless
Balance
12,
11%
Rabies and animal bites
Animal rabies cases in Kansas City occur sporadically and, since 1980, almost exclusively involve bats (Table 25-5). The last known
human case of rabies in the City occurred in
1933, while the most recent case in Missouri
occurred in November 2008 in a resident of
Table 25-5 Rabies in Kansas City, Mo
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
Total
Bat
Cat
1
1
2
1
1
5
1
Other
Year
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Bat
1
1
1
3
4
10
Cat
Other
Year
Dog
Cat
Other
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
112.3
72.9
95.6
84.2
94.7
84.2
72.2
76.1
67.7
13.8
13.8
15.2
12.4
15.4
12.0
11.6
11.6
9.5
4.3
0.2
5.2
2.5
7.9
10.9
37.6
27.6
19.7
Texas County. Prior to that death, the last reported case in Missouri had been in 1959.
Despite the relative rarity of true human
exposures to rabid animals in Kansas City, the
possibility of rabies needs to be considered
every time a person is bitten by a carnivorous
animal, eg dog, cat, or bat. Table 25-6 shows
the rates per 100,000 population of animal bites
reported to the Kansas City Animal Health and
Public Safety Division each year over the past
decade. These rates represent minimal estimates of the actual number of bites that residents incur.
In 2005, the Health Department and the
Animal Health and Public Safety Division collaboratively reviewed emergency department visits and hospitalizations of City residents resulting
from dog bites.5 During 1998-2002, there were
3,467 emergency department visits and 96 hospitalizations due to dog bite, for an annual average rate of 157.0 emergency department visits
per 100,000 population and 4.3 hospitalizations
per 100,000 population. For the entire
population of Kansas
Year
Bat
Cat
Other
City, these rates
2000
1
represented 693 dog
2001
bites seen in emer2002
2003
1
gency departments
2004
and 19 hospitaliza2005
1
2006
10
tions each year.
2007
3
Based on the results
2008
8
2009
of the study, it was
24
Page 272 of 294
Figure 25-7 Age distribution of dog bite
injuries, Kansas City, Mo 2007
142
Literature cited
Literature cited
93
52
<5 y
68
59
61
35
27
5-14 y 15-24 y 25-34 y35-44 y45-54 y55-64 y >=65 y
estimated that only 10-36% of dog bites requiring medical attention were actually reported to
the Animal Health and Public Safety Division.
The highest rates for emergency department visits were for persons less than 15
years of age, while for hospitalizations the highest rates for those less than 10 years of age.
The emergency department visit rate for males
(183.9) was 39% higher than for females
(131.9), although hospitalization rates were similar (4.4 and 4.3, respectively). The rates of
emergency department visits for whites and
blacks were similar, 151.5 and 147.5, respectively, but whites were 25% more likely to be
hospitalized. Hispanics had much lower rates for
both emergency department visits (80.9), and
hospitalizations (0.7).
Reported charges for 3,644 emergency
department visits totaled $1,452,845, with a median charge of $300 per visit. For 92 hospitalizations, the reported charges totaled $550,044,
with a median charge of $4,698 per hospitalization. These costs include only the original hospital charges and not physician charges or the
cost of follow-up visits.
In 2007, there were 6 hospitalizations
and 531 emergency department visits for dog
bite injuries among Kansas City residents. As
noted above, males experienced more injuries
(52.3%) than females. In addition, non-Hispanic
whites accounted for 64.4% of the persons bitten, non-Hispanic blacks 25.7%, and Hispanics
5.8%. The age distribution of bite victims is
shown in Figure 25-7.
1
2
Kansas City Health Department. 2006 Health Planning and
Assessment Survey. www.kcmo.org/health.
3
Centers for Disease Control and Prevention. Reported
tuberculosis in the United States, 2004. www.cdc.gov/tb
4
Pratt R et al. Trends in tuberculosis incidence – United
States, 2008. MMWR Morb Mortal Wkly Rep 2009;58:249253.
5
Hoff GL et al. Emergency department visits and hospitalizations resulting from dog bites, Kansas City, MO, 1998-2002.
Missouri Med 2005;102 565-568.
Page 273 of 294
26. Environmental Health
The first significant efforts to improve
the health of populations came from the sanitary
movement that stressed, among other things,
clean and safe food, beverages, and water, protection from contamination whether natural or
made-made, and decent housing. Many of the
efforts of the sanitary movement resulted in the
interruption in the transmission of communicable
and infectious diseases. That linkage to protection from disease persists today in programs
such as restaurant inspection and drinking water
safety. Other efforts sought to make the environment cleaner and safer through the removal
and proper disposal of garbage, industrial
wastes, etc. And still others concentrated on
living and working conditions in the home, in
lodging facilities, and on the job. While most of
these efforts were the focus of early public
health departments, many of them eventually
were separated from those agencies and the
responsibilities assigned to others, such as garbage disposal, provision of safe drinking water,
and weed control. Today, in Kansas City, multiple City agencies have responsibility for environmental programs that protect the health of
the residents and visitors to the community.
The 2006 Health Assessment Survey
commissioned by the Kansas City Health Department found that 27% of respondents felt that
environmental services should receive the most
emphasis by the Health Department.
Prevention’s (CDC) Environmental Public Health
Tracking Network website
(www.cdc.gov/Features/TrackingNetwork) offers
information for many environmental hazards and
health conditions, such as asthma, cancer, and
air and water contaminants. Missouri is a participating state in this network.
Reportable conditions
The same City ordinances that require
the reporting of infectious and communicable
diseases also require the reporting of cases of
injury, illness, or death due to environmental
contaminants and weather-related health problems. For the purposes of this report, the only
reportable conditions that will be discussed are
heat related illnesses and lead poisoning.
Heat-related illness
The risk of death from natural hazards
such as excessive heat, tornados, earthquakes,
etc depend a lot on where in the US a person
lives.1 In the Midwest, excessive heat can pose
a significant risk. During July 1980, Kansas City
experienced a heat wave that led to 443 reported cases of heat related illnesses including
75 cases of heatstroke.2 3 Of these 443 cases,
157 persons (35.4%) died from hyperthermia.
Since that time, the Health Department has monitored weather conditions and alerted the citizens when the risk of heat-related illnesses
could be expected to increase. Over the past 10
years, 49 Kansas Citians have died from heatrelated illnesses (Figure 26-1). Monitoring heat
Figure 26-1 Heat-related deaths, Kansas
City, Mo, by year
20
8
6
5
2
4
1
6
3
0
ENVIRONMENTAL HEALTH
Page 274 of 294
related illnesses has proven difficult as the majority of persons who visit an emergency department for a heat-related illness are not reported to the Health Department (Figure 26-2);
often even persons with heat-stroke are not reported. The age distribution of heat-related injuries during 2007 is shown in Figure 26-3. Males
account for >75% of the persons experiencing a
heat-related injury.
Slightly more than half of Missouri's
heat-related deaths have occurred in the urban,
more densely populated areas of St. Louis City,
St Louis County and Jackson County. During
1999-2003, Missouri had the 3rd highest average
annual hyperthermia-related death rate (0.6
deaths per 100,000 population) in the nation
behind Arizona (1.7) and Nevada (0.8).4 In Mis-
Figure 26-2 Emergency department visits
and hospitalization due to hyperthermia,
Emergency Dept
Hospitalization
122
96
90
104
89
65
55
32
12
10
11
6
7
6
5
12
2000 2001 2002 2003 2004 2005 2006 2007
Figure 26-3 Age distribution of hyperthermia injuries, Kansas City, Mo, 2007
souri, white males are the most frequent victims
of heat-related illness resulting in death and the
greatest number of deaths occur among people
>65 years old. On average, approximately half of
the hyperthermia deaths in any given year occur
in the month of July.
Lead poisoning
Increasing amounts of lead in the body
can cause impaired neuro-behavioral development in children, increased blood pressure, kidney damage, and anemia. For children, the major sources of exposure to lead are from deteriorated lead-based paint and the resulting dust
and soil contamination. In addition, uncommon
sources of lead exist, including unglazed lowtemperature-fired ceramic pottery, pewter drinking vessels, plumbing systems with leadsoldered joints, old paint removal, indoor gun
ranges, jewelry, some imported candy, and
nearby mining and smelting operations. During
1999-2004, the prevalence of elevated blood
lead levels in children in the US was 1.4%.5 In
2008, Missouri’s rate was 1.3%.6
Missouri requires annual lead testing for
children 6 months to 6 years of age who live in
designated high risk areas and targeted screening in other zip codes. Day care centers in high
risk zip codes are required to keep annual
Figure 26-4 Percent of tested children <6
years of age who had elevated blood lead
levels (>10 μg/dl), Kansas City, Mo, 20042008
3.6%
30
3.0%
20
18
16
11
1
2
8
1.5%
7
3
1.0%
2004
1.3%
2005
2006
2007
2008
Page 275 of 294
records proving children were tested. The high
risk zip codes designated in Kansas City include: 64101, 64102, 64108, 64105, 64106,
64109, 64110, 64111, 64112, 64113, 64114,
64116, 64120, 64123, 64124, 64125, 64126,
64128, 64129, 64131, 64139, 64149, 64161,
and 64165. In 2008, zip code 64132 went from
universal to targeted screening as the number of
children tested increased and the percentage of
children identified as have an elevated blood
lead level decreased. In August 2009, CDC issued new testing guidance for blood lead
screening of Medicaid-eligible children.7
The Healthy People 2010 national objective is that no children have an elevated
blood lead level. Data for Kansas City children for the period 2004-2008 is shown in Figure 26-4 and the age distribution is shown in
26-5. The distribution of children with elevated blood levels by zip code and the zip
codes with levels exceeding the citywide average are shown in Figure 26-6. In 2007, the
Lead Poisoning Prevention Program of the
Kansas City Health Department estimated
that 52,243 children had not been tested for
blood lead levels.
In addition to children poisoned by
lead, the Kansas City Health Department has
data regarding adults who have elevated
blood lead levels. The vast majority (95%) of
reported elevated blood lead levels among
adults are work related.8 One of the Healthy
People 2010 national public health objectives
is to reduce to zero the prevalence of blood
lead levels ≥25 µg/dL among adults. The national rate of elevated blood lead levels among
employed adults was 7.4 per 100,000 in 2007.
Rates are considerably higher among Missouri
and Kansas workers; 36.4 per 100,000 in Missouri and 34.0 in Kansas. According to the National Institute of Occupational Safety and
Health, the average blood lead level among
adults in the US is <3 μg/dl. The Kansas City
Health Department uses a lower threshold for
elevated blood lead levels in adults than de-
Figure 26-5 Age distribution of children
with elevated blood lead levels ( >10
μg/dl), Kansas City, Mo, 2004-2008
2.6%
1.8%
1.8%
1.3%
<1
1
2
3
1.3%
1.2%
4
5
Age (years)
Figure 26-6 Percent of children <6 years of age
with elevated blood lead levels by zip code, Kansas City, Mo, 2004-2008
scribed above; it follows the recommendations
of the Association of Occupational and Environmental Clinics and uses the same >10 µg/dL
standard as for children. Based on that standard, the distribution of adult elevated blood lead
levels among those tested appears to be declining as shown in Figure 26-7. Studies have suggested that there is an association between lead
levels in adults and memory impairment that is
mediated by hypertension.9
Page 276 of 294
2004
2005
2006
2007
Food protection
The Food Protection Program of the
Kansas City Health Department is responsible
for inspecting all food establishments including
restaurants, grocery stores, convenience stores,
mobile units, push carts, temporary events,
school cafeterias, hospital cafeterias, food pantries, and summer food service sites. There are
over 3,000 permits issued each year for food
service of which approximately 10% are for temporary events. In addition, annually, there are 70
summer feeding sites.
During 2008, the Food Protection Program conducted 4,244 routine inspections of
food establishments and 1,019 reinspections.
During these inspections 11,435 critical and
Figure 26-8 Food establishment inspections, Kansas City, Mo
2005
4,000
2007
2008
12,961 non-critical violations were found resulting in 108 permits being suspended (Figures 268 and 26-9).
Kansas City requires that food handlers
and food managers are properly trained and
knowledgeable about food safety, foodborne
illness and food handling, and have a food handler card. In 2008, 8,874 food handlers and 380
food managers underwent training (Figure 2610).
Water
The Kansas City Water Services De-
Figure 26-10 Food handler training by job
category, Kansas City, Mo
Workers
8,581
3,951
2006
Managers
Reinspection
4,175
11,435
2008
2004
Routine inspection
10,908
10,898
1.6%
8,172
3.9%
5,782
3.0%
Non-critical
10,418
Critical
7,588
4.3%
8,554
9.6%
12,961
Figure 26-9 Type of violations found upon
inspection of food establishments, Kansas City, Mo
12,023
Figure 26-7 Percent of tested adults with
elevated blood lead levels (>10 μg/dl),
4,244
8,190
8,874
3,200
3,297
603
865
451
1,019
400
349
2005
2004
2005
2006
2007
2008
657
2006
459
2007
380
2008
2009
Page 277 of 294
partment is responsible for drinking water,
wastewater, industrial waste, and storm water.
The primary source of drinking water is the Missouri River (94%), with the balance from wells in
the Missouri River aquifer. The Water Services
Department processes and delivers 115 million
gallons of high-quality water that exceeds all
federal and state water quality standards. The
Environmental Protection Agency (EPA) requires testing for >180 regulated compounds,
yet the Water Department tests for >300 compounds; performing >25,000 tests monthly.
There never has been a violation of contamination levels or other water quality regulations.
The Water Services Department functions as a regional water provider selling water
to a number of communities in both Missouri and
Kansas. Thus, the quality of the water produced
for the City has regional implications. The March
2007 issue of Men’s Health Magazine ranked
Kansas City’s tap water as grade A and placed it
in the top 10% of communities surveyed. In
2006, the Water Services Department received
a #1 ranking for tap water quality from SustainLane.com.
The City is served by 8 waste water
treatment plants, 5 staffed and 3 automated.
These plants serve the City proper and some
neighboring communities. The only interconnected plants are the main facility (70 million
gallons per day capacity) and two smaller
staffed facilities (20 million gallons per day capacity, each). The reclaimed water is purified
and returned to local waterways. Some sewage
sludge (biosolids) is applied to crop lands that
are then leased to local farmers. This sludge
meets the EPA’s standards for protecting the
public’s health. In addition to the municipal
waste water system, approximately 6,000 private septic systems exist in Kansas City.
Water recreational facilities
Water recreational facilities that are
open to the public are permitted and inspected
by the Community Environmental Health Program of the Kansas City Health Department.
There are approximately 150 facilities that operate year around and 425 that operate during the
spring and summer. Water quality at swimming
beaches of lakes and ponds within the City is
not monitored.
Environmental management
Environmental issues such as garbage,
trash, recycling, hazardous materials, and property abatement, are handled by various City departments. The Office of Environmental Quality
in the City Manager’s Office ensures all City
government actions are performed in an environmentally responsible manner; promote City
policies that encourage the private sector to preserve and enhance the environment; and collaborate with public and private partners on
projects that preserve and enhance the environment.
Septic waste haulers are permitted and
inspected annually by the Community Environmental Health Program of the Kansas City
Health Department; there were 40 septic waste
haulers regulated during 2008.
Air quality
The Missouri Department of Natural Resources operates the air quality monitors in the
Kansas City area. The Air Quality Program of
the Kansas City Health Department permits and
inspects two hundred sources that emit a variety
of pollutants into the metropolitan area air shed
to ensure that pollution levels are kept as low as
possible; 112 notices of violation were issued in
2008.
The priority air pollutant is ozone which
has been linked to premature deaths.10 The EPA
changed the ground level ozone standard from
84 parts per billion (ppb) averaged over eight
hours; to a new standard of 75 ppb. This change
Page 278 of 294
is expected to result in the Kansas City region
losing its clean air status. The EPA is expected
to classify areas that do not meet the new standard by March 2010. States will then have three
years to develop regulatory plans for those
areas. Compounding the issue for the region is
the State of Missouri requirement that gasoline
contain bioethanol. Burning such fuel will hamper ozone reduction more than burning fuel
without bioethanol.
The American Lung Association’s State
of the Air: 2009 report claimed that 60% of
Americans live in areas with unhealthy air pollution levels. The report assigned Clay County an
‘A’ for air particulates and a ‘F’ for high ozone
days, while giving Jackson County a ‘C’ for par-
Table 26-1 Estimated number of persons in
Kansas City area at risk from air pollutants
(source: American Lung Association, State of the Air:
2009 report)
Groups at risk
Pediatric asthma
Adult asthma
Chronic bronchitis
Emphysema
Cardiovascular
disease
Diabetes
Clay
County
Jackson
County
Platte
County
4,982
13,374
5,288
2,517
15,513
42,222
17,041
8,464
1,892
5,480
2,166
1,021
55,142
181,148
22,467
11,764
39,016
4,796
ticulates (www.stateoftheair.org). That report
also estimated the number of persons at risk
from air pollutants (Table 26-1).
In June 2009, the EPA released its 3rd
national assessment of 181 toxic air pollutants.11
According to that report, most people in the US
have an average cancer risk of 36 in 1 million if
exposed to 2002 emission levels over the
course of their lifetime. In addition, 2 million
people (<1% of US population) have an increased cancer risk of greater than 100 in 1 million. The Kansas City region had a below average cancer risk. Benzene was the largest contributor to the increased cancer risks.
The Air Quality Program also regulates
the removal of asbestos from commercial structures and facilities.
Indoor air quality issues (including enforcement of Kansas City’s prohibitions on
smoking) and noise complaints are handled by
the Health Department’s Industrial Hygiene and
Safety Program.
Industrial Hygiene & Safety
Indoor air and noise issues are handled
by the Kansas City Health Department’s Industrial Hygiene and Safety program. In 2008, the
program issued 170 noise permits in accordance
with City’s Noise ordinance as well as 72 warning letters for violations of that ordinance. Most
complaints regarding indoor air were moldrelated; 23 indoor air investigations were conducted. In addition, the program is responsible
for enforcement of the smoke-free ordinance. In
2008, 17 General Ordinance Summons were
issued for knowingly possessing lighted tobacco
products in an enclosed public place.
Childcare & lodging facilities
Childcare and lodging facilities are both
regulated and permitted by the State of Missouri.
Under a contract from the Missouri Department
of Health and Senior Services, the Community
Environmental Health Program of the Kansas
City Health Department inspects 530 childcare
establishments and 100 lodging facilities.
Rat control
The Health Department operates a Rat
Control program that provides rat extermination
to residents living in single family homes and
duplexes as well for vacant houses, vacant lots,
city construction sites, around city blocks and in
sewers. Of the 1,159 rat complaints in 2008,
1,142 (98.5%) resulted in service.
Page 279 of 294
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Borden KA, Cutter SL. Spatial patterns of natural hazards
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Donnell HD et al. Heatstroke – United States, 1980.
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3
Jones TS et al. Morbidity and mortality associated with the
July 1980 heat wave in St Louis and Kansas City, Mo. J Am
Med Ass 1982;247:3327-3331.
4
Luber GE, Sanchez CA. Heat-related deaths – United
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Jones RL et al. Trends in blood lead levels and blood lead
testing among US children aged 1 to 5 years, 1988–2004.
Pediatrics 2009;123:e376-e385.
6
Missouri Department of Health and Senior Services. Missouri Childhood Lead Poisoning Prevention Annual Report
Fiscal Year 2008. www.dhss.mo.gov
7
Wengrovitz AM, Brown MJ. Recommendations for blood
lead screening of Medicaid-eligible children aged 1-5 years:
an updated approach to targeting a group at high risk.
MMWR Recomm Rep 2009;58:RR-9.
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Alarcon WA et al. Adult blood lead epidemiology and surveillance-United States, 2005-2007. MMWR Morb Mortal
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Van Wijngaarden E et al. Bone lead levels are associated
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10
Committee on Estimating Mortality Risk Reduction Benefits from Decreasing Tropospheric Ozone Exposure, Natural
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Washington: National Academies Press, 2008, 206.p.
11
Environmental Protection Agency. 2002 National-Scale Air
Toxics Assessment. June 24, 2009. www.epa.gov/nata2002
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2008
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excess fetal and infant mortality using Perinatal
Periods of Risk (PPOR) analysis . J Natl Med
Ass 2008;100:1450-1456.
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between the ages of 18 and 44. Maternal Child
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2008;12:24-29.
Garza AG, Gratton MC, McElroy J, Lindholm D,
Coontz D. Environmental factors encountered
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2007
Archer R, Hoff GL. Citizen preparedness. Missouri Municipal Rev 2007;72(6):15-16. (reprinted
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Interaction of health compromising behaviors on
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Fitzgerald K, Cai J, Hoff GL, Dew PC, Okah FA.
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Griffin R, Wilkinson T, Hoff GL. Hepatitis vaccination of men-who-have-sex-with-men by taking
the vaccine to the community. J Men’s Health
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Hoff GL, Cai J, Okah FA, Dew PC. Changes in
smoking behavior between first and second
pregnancies. Am J Health Behavior
2007;31:583-590.
Okah FA, Hoff GL, Dew PC, Cai J. Cumulative
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2003
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taking. Greater Kansas City Med Bull
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Cai JW, Hoff GL, Dew PC, Guillory VJ, Manning
J. Perinatal Periods of Risk: analysis of fetalinfant mortality rates in Kansas City, Missouri.
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Hoff GL, Cai J, Kendrick R, and Archer R.
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1998-2002. Missouri Med 2005;102(6):467-470.
Hall RT, Santos SR, Cofield F, Brown MJ, Teasley SL, Cai J. Perinatal outcomes in a schoolbased program for pregnant teen-agers. Missouri Med 2003;100:148-152
Hoffman MA, Wilkinson TH, Bush A, Myers W,
Griffin RG, Hoff GL, Archer R. Multijurisdictional
approach to biosurveillance, Kansas City. Emerg
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Okah FA, Cai J, Hoff GL. Term gestation, low
birthweight and health compromising behaviors
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Okah FA, Cai J, Dew PC, and Hoff GL. Are fewer women smoking during pregnancy? Am J
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Riederer-Trainor C, Wilkinson T, Snook WD,
Hoff GL, Griffin R, Archer R. When bioterrorism
strikes: Communication issues for the local
health department. Health Promotion Practice
20056(4):424-429.
Young TW, Wooden S, Dew PC Cai J, Hoff GL.
The Richard Cory Phenomenon: Suicide and
socioeconomic status in Kansas City, Missouri. J
Forensic Sci 2005;50(2):443-447.
2004
McLean CA, Wang SA, Hoff GL, Dennis LY,
Trees DL, Knapp JS, Markowitz LE and Levine
WmC. The emergence of Neisseria gonorrhoeae
with decreased susceptibility to azithromycin in
Kansas City, Missouri, 1999-2000. Sexually
Trans Dis 2004;31:73-78.
PUBLICATIONS
Fernquist RM, Cai J. African-American and
white suicide in Kansas City, Missouri 19951997: individual and aggregate circumstances.
Missouri Electronic J Sociol 2000;1:1-12.
Hoff GL, Joyce J, Dennis L Archer R. Reduced
susceptibilities in treatment of gonorrhea - part
2. Greater Kansas City Med Bull 2000;95(34):25.
Ohye R, Lee V, Whiticar P, Ellier P, Domen H,
Hoff G, Joyce J, Archer R, Hayes, M, Hale, J,
Holmes K, Doyle L, Procop G. Fluoroquinoloneresistance in Neisseria gonorrhoeae Hawaii,
1999 and decreased susceptibility to azithromycin in N. gonorrhoeae, Missouri 1999. MMWR
Page 283 of 294
28. Glossary
Adequacy of Prenatal Care Utilization (APNCU) Index Method for assessing adequacy of
prenatal care by utilizing two independent and
distinctive dimensions – namely adequacy of
initiation of prenatal care and adequacy of received services (number of prenatal care visits)
once prenatal care has begun. The index uses
information readily available on birth certificates
(month of initial prenatal care visit, number of
visits, and gestational age).
Adequacy of initiation of prenatal care collapses
the initiation months into four distinct groupings:
(1,2) (3,4) (5,6) (7-9 or none) months. Adequacy
of received services is based on one visit per
month through 28 weeks, one visit every 2
weeks through 36 weeks, and one visit per week
thereafter, adjusting for the for date of initiation
of prenatal care. The proportion of observed visits/expected visits is calculated and the results
are scaled: 0-49% of expected visits = Inadequate; 50-79% = Intermediate; 80-109% = Adequate; 110+% = Adequate Plus.
Birthweight The weight of a fetus or live birth
infant at the time of delivery and measured in
grams; normal birthweight is >2,500 grams (5 lb
8 oz), low birthweight is <2,500 grams, very low
birthweight is <1,500 grams (3 lb 4 oz), and very
high birthweight (macrosomia) >4,000 grams (8
lb 13 oz).
Cause of death For the purpose of mortality
statistics, every death is attributed to one underlying condition, based on information reported
on the death certificate and using the international rules for selecting the underlying cause of
death from the conditions stated on the death
certificate. The underlying cause is defined by
the World Health Organization (WHO) as the
disease or injury that initiated the train of events
leading directly to death, or the circumstances of
the accident or violence, which produced the
fatal injury. Generally more medical information
is reported on death certificates than is directly
reflected in the underlying cause of death. The
conditions that are not selected as underlying
cause of death constitute the non-underlying
cause of death, also known as multiple cause of
death.
Cause of death is coded according to the appropriate revision of the International Classification
of Diseases (ICD). Effective with deaths occurring in 1999, the United States began using the
Tenth Revision of the ICD (ICD-10); during the
period 1979-1998, causes of death were coded
and classified according to the Ninth Revision
(ICD-9).
Confidence intervals Calculation that provides
the margin of error for a given statistic; the margin of error is the amount added or subtracted
from the statistic; for example, a person averages 35 minutes to drive to work + 5 minutes,
the confidence interval is 30 to 40 minutes; confidence intervals can be calculated for means
(averages), proportions, the differences of
means or proportions, or paired differences.
Disparity Inequalities; differing levels of health
indicators that are observed among segments of
a population that often correlate with economic
indicators, educational level, employment, and
housing conditions.
Health indicator Numerical data that characterize the health of a population and the influences
that affect its health. Health indicators are distinguished by their focus on (1) quantification; (2)
aggregation of data from observations on individuals, their communities, and the context of
their communities; and (3) population health and
influences on it.
GLOSSARY
Page 284 of 294
Gestation The period of gestation is defined as
beginning with the first day of the last normal
menstrual period and ending with the day of
birth or day of termination of pregnancy.
Term: 37-42 weeks gestation; average is considered 40 weeks gestation.
Preterm: <37 weeks gestation; subclassified
as moderately preterm 32-36 weeks gestation and very preterm <32 weeks gestation.
Gravidity The total number of times a woman
has been pregnant. This number is distinguished
from parity, which is defined as the total number
of live births ever had by the woman.
Incidence In epidemiology, the occurrence of
new events or cases. This is expressed as an
absolute number or as a rate. The incidence rate
= number of new cases or events in a specified
time period ÷ population at risk. This rate generally is multiplied by some factor of 10 such as
1,000, 10,000, 100,000 or 1,000,000 to produce
a whole number that can be easily compared to
other incidence rates.
Neonatal Period The period from time of birth
through the completion of the 27th day of life.
Divided into early neonatal period (days 0
through completion of the 6th day of life) and late
neonatal (days 7 through the completion of the
27th day of life).
Parity The total number of live births ever had
by the woman. This number is distinguished
from gravidity, which is the total number of times
she has been pregnant. Nulliparous women are
those who have had no live births, and parous
women are those who have given birth to at
least one baby. For example, a woman classified as "parity 0" has never had a live birth.
Whereas, "parity 1 or more" means that she has
had one or more live births. Children ever born
is also known as parity.
GLOSSARY
Perinatal Periods of Risk (PPOR) A technique
used to analyze fetal and infant death data for a
community.
Pregnancy, unintended Births to women less
than 18 years old, or to women 18 to 35 years
old with spacing of less than 12 months since a
prior birth, or unmarried and lacking a college
education.
Prenatal care Medical care provided to a pregnant woman to prevent complications and decrease the incidence of maternal and prenatal
mortality.
Rate A rate is a measure of some event, disease, or condition in relation to a unit of population, along with some specification of time.
Rate, abortion Number of abortions regardless
of the mother’s age divided by number of women 15-44 years old times 1,000.
Rate, age-adjusted death A measurement of
mortality that can be used either to compare different populations (states, counties, cities, etc.)
or to compare the mortality experience over time
for one area with a changing population; ageadjusted death rates eliminate the bias of age in
the makeup of the populations being compared,
thereby providing a much more reliable rate for
comparison purposes; in the United States
death rates typically are age-adjusted to the
year 2000 US standard population.
Rate, birth The number of live births in a population or subpopulation in a calendar year divided by the number of number of persons in the
population or subpopulation multiplied by 100,
1,000, 10,000, 100,000 or 1,000,000 population.
The rate may be restricted to births to women of
specific age, race, marital status, or geographic
location (specific rate), or it may be related to
the entire population (crude rate).
Page 285 of 294
Rate, birth teenage The number of live births in
a calendar year to females 10-19 years of age
divided by the number of females of that age in
the population, per 1,000 females of that age;
typically presented as 10-14 years olds, 15-17
year olds, 18-19 year olds, or 15-19 year olds.
Rate, death The number of deaths in a population or subpopulation in a calendar year divided
by the number of number of persons in the
population or subpopulation and multiplied by
100, 1,000, 10,000, 100,000 or 1,000,000 population. The rate may be restricted to deaths in
specific age, race, sex, or geographic groups or
from specific causes of death (specific rate) or it
may be related to the entire population (crude
rate).
Rate, fertility The number of live births, regardless of the age of the mother, divided by the
number of women 15-44 years of age and multiplied by 1,000.
Total fertility rate is the average number of
children a woman would bear if all women live
to the end of their childbearing years and have
children according to a given set of agespecific fertility rates. It is the sum of agespecific fertility rates for women 15-44 years of
age multiplied by the number of years in each
interval, typically 5.
Rate, fetal death The number of fetal deaths
with stated or presumed gestation of 20 weeks
or more divided by the sum of live births plus
fetal deaths multiplied by 1,000; abbreviated as
FMR.
Late fetal death rate is the number of fetal
deaths with stated or presumed gestation of
28 weeks or more divided by the sum of live
births plus late fetal deaths, per 1,000 live
births plus late fetal deaths.
Rate, infant mortality The death of a live-born
child before his or her first birthday. Deaths in
the first year of life may be further classified according to age as neonatal and postneonatal.
Neonatal deaths are those that occur before the
28th day of life; postneonatal deaths are those
that occur between 28 and 365 days of age.
The number of infant deaths in a calendar year
divided by the number of live births reported in
the same calendar year and multiplied by 1,000;
expressed as IMR.
Neonatal mortality rate is the number of
deaths of children under 28 days of age, per
1,000 live births.
Postneonatal mortality rate is the number of
deaths of children that occur between 28 days
and 365 days after birth, per 1,000 live births .
Rate, pregnancy teenage The number of fetal
deaths, live births and abortions in a calendar
year to females 15-19 years of age divided by
the number of such females in the population,
per 1,000 females 15-19 years of age.
Ratio A fraction that divides two quantities; the
ratio of 3 girls to 2 boys means that for every 3
girls there are 2 boys, but it does not mean
there are only 5 children in the group; ratios are
expressed in lowest terms (simplified as small
as possible) so that 300 girls and 200 boys or 30
girls and 20 boys both are ratios of 3 to 2 (often
written as 3:2).
Ratio, abortion Number of abortions divided by
number of live births multiplied by 1,000.
Ratio, relative disparity A ratio or fraction that
results from dividing one number (such as a
rate) by another; typically the rate for a minority
population divided by that for the reference population, usually, but not restricted to, the majority
population.
GLOSSARY
Page 286 of 294
Ratio, sex The number of male live births per
1,000 female live births.
Small for gestational age (SGA) A term used
to describe a baby who is smaller than the usual
amount for the number of weeks of pregnancy.
SGA babies have birthweights below the 10th
percentile for babies of the same gestational
age. This means that they are smaller than 90
percent of all other babies of the same gestational age.
GLOSSARY
Page 287 of 294
29. Data Sources
The data used in this report were derived from a variety of primary and secondary
sources. The demographic data comes from
Census 2000, while birth, death, and hospital
related information were extracted and interpreted from data sets provided by the Missouri
Department of Health and Senior Services. Primary data came from the Kansas City Health
Department programs and from community
health assessments and telephone surveys
conducted by the Health Department. The
sources of other data are cited throughout this
report. When appropriate, rates were ageadjusted to Census 2000.
This document is not inclusive of all
health issues that Kansas residents experience
or feel passionately about. It does, however,
attempt to address the more pertinent issues as
well as those topics for which partnerships between the community and Health Department
exist. Draft copies of all sections of this report
were posted on the Kansas City Health Department’s website as they were completed, along
with any significant revisions, for review and
comment by the community. In addition, the
Kansas City Health Commission members reviewed the draft sections and provided feedback.
Suggestions for topics or information as
to where more relevant data may exist within the
community are welcome and very much encouraged. This should be communicated to:
Office of Epidemiology & Community Health Monitoring
Kansas City Health Department
2400 Troost, Suite 3300
Kansas City Mo, 64108
816.513.6149
Gerald L Hoff, PhD, FACE
Epidemiologist & Manager
816.513.6149
[email protected]
Jinwen Cai, MD
Public Health Statistician
816.513.6044
[email protected]
DATA SOURCES
Page 289 of 294
30. Index
2
2008 Physical Activity Guidelines for
Americans., 216
A
abortion, 5, 27, 28, 36, 37, 63
rate. See rate, abortion
ratio. See ratio, abortion
therapeutic, 57
Academy of Management, 263
activities of daily living, 11, 149, 186,
193, 200
air pollution
asbestos, 278
indoor, 278
ozone, 168, 277
particulate matter, 168
alcohol consumption, 22, 32, 50,
132, 141, 181, 187, 204, 210,
218, 236, 241, 250, 254, 264
abuse, 241, 242, 243
binge drinking, 50, 242, 243,
244, 245
dependence, 241, 242
heavy drinking, 242, 244, 245
tolerance to, 241
blood alcohol concentration, 245,
246
driving under the influence, 243,
245
fetal alcohol spectrum disorder,
241
motor vehicle crashes, 246
pregnancy, 36, 43, 46
pregnancy outcomes, 243
allergy
allergens, 161, 162
Alzheimer’s disease, 6, 79, 88
American Academy of Dermatology,
142
American Academy of
Ophthalmology, 220
Eye-Smart, 220
American Academy of Pediatrics, 55
American Association of Clinical
Endocrinologists, 172
American Cancer Society, 132, 133,
135, 138, 139, 140, 142
American College of Allergy, Asthma
and Immunology, 164
American Heart Association, 156
American Lung Association (ALA),
235, 278
American Optometric Association,
221
InfantSEE Program, 221
American Psychiatric Association,
242
American Speech-Language Hearing
Association, 220
arthritis, 216, 217
pediatric, 217, 218
SPARC, 218
Association of Occupational and
Environmental Clinics, 275
asthma, 161, 168
allergic, 161
death, 162, 163, 164
inducers, 161
triggers, 161
Asthma and Allergy Foundation of
America, 164
avoidable mortality analysis, 81
B
Battle of the Belt Challenge, 205
Behavioral Risk Factor Surveillance
System
BRFSS, 131, 136, 138, 139, 148,
155, 162, 173, 174, 182, 183,
188, 204, 217, 226, 235, 242,
244, 246
Big Cities Health Inventory, 78
birth
birthweight
low, 32
birth
average age at first birth, 5
birth defects, 10
cesarean/C-section, 5
fertility rate
general, 25, 26
gestation
clinical estimate, 30
gestational age, 30
last menstrual period estimate,
30
late preterm, 30
moderately preterm, 30, 31
postterm, 30
preterm, 5, 10, 30, 32
term, 30
very preterm, 30, 31, 32
pregnancy
complications, 10
intention
intended, 28
unintended, 5, 28
outcomes, 5
pregnancy issues, 7
prenatal care, 32
adequate, 5
inadequate, 5
intermediate, 25
trimester, 32
prepregnant weight, 5
repeat, 5
sex ratio, 27
stillbirths, 27
teenage, 5
birth certificate, 30, 39, 46, 49
birth order, 25
multiple, 26
singleton, 26, 45, 47, 48
triplet, 26
twin, 26
birthweight
low, 5, 27
body mass index
at risk of overweight, 181
BMI, 55, 149, 157, 181, 182, 187
body weight, 181
morbidly obese, 186, 187
normal weight, 51, 53, 70, 181,
183, 186, 216, 217
obese, 5, 9, 10, 51, 53, 71, 72,
131, 132, 141, 147, 149, 155,
156, 157, 161, 171, 173, 181,
182, 183, 186, 187, 188, 215,
216, 217, 218
children, 49
moderately obese, 181
morbidly obese, 181
overweight, 10, 51, 53, 131, 132,
155, 173, 181, 182, 183, 186,
216, 217
underweight, 51, 53, 181, 183,
225
C
cancer, 6, 88, 131, 181, 186, 225
breast, 6, 10, 55, 78, 133, 135,
137, 186, 243
death, 132, 133, 135, 136
male, 135
mammogram, 136, 137
colorectal, 133, 140, 141, 187
blood stool test, 140
death, 132, 140, 141
death, 131, 132, 133, 140, 148,
150
esophageal
death, 132
female reproductive tract, 133
cervical, 137
death, 138
pap test, 138
INDEX
Page 290 of 294
death, 138
ovarian, 55, 137
death, 138
uterine
death, 138
liver
death, 132
lung, 6, 79, 133, 134, 234
death, 132, 133, 134
pancreatic
death, 132
prostate, 133, 139, 140
death, 132, 139
digital rectal exam, 140
prostate specific antigen
test/PSA, 139
rectal, 140
skin, 133, 142
basal cell/squamous cell
cancers, 142
death, 142
melanoma, 142
survivors, 132, 138, 141
tobacco related, 233
cardiovascular disease, 7, 57, 147,
156, 157, 158, 171, 172, 186,
215, 217, 218
blood pressure, 147, 153, 154,
156, 173, 187, 217, 218, 244,
274
cholesterol, 157, 217
heart, 6, 79, 82, 88, 112, 131,
147, 150, 153, 154, 156, 172,
187, 234, 241, 244
death, 150, 151, 152
death disease, 148
emergency department visits,
152
hospitalizations, 152
hypertension, 37, 48, 147, 153,
155, 173, 182, 186, 187
malignant, 154
prehypertension, 153, 154, 155
residual hypertension, 153
secondary hypertension, 154
stroke, 6, 88, 147, 148, 150, 152,
153, 154, 156, 241, 244
death, 148, 150, 152
Children’s Mercy Hospital, 164, 236
chronic lower respiratory
disease/CLRD, 6, 88, 167, 168
chronic bronchitis, 168
chronic obstructive pulmonary
disease/COPD, 168, 234
emphysema, 168
Citizens for Missouri’s Children, 231
Committee on Understanding
Premature Birth and Asssuring
Healthy Outcomes, 30
Community Health Assessment
2007, 72
Community Health Assessment
2009, 18
INDEX
costs
bed-nights, 264
dental care, 226
direct, 147, 173, 193, 194, 217,
220
earnings lost, 263
economic impact, 10, 11, 30, 41,
182, 197, 203, 215, 235, 241,
267
hospital charges, 147, 163, 176,
194, 212, 227, 272
indirect, 132, 147, 217, 220
lost productivity, 132, 147, 197,
241, 263
medical treatment, 132, 171, 172,
173, 186, 187, 197, 217, 237,
241, 263, 272
service, 264
smoking cessation, 234
Council of the Obesity Society, 181
county
Allen/Ks, 228
Atchinson/Ks, 13
Bates/Mo, 13
Cass/Mo, 13, 162, 228
Clay/Mo, 13, 19, 21, 64, 74, 152,
155, 162, 174, 183, 205, 227,
235, 246, 260, 278
Clinton/Mo, 13
Dane/Wi, 67
Franklin/Ks, 13
Jackson/Mo, 13, 19, 21, 64, 74,
77, 86, 151, 155, 162, 174,
183, 202, 203, 205, 208, 215,
228, 235, 246, 254, 260, 268,
274, 278
Johnson/Ks, 13, 74, 228
Johnson/Mo, 13
Lafayette/Mo, 13, 162, 228
Leavenworth/Ks, 13
Linn/Ks, 13
Miami/Ks, 13
Platte/Mo, 13, 19, 21, 64, 74, 86,
152, 155, 162, 174, 183, 205,
227, 235, 246
Ray/Mo, 13, 162
St Louis City/Mo, 260, 268, 274
St Louis County/Mo, 235, 260,
274
Wyandotte/Ks, 13, 74, 228
D
death
actual cause of death, 186, 233,
241, 249
average age of, 79, 133, 141,
150, 167, 174, 260
causes of, 70, 78, 81, 86, 88, 148
chronic lower respiratory
disease/CLRD, 150
fetal, 36, 37, 57, 63, 68, 70
indirect, 132
infant, 10, 27, 34, 36, 43, 53, 63,
66, 67, 68, 69, 70, 88
cause of, 30, 69
homicide, 259, 261
neonatal, 43, 68
early, 68
perinatal mortality rate, 72
postneonatal, 68
leading cause of, 6, 77, 81, 87,
88, 173, 253, 259, 261, 267
maternal, 43, 46, 53, 56
median age at, 79, 260
mortality, 18, 69, 88, 173, 194
premature, 6, 9, 79, 80, 81, 82,
133, 147, 150, 152, 174, 182,
187, 216, 277
death certificate, 56, 70, 173
ICD codes, 86
dental care
absence of teeth, 225, 226
cavities, 225, 226, 227
fluoradation of drinking water,
225
dentists, 231
visits to, 226
discoloration, 225
orthodontic treatment score, 229
periodontal disease, 226
sealants, 229
tooth loss, 225, 226
tooth retention, 225
trauma, 229
Dental Care Counts, Decay in the
Heartland
A Crisis for Kansas City Children,
231
Deron Cherry Foundation, 220, 228
diabetes, 5, 34, 72, 78, 156, 157,
176, 182, 187, 217, 218, 226, 241
amputation of extremities, 176
blood glucose, 48, 158, 171, 172,
173
foot care, 173
gestational, 47, 48, 53, 171, 172
glucose intolerance, 171, 226
glycemic control, 176, 226
insulin dependent, 47
maturity-onset diabetes of the
young/MODY, 172
monogenic, 172
neonatal diabetes mellitus/NDM,
172
non-insulin dependent, 47
polygenic, 171
prediabetes, 172
prepregnancy, 48
type 1, 46, 48, 171, 172
type 2, 48, 55, 171, 172, 182, 186
undiagnosed diabetes, 171, 172
disability, 11, 18, 43, 168, 171, 186,
193, 197, 215, 225, 226, 267
disability-adjusted life years, 216
disparities, 6, 9, 31, 35, 43, 55, 56,
64, 81, 82, 135, 139, 141, 176
measures of disadvantage, 171
Page 291 of 294
drug use, 22, 32, 50, 142, 204, 210,
236, 242, 249, 254, 264
driving under the influence, 245,
249
pregnancy, 36
Dying so Young
Infant Mortality in Kansas City,
Mo, 9, 72
educational level, 22, 39, 56, 148,
153, 157, 173
college, 34, 54, 67, 162, 168, 226,
233, 245
high, 138
high school, 54, 140, 183, 216,
219, 243, 244, 246
less than high school, 47, 54, 72,
140, 226
low, 138, 216, 233
more than high school, 140
technical school, 162
exercise
physical inactivity, 141, 156, 171,
172, 181, 183, 216, 217
reduced physical activity, 188
Healthy study, 172
hearing
deaf, 218, 219
difficulties in, 218, 219
good, 218
loss of, 173, 215, 218, 219
childhood, 219
newborn screening, 219
screening, 219
HIV, 7, 82, 233, 269
homeless, 270
homicide, 6, 79, 88, 212, 259, 263,
264
hospitals
admissions to, 10, 111, 112, 133,
152, 161, 162, 168, 175, 193,
194, 197, 198, 206, 208, 209,
211, 213, 217, 237, 244, 250,
269, 271, 272
asthma, 164
emergency department visits,
111, 112, 149, 152, 161, 162,
164, 168, 175, 176, 193, 197,
198, 200, 206, 209, 210, 214,
218, 227, 237, 244, 250, 271,
272, 274
asthma, 164
outpatient visits, 153, 162
F
I
F as in Fat: How Obesity Policies are
Failing in America, 2007, 186
food establishments, 188, 276
food handler training, 276
food protection, 273
Framington Heart Study, 242
Free and Reduced Lunch (FRL)
Program, 22, 228
income, 55
household, 24
income levels, 173, 175
high, 138
low, 138, 162, 225
lower, 237
poor, 182
income leves
high, 162
median family income, 6, 49, 68,
134, 152, 175
not poor, 168
poverty, 181
infectious and communicable
diseases, 7, 11, 267, 270, 273
injury, 7, 112, 197, 241, 244, 272,
273
abuse/neglect/rape, 213
physical abuse, 213
animal bite/sting, 208, 271
classification
body region, 197
diagnosis, 197
external cause, 197
intent, 197, 198
assault, 211, 212, 263
intentional, 197, 198, 202,
210, 244, 259, 264
self-inflicted, 197, 198, 211,
212, 253
unintentional, 6, 88, 197,
198, 202, 208, 210, 211,
212
E
H
Health Assessment Survey, 155,
188, 205, 226, 273
Health Care Foundation of Greater
Kansas City, 231, 235
health priorities, 9
Health Zones, 68, 119, 235
Clay01, 122
Clay02, 123
Jackson01, 112, 124
Jackson02, 68, 112, 125
Jackson03, 68, 126
Jackson04, 127
Platte, 121
Healthcare Cost and Utilization
Project, 45
Healthy People 2010, 6, 31, 32, 42,
45, 56, 64, 66, 71, 78, 133, 136,
139, 141, 151, 152, 167, 174,
176, 182, 198, 203, 205, 217,
221, 226, 227, 229, 251, 254,
260, 267, 275
legal intervention, 197, 211
mechanism, 197
nature of, 197
cutting/piercing wound, 208
falls, 188, 193, 197, 198, 200,
201, 221
fire/burns, 209
hyperthermia, 208, 273, 274
motor vehicle, 186, 203, 204, 205
motorcycle, 205
pedestrian, 204, 205
seat belt use, 204, 205
occupational, 198
over exertion, 208
poisonings/overdoses, 210
stabbing/gunshot, 253, 254, 259,
260
firearms, 211, 212
struck by/against, 197, 202
insurance
dental coverage, 227, 231
Health Levy, 10
Medicaid, 11, 25, 32, 36, 45, 163,
168, 186, 226, 227, 231, 234
Medicare, 11, 168, 182, 186, 220,
225
Missouri Health Net, 231
private, 11, 45, 111, 163, 168, 226
self-pay, 112, 227
State Children’s Health Insurance
Program (SCHIP), 226
uninsured, 111, 212, 226
International Classification of
Diseases and Related Health
Problems, 197
External Causes of Injury, 197
Functioning, Disability, and
Health, 216
International Statistical Classification
of Diseases and Related Health
Problems (ICD), 82
intimate partner violence/IPV, 213,
263, 264
K
Kansas City
Councilmatic Districts, 235
Kansas City Animal Health and
Public Safety Division, 271, 272
Kansas City Health Commission, 36,
242
Kansas City Health Department, 9,
67, 68, 82, 132, 155, 163, 174,
188, 205, 218, 221, 235, 236,
243, 250, 260, 264, 267, 271,
273, 287
Air Quality Program, 277, 278
Community Environmental Health
Program, 277, 278
Community Industrial Hygiene
and Safety Program, 278
INDEX
Page 292 of 294
Division of Communicable
Disease Prevention and Public
Health Preparedness, 267
Food Protection Program, 276
Lead Poisoning Prevention
Program, 275
Office of Epidemiology and
Community Health Monitoring,
86, 133, 227, 287
Rat Control Program, 278
Kansas City Office of Environmental
Quality, 277
Kansas City Planning and
Development Department, 13
Kansas City Police Department, 205,
213, 245, 250, 260
Kansas City Quality Improvement
Consortium, 176
Kansas City Star, 212
Kansas City Stroke Study, 149
Kansas City University of Medicine
and Biosciences, 185, 220, 236
Score 1 for Health, 228
Kansas City Water Services
Department, 277
L
lead
elevated blood lead levels, 7
poisoning, 273, 274
adult, 275
childhood, 274
Lesbian and Gay Community Center
of Greater Kansas City, 264
Lesbian Cancer Project, 137
life expectancy, 9, 18, 19, 27, 77, 79,
186
lifestyle, 81, 193, 254
M
March of Dimes, 30
marital status
cohabitation, 39
married, 5, 28, 39
unmarried, 5, 32, 34, 36, 38, 39,
72, 264
Men’s Health magazine, 226, 277
metabolic syndrome, 172
metropolitan area
combined statistical area/CSA, 13
metropolitan statistical area/MSA,
268, 269
Minority Health Indicators, 9, 82
Missouri Asthma Surveillance Report
2006, 162
Missouri Child Fatality Review
Program, 71
Missouri Children Health Insurance
Program, 231
Missouri County-Level Survey, 183
INDEX
Missouri County-Level Survey of
Adult Tobacco Use and Related
Chronic Conditions and Practices,
235
Missouri Department of Elementary
and Secondary Education, 22,
219
Missouri Department of Health and
Senior Services, 149, 162, 173,
176, 194, 210, 217, 219, 278, 287
Bureau of Genetics and Healthy
Childhood, 219
Missouri Department of Natural
Resources, 277
Missouri Department of
Transportation, 205
Missouri State Highway Patrol, 203,
205
Monitoring the Future, 249
N
natality
foreign-born, 5, 7, 14, 20, 25, 33,
46, 270
US-born, 14, 18, 20, 33, 270
National Academy of Sciences, 51
National Arthritis Data Work Group,
216
National Association of County and
City Health Officials, 78
National Center of Addiction and
Substance Abuse, 243
National Health and Nutrition
Examination Surveys, 148, 220
NHANES, 148, 155, 182
National Health Interview Survey,
147, 148, 167, 172, 181, 218,
220, 221, 242
National Hospital Ambulatory
Medical Care Survey, 227
National Long Term Care Study, 215
National Oral Health Surveillance
System, 226
National Osteoporosis Foundation,
193
National Prostate Cancer Coalition,
139
National Survey of Children’s Health,
183
National Survey on Drug Use and
Health, 243
National Violent Death Reporting
System, 259
Newborn Hearing Screening Service
Coordination Project, 219
noise exposure, 218, 278
nutrition
breastfeeding, 55, 230
diet, 148, 156, 181, 187, 193, 194
folic acid, 32, 55
food stamps, 55
fruit juice, 230
fruits/vegetables, 132, 141
Women, Infants, and Children
(WIC) program, 55
O
obesity, 182, See body mass index
children, 51
obesity paradox, 186
pregnancy, 48, 53, 55
Obesity Reduction Survey, 186
Obesity Report Card, 186
Oral Health Surveillance Project, 228
Oral Quality of Life (OQOL), 225
osteopenia, 193, 194
osteoporosis, 194, 217
P
Park Hill South High School, 205
Perinatal Periods of Risk (PPOR), 74
physical activity, 193, 194, 218
physicians
visits to, 162, 175, 176, 193, 197,
218
poverty
children living in, 22, 182, 228
federal poverty level, 233
above, 161
below, 161
guidelines, 22
poor, 226
poor families, 22, 168, 220, 233
working, 22, 228
status, 148, 149, 153
pregnancy
complications, 152
prenatal care
trimester, 51
Project Ready Smile, 231
R
rabies, 271
race/ethnicity
Asian, 5, 19, 25, 27, 35, 38, 39,
43, 47, 52, 63, 64, 66, 78, 88,
112, 149, 157, 171, 172, 182,
194, 219, 220, 242
non-Hispanic, 14, 164
black, 148, 149, 150, 153, 157,
171, 172, 173, 175, 182, 185,
187, 204, 219, 220, 226, 227,
228, 249, 253, 272
non-Hispanic, 5, 6, 14, 19, 25,
26, 27, 28, 31, 33, 34, 35,
36, 38, 39, 42, 43, 45, 51,
52, 56, 63, 64, 66, 68, 69,
74, 77, 78, 82, 88, 112, 133,
134, 135, 136, 139, 141,
143, 150, 152, 154, 155,
161, 162, 163, 164, 167,
172, 174, 176, 194, 199,
Page 293 of 294
200, 202, 208, 209, 211,
212, 213, 217, 218, 228,
229, 230, 234, 237, 242,
250, 259, 260, 261, 264
Hispanic, 5, 6, 14, 18, 19, 25, 31,
33, 35, 36, 38, 39, 43, 45, 54,
55, 63, 64, 66, 68, 74, 78, 80,
82, 88, 133, 136, 143, 149,
152, 153, 154, 157, 172, 176,
185, 194, 200, 202, 208, 209,
210, 211, 212, 221, 226, 228,
230, 234, 242, 261, 264, 272
Mexican, 14, 18, 182
Puerto Rican, 18
minority, 9, 132, 163, 172
Native American, 5, 18, 25, 27,
35, 36, 37, 39, 43, 66, 78, 88,
136, 157, 161, 172, 219, 220,
245
non-Hispanic, 14
white, 5, 148, 149, 150, 157, 172,
173, 175, 185, 204, 220, 221,
226, 228, 249, 253, 272
non-Hispanic, 6, 9, 14, 19, 25,
26, 27, 28, 31, 33, 34, 35,
37, 39, 43, 45, 51, 56, 63,
64, 66, 68, 74, 77, 78, 80,
82, 88, 131, 133, 134, 135,
136, 139, 141, 143, 150,
152, 154, 161, 163, 164,
167, 172, 174, 176, 182,
194, 199, 200, 202, 208,
209, 210, 211, 212,
213, 218, 219, 228, 230,
234, 242, 245, 250, 254,
261, 264
rate
abortion, 28
age-adjusted, 162, 287
death, 6, 77, 78, 79, 133, 134,
136, 139, 141, 149, 151,
152, 167, 174, 198, 205,
212, 244, 251, 253, 254,
260
hospitalization, 133
prevalence, 153
age-specific, 259, 261
death, 6, 79, 81, 254
birth, 5, 30, 37
calculation, 14
crude, 259
death, 136, 141, 164, 172, 186,
274
cancer, 132
crude, 79
motor vehicle, 203
unintentional injury, 198
fertility
general, 25
total, 26
fetal mortality/FMR, 63, 64
infant mortality/IMR, 6, 37, 66, 68
ratio
abortion, 5, 28
disparity, 66, 68, 167, 176
sex, 63
REACH Healthcare Foundation, 228,
231
Report on Carcinogens, 131
risk factors, 253, 254
S
Score 1 for Health, 155, 156, 185,
220, 221, 228
sexual orientation
bisexual, 264
lesbian, 137, 264
men-who-have-sex-with-men,
264, 269
transgendered, 264
sexually transmitted diseases
chlamydia, 268
gonorrhea, 267, 268
syphilis, 267, 269
primary and secondary/P&S, 7
sleep, 149, 182, 218, 233, 242
socioeconomic
factors, 141
gradient, 215
resources, 56
status, 221, 228
high, 10, 132, 185
low, 10, 132, 185, 216
middle, 132
St Luke’s Hospital, 217
State Children's Health Insurance
Program, 235
State of Diabetes Complications in
America, 173
sudden infant death syndrome
SIDS, 55, 70
suicide, 6, 212, 253, 254
Surgeon General’s Report on Bone
Health and Osteoporosis, 193,
194
Susan G Komen Breast Cancer
Foundation, 137
T
The PULSE, 137, 264
tobacco
cigarette tax, 234, 235
current smokers, 135, 149, 162,
173, 218, 225, 233, 234, 237,
244
former smokers, 134, 162, 233,
234
nicotine, 244
non-smokers, 134, 149, 234, 237
pregnancy-smoking, 5, 32, 36, 43,
46, 49, 50, 51, 54, 72, 187, 236
second-hand smoke, 134, 156,
161, 162, 235, 237
smokeless, 156
smoking, 6, 132, 133, 134, 141,
156, 168, 181, 187, 193, 218,
233, 235, 241, 278
permitted, 237
prohibited, 237
restrictions, 237
smoking cessation, 234
smoking-attributable causes of
death, 235
Smoking-Attributable Mortality,
Morbidity and Economic Costs,
133, 235, 236
smoking-attributable productivity
losses, 236
smoking-related diseases, 233,
234
years of potential life lost (YPLL),
236
Trust for America’s Health, 186
tuberculosis, 270
Kansas City Tuberculosis
Sanitarium, 270
U
University of Missouri
School of Dentistry, 227
Oral Health Surveillance
Project, 228
Score 1 for Health, 228
Unnatural Causes, 9
Urban Land Institute, 188
US Census Bureau
Census 2000, 215, 287
US Department of Agriculture, 22
US Department of Commerce
Census Bureau, 13, 14
Ameican Community Survey,
14, 22
Census 2000, 13, 14, 21
US Department of Health and
Human Services, 131
Agency for Healthcare Research
and Quality, 216
Centers for Disease Control and
Prevention, 21, 49, 51, 55, 133,
172, 181, 185, 218, 221, 235,
249, 273
National Center for Health
Statisitcs, 56, 69, 73, 148,
161, 175, 197, 227, 242,
259
National Institute of
Occupational Safety and
Health, 275
Sudden Unexpected Infant
Death Investigation (SUIDI),
71
National Institutes of Health, 132,
241
National Cancer Institute, 132
National Eye Institute, 221
National Heart, Lung and Blood
Institute, 156
INDEX
Page 294 of 294
National Institute of Alcohol
Abuse and Alcoholism, 241,
245
National Institute on Drug
Abuse, 249
Substance Abuse and Mental
Health Services
Administration, 234, 242,
245, 249
Drug Abuse Warning
System (DAWN), 250
US Department of Justice
National Drug Intelligence Center,
249
US Department of Labor, 199
Bureau of Labor Statistics, 197
US Department of Transportation
INDEX
National Highway Traffic Safety
Administration, 188, 197, 203,
204, 245
US Environmental Protection
Agency, 277
US Social Security Administration,
233
V
vision, 154, 215
diabetic retinopathy, 220, 221
eye exams, 174
impaired, 215, 220, 221
presbyopia, 220
loss, 153
retinopathy, 174
screening, 220
W
water
drinking, 273, 277
recreational facilities, 277
wastewater, 277
World Health Organization, 56, 142,
216
Y
years of potential life lost, 79

Document 6424475

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