Supplemental Measures

Introduction Findings Comparison With Other Nations Core Measures Behaviors Community & Environment Policy Clinical Care Outcomes Supplemental Measures State Summaries
Alabama
US SummaryAppendixDescription of Core Measures Description of Supplemental Measures Methodology Model Development Scientific Advisory Committee The Team Acknowledgements Conclusion
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Behaviors
Binge Drinking
Excessive alcohol use caused 1 in 10 deaths among adults aged 20 to 64 years from 2006 to 2010; more than half were from binge or heavy episodic drinking. Roughly 38 million US adults binge drink 4 times monthly (average). Surprisingly, 90% of binge drinkers are not alcohol dependent. Excessive drinking contributes to fetal damage, liver diseases, hypertension, and cardiovascular diseases. Binge drinking contributes to motor vehicle injuries and deaths, increased aggression, injuries, and risky sexual behavior leading to unintended pregnancies and sexually transmitted infections. Excessive drinking cost $223.5 billion nationally in 2006, largely from workplace-productivity losses. 

Data source: Behavioral Risk Factor Surveillance System, 2014 
For details: www.americashealthrankings.org/ALL/Binge  

Chronic Drinking
Consuming 8 or more drinks per week for women and 15 or more drinks per week for men is considered chronic or heavy drinking. The prevalence of chronic drinking among US adults was 5% in 2009, up from 3% in 1993. Excessive drinking contributes to fetal damage, liver diseases, hypertension, cardiovascular diseases, and other health problems. The 2006 US excessive drinking cost was $223.5 billion, or $746 per person, in missed work, additional health care expenses, and increased crime. Healthy People 2020 goal: reduce average annual alcohol consumption from 2.3 to 2.1 gallons per person.  

Data source: Behavioral Risk Factor Surveillance System, 2014 
For details: www.americashealthrankings.org/ALL/chronic_drinking

Cholesterol Check 
Elevated total serum cholesterol is a major and modifiable risk factor for heart disease, the US’s leading death cause. Approximately 1 in 6 people have high cholesterol, which has no symptoms but increases risk of stroke, cardiovascular disease, and premature death. A blood test measures total cholesterol, LDL (low-density lipoprotein, “bad” cholesterol), HDL (high-density lipoprotein, “good” cholesterol), and triglycerides. Reducing LDL is the primary goal. Mean total serum cholesterol level for US adults aged 20 years or older from 2009 to 2012 was 196 mg/dL; 13.4% had total cholesterol greater than or equal to 240 mg/dL. 

Data source: Behavioral Risk Factor Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/cholesteroltest 

Dental Visit, Annual
In 2013, 62% of adults aged 18 to 64 and 83% of children had a dental visit. Cost was the biggest obstacle; 42% could not afford treatment or did not have dental insurance. Other obstacles: fear, low oral health literacy, and limited access to and availability of dental services. Preventive dental services use is low in non-Hispanic blacks, Hispanics, low-income families, and families with low educational attainment by head of household. These groups have more untreated tooth decay than the general population. The Institute of Medicine recommends increasing dental workforce diversity to improve patient access, satisfaction, and communication.

Data source: Behavioral Risk Factor Surveillance System, 2014  
For details: www.americashealthrankings.org/ALL/dental

Fruits
Roughly half of US adults suffer from 1 or more preventable chronic diseases related to poor diet and physical inactivity. High fruit-and-vegetable diets reduce the risk of chronic diseases and assist with weight management. Unfortunately, US adults consume fruits about 1.1 times daily and vegetables about 1.6 times daily. The first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study showed a 27% reduction in cardiovascular disease mortality and a 15% decrease in all-cause mortality in those consuming fruits and vegetables 3 or more times daily compared with those eating them less than once daily. 

Data source: Behavioral Risk Factor Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/fruit  

Vegetables 
Epidemiological data show quantity, not variety, of fruit and vegetable intake associates with lower cardiovascular disease risk. The first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study showed a 27% reduction in cardiovascular disease mortality and a 15% decrease in all-cause mortality in those consuming fruits and vegetables 3 or more times daily compared with those consuming them less than once daily. Higher fruit-and-vegetable intake is also associated with a lower risk of myocardial infarction, ischemic heart disease, and ischemic stroke. Unfortunately, US adults daily consume fruits about 1.1 times and vegetables about 1.6 times. 

Data source: Behavioral Risk Factor Surveillance System, 2013 
For details: www.americashealthrankings.org/ALL/Veggie 
 
Insufficient Sleep 
Insufficient sleep has become a public health epidemic. About 70 million US adults suffer from chronic sleep and wakefulness disorders. According to the National Center on Sleep Disorders Research, “each year, sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national health care bill. Additional costs to society for related health problems, lost worker productivity, and accidents have not been calculated.” Adults averaging fewer than 7 hours of sleep nightly are more likely to have obesity, diabetes, cancer, hypertension, and depression. National Sleep Foundation nightly goals: adults 7 to 9 hours, children 9 to 11. 

Data source: Behavioral Risk Factor Surveillance System, 2014   
For details: www.americashealthrankings.org/ALL/sleep

Teen Birth Rate 
CDC estimates teen pregnancy and childbirth accounted for $9.4 billion in increased health care and foster care costs in 2010 due to “increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers.” The teen birth rate declined 57% since 1991. The 2012 to 2013 decline was greatest in non-Hispanic black and American Indian Alaskan Native teenagers (11%) followed by Hispanic and Asian Pacific Islander teenagers (10%). However, Hispanic and non-Hispanic black rates remain twice that of non-Hispanic whites. Policies supporting family planning and education help lower teen birth rates. 

Data source: National Vital  Statistics Reports, 2013
For Details: www.americashealthrankings.org/ALL/teenbirth

Youth Smoking
More than 21% of high school students use tobacco. By race and ethnicity, white students have the highest prevalence. Youth smoking cost is realized in adulthood with an annual average of $130 billion in direct medical costs and $150 billion in productivity losses. Nearly 90% of adult daily smokers started before age 18, and nearly 100% of adults who smoke daily started smoking when they were younger than 26 years. Electronic cigarettes were the most commonly used tobacco product among high school (13.4%) and middle school (3.9%) students in 2014, with no use difference between males and females.   

Data source: Youth Risk Behavior Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/youthsmoking  

Youth Obesity 
Obesity affects 1 in 6 young people and contributes to heart disease, diabetes, stroke, certain cancers, and poor general health. Overweight adolescents are 10 times more likely to have at least 2 risk factors for adult obesity and biochemical abnormalities versus normal weight adolescents. Among obese children, 70% have at least 1 cardiovascular disease risk factor; 39% have 2 or more. The South has the greatest geographic prevalence of youth obesity. Direct economic costs of childhood obesity are an estimated $14.2 billion annually, including inpatient and outpatient visits and annual prescription drug costs.  

Data source: Youth Risk Behavior Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/youthobesity  
 
Chronic Disease
Heart Disease 
In 2011, 375,000 deaths were attributable to coronary heart disease (CHD). By 2030, CHD prevalence is projected to increase 16.6% from 2010 estimates, affecting 9.3% of the US population. An estimated 44% decline in CHD deaths from 1980 to 2000 was attributable to increasing physical activity and lowering total cholesterol, systolic blood pressure, and smoking prevalence. For men with 2 or more risk factors, the lifetime risk of CHD is 37.5%; for women, 18.3%. CHD’s estimated economic cost will exceed $129 billion annually in 2015; direct and indirect costs are projected to exceed $218 billion annually by 2030. 

Data source: Behavioral Risk Factor Surveillance System, 2014  
For details: www.americashealthrankings.org/ALL/CHD  

High Cholesterol
Total blood cholesterol higher than 240 mg/dL is unhealthy. Among US adults, 73.5 million have high cholesterol; only 48.1% of them receive treatment, and less than a third manage their condition. Because there are no symptoms for high cholesterol, adults over age 20 should have their cholesterol checked with a blood test every 5 years. High cholesterol is a risk factor for heart disease including heart attack and stroke; high cholesterol doubles the risk of heart attack. To lower cholesterol, eat vegetables, beans, whole grains, nuts, and seafood instead of solid fats, added sugars, refined grains, and red meat.  

Data source: Behavioral Risk Factor Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/High_Chol  

Heart Attack
An estimated 525,000 heart attacks and 210,000 recurrent heart attacks occur yearly in US adults aged 35 years and older; 15% of those die as a result. The average age at first heart attack, or myocardial infarction (MI), is 65 years for men and 71.8 years for women. Adjusting for age, patient, and hospital characteristics, black men, white men, and white women have similar in-hospital mortality rates; black women have the highest. Black women have the lowest rate of in-hospital interventions for acute MI treatment. MI’s estimated direct and indirect costs were $11.5 billion in 2010. 

Data source: Behavioral Risk Factor Surveillance System, 2014  
For details: www.americashealthrankings.org/ALL/MI  

Stroke
Roughly 800,000 people yearly experience a new or recurrent stroke, which is among the 5 leading causes of US deaths. Strokes cost an estimated $67.7 billion annually in direct medical costs and indirect costs (lost productivity). A higher incidence is among white women >85 years of age compared with men of the same age, and in blacks versus whites. Prevalence is greater in people with lower income levels and educational attainment, and in those in the southeastern US. Stroke prevalence is estimated to increase 22% by 2030, with the greatest increase (29%) in Hispanic men. 

Data source: Behavioral Risk Factor Surveillance System, 2014  
For details: www.americashealthrankings.org/ALL/stroke

High Blood Pressure
High blood pressure is a modifiable risk factor for heart disease and stroke, 2 of the 5 leading causes of US death. Hypertension often has no symptoms and is estimated to afflict 1 in 3—or 70 million—Americans. Only 52% of those with hypertension have it controlled, and many do not know they have it. Hypertension expenses—medical, medication, and lost productivity costs—are an estimated $46 billion annually. Blacks are more likely to develop high blood pressure than whites and Hispanics, and blacks are more likely to develop it at a younger age. Reducing sodium could prevent 11 million hypertension cases annually. 

Data source: Behavioral Risk Factor Surveillance System, 2013  
For details: www.americashealthrankings.org/ALL/hypertension

Clinical Care 
Preterm Birth
There are 500,000 US preterm births yearly, or 1 in 9 births. In 2010, 35% of all infant deaths were attributed to preterm birth. Late-preterm babies (34 to 37 weeks) are usually healthier than babies born earlier but are 3 times more likely to die in the first year than full-term infants. Preterm birth is associated with low or high maternal age, low maternal income or socioeconomic status, single marital status, tobacco and alcohol use, substance abuse, late prenatal care, stress, and occupational and environmental exposures. Blacks are 60% more likely to experience a preterm birth than whites. 

Data source: National Vital Statistics System, 2013  
For details: www.americashealthrankings.org/ALL/preterm

Community & Environment
Personal Income 
Personal income reflects a person’s ability to make purchases supporting a healthy lifestyle, preventive medicine, and curative care. National Longitudinal Mortality Survey data indicate the relative risk of premature death decreases with increasing family income, adjusted for sex and age. The most significant mortality increase occurs at incomes below $30,000; this increase flattens out above $35,000. Data exclude non-family households and therefore have limitations. This relationship is independent of the classification of poverty, meaning people with low personal income—regardless of if they are classified as living in poverty—are more likely to have poorer health than higher income people.   

Data source: US Bureau of Economic Analysis, 2014  
For details: www.americashealthrankings.org/ALL/income

Median Household Income
Median household income (MHI) reflects a household’s ability to afford a healthy diet, preventive medicine, and curative care. MHI tends to more accurately reflect the “typical” household than does average household income, which is based on a mean and can be distorted by a few extremely wealthy households. The 2013 US MHI was $51,939. Compared with 2012, there was no statistically significant difference in 2013 MHI across all socioeconomic groups. The largest difference in health is between those with the highest and lowest incomes, and at every income level there are health differences between those with lesser versus those with higher income.

Data source: US Census Bureau, 2014 
For details: www.americashealthrankings.org/ALL/medianincome  

Unemployment Rate
Unemployed adults are more burdened by medical care costs than those employed, more likely to experience delays in treatment, and report more chronic disease and poorer physical and mental health. Unemployment is also associated with an increase in unhealthy behaviors such as poor diet, lack of exercise, tobacco use, and excessive alcohol consumption. The US’s most common form of health insurance is employer-sponsored, and unemployment provides information about the number of uninsured. From 2009 to 2010, 81.4% of employed adults aged 18 to 64 had health insurance compared with only 48.1% of unemployed adults.

 Data source: US Bureau of Labor Statistics, 2014  
 For details:www.americashealthrankings.org/ALL/unemployed

Underemployment Rate
Underemployment is associated with a lack of health insurance and potentially leads to heightened stress, depression, and decreased earnings—all contributors to poor health. The underemployed are more likely than others to report lower levels of general well-being, while those underemployed based on income alone report more depression and alcohol abuse. Women experience income-related underemployment 4 times more than men, and non-white women are underemployed twice as much as white women. Young and old workers are at higher risk of underemployment than middle-aged workers. Among native-born and ethnic immigrant workers, Asian men and women are most underemployed by skill. 

Data source: US Bureau of Labor Statistics, 2014
For details: www.americashealthrankings.org/ALL/underemployed

Income Disparity
US income disparity increased over the past 45 years due to real median family income falling while the top tier of income distribution experienced growth. Countries with greater income disparity have higher rates of obesity, imprisonment, violence, and chronic stress as well as less social cohesion and trust. Individuals in states with the largest income disparity were 30% more likely to self-report poor health compared with individuals in states with the smallest income disparity. Most developed European nations and Canada have Gini indices between 0.22 and 0.38, while the United States Gini index has stayed between 0.45 and 0.48 since the mid-1990s.

Data source: US Census Bureau, 2014
For details: www.americashealthrankings.org/ALL/gini

Outcomes
High Health Status
Research shows those with a higher self-reported health status have lower rates of mortality from all causes than those with lower self-reported health status. The subpopulation with the highest proportion reporting very good or excellent health is white adults without disabilities. A greater proportion of men report good or better health compared with women. Adults aged 18 to 44 have a higher self-reported health status than adults aged 65 and older. Adults aged 25 years and older who have an advanced degree report good or better physical and mental health more often than those with less than a high school education.

Suicide 
There were more than 41,000 deaths by suicide in 2013, making it the 10th-leading cause of death. Firearm discharge caused about half of those deaths. Each year 2.5 times as many deaths occur from suicide than from homicide. For each successful suicide there are 10 attempted suicides; many lead to hospitalizations and indicate how poor mental health burdens the population. While the highest suicide rate occurs in white men aged 50 to 59, suicide is of great concern in young adult populations. The suicide rate in 2013 among American Indian/Alaska Native men aged 20 to 24 was 34.6 per 100,000, much higher than the overall rate of 21.8 for all males in this age group. 

Data source: National Vital Statistics System, 2013
For details: www.americashealthrankings.org/ALL/suicide
Injury Deaths
Unintentional injuries are the fourth-leading cause of mortality, with accidental poisonings, motor vehicle accidents, and falls the top 3 contributors. Leading causes of intentional injury fatalities include suicide by firearm, homicide by firearm, and suicide by suffocation. Suicide is the 10th-leading cause of US deaths. Firearm discharge causes more than half of suicides, and 2.5 times as many yearly deaths are from suicide as homicide. Drugs cause the majority of poisonings, and 81% of drug poisoning deaths are unintentional. Unintentional and intentional injury fatalities had a 2010 economic burden—due to work loss and medical costs—of nearly $190 billion.

Data source: National Vital Statistics System, 2011 to 2013 
For details: www.americashealthrankings.org/ALL/injury_deaths

  Behaviors
High School Graduation (AFGR)
Studies show if the health of less-educated Americans equaled that of college-educated Americans, health improvements would result in more than $1 trillion in savings annually. College graduates’ life expectancy is 5 years longer than those who did not complete high school. For those without a high school education, life expectancy has decreased since the 1990s. Individuals with more education are less likely to smoke, drink heavily, or be overweight or obese; they are more likely to have a higher earning potential and better employment opportunities, allowing for access to healthier food, health insurance, medical care, and safe neighborhoods.

Data source: Compiled from State Education Departments’ websites, phone interviews, and NCES enrollment data 
For details: www.americashealthrankings.org/ALL/Graduation
Behaviors

Binge Drinking

Chronic Drinking

Cholesterol Check

Dental Visit, Annual

Fruits

Vegetables

Insufficient Sleep

Teen Birth Rate

Youth Smoking

Youth Obesity

Chronic Disease

Heart Disease

High Cholesterol

Heart Attack

Stroke

High Blood Pressure

Clinical Care

Preterm Birth

Community & Environment

Personal Income

Median Household Income

Unemployment Rate

Underemployment Rate

Income Disparity

Outcomes

High Health Status

Suicide

Injury Deaths

Behaviors

High School Graduation (AFGR)

Reports

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