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Nationally, the most common unhealthy behavior among the five analyzed was insufficient sleep while physical inactivity had the strongest association with self-reported fair or poor health status (adjusted OR=2.9). Notably, excessive drinking had an inverse association with self-reported fair or poor health status, in both the univariable and multivariable model. This association varied across race/ethnicity, education level, and was confounded by age. Excessive drinking remained in the overall model of the five unhealthy behaviors due to the association being positive for certain race/ethnicity subpopulations (non-Hispanic blacks, OR=1.6; Hispanics, OR=1.9; American Indians, OR=1.8; and Hawaiian or Pacific Islander, OR=1.3; all compared to non-Hispanic whites).
The association between increasing number of unhealthy behaviors and fair or poor health status varied across levels of sex, race/ethnicity, education level, and income. All interaction terms were statistically significant at p<0.001. The association between MUBs and fair or poor health status differed across age group, sex, race/ethnicity, education level, and income and all interaction terms were statistically significant (p<0.001).

SMOKING

Public Health Impact

Smoking has a well-documented unhealthy impact on overall health. It is the leading cause of preventable death in the United States; approximately 14 million major medical conditions among adults are attributed to smoking. [xvii] Annually, more than 480,000 people die from cigarette smoking with nearly 42,000 deaths caused by exposure to secondhand smoke. [vii] Another 10.9 million adults suffer from a serious smoking-related illness. [xvii] Smoking damages nearly every body organ and causes respiratory disease, heart disease, stroke, cancer, preterm birth, low birthweight, and premature death. [vi], [xviii] Smokers lose an average of 10 years of life because of their smoking. [xix] Furthermore, smoking harms not only smokers, but also affects non-smokers by causing respiratory infections in children and heart disease and lung cancer in adults. [xx]
Smoking prevalence among adults in the United States has consistently decreased since 2012 from 21.2% to 18.1% in 2015.

Odds Ratio—Fair or Poor Health Status

The odds of self-reporting fair or poor health status among smokers was 1.9 compared to non-smokers (adjusted OR=1.8, controlling for other unhealthy behaviors in the model).
Smoking Prevalence by State (BRFSS 2014)


EXCESSIVE DRINKING

Public Health Impact

Excessive drinking is a leading cause of premature death in the United States, accounting for one in 10 deaths among working adults. [xxi] From 2006 to 2010 there was an annual average of 87,798 alcohol-attributable deaths and 2.5 million years of potential life lost due to excessive alcohol use. [xxi] In that same time span, an average of 12,460 motor vehicle traffic crashes were attributed to excessive drinking. [xxii] Excessive alcohol use includes binge drinking and heavy drinking; [xxiii] it can lead to fetal damage, liver diseases, high blood pressure, cardiovascular diseases, and other major health problems. [xxv]
Excessive drinking prevalence among adults in the United States decreased from 18.2% to 17.6% over 2014-2015.

Odds Ratio—Fair or Poor Health Status

The odds of self-reporting fair or poor health status is less in those who self-report as excessive drinkers compared to those who do not (unadjusted OR=0.59; adjusted OR=0.58, controlling for other unhealthy behaviors in the model). This finding is intriguing and could be due to a variety of factors, not limited to: the perceived beneficial effect of social drinking, the type of alcohol consumed, and the gradual detrimental effect of excessive alcohol use on health compared to the more immediate effect of smoking, obesity, physical inactivity and insufficient sleep on one’s perceived health status.
Excessive Drinking Prevalence by State (BRFSS 2014)







OBESITY

Public Health Impact

One of the greatest health threats to the United States is obesity. It contributes to heart disease, type 2 diabetes, stroke, certain cancers, hypertension, liver disease, kidney disease, Alzheimer’s disease, dementia, respiratory conditions, osteoarthritis, and poor general health. [xxvi] One-third of US adults are obese [xxvii], and obesity is a leading factor in preventable diseases causing an estimated 200,000 deaths per year. [xxviii] Children and teens who are obese are more likely to be obese as adults and are at increased risk for developing heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis. [xxix]
The prevalence of obesity is greater than the prevalence of smoking, and obesity is similar to smoking and excessive alcohol consumption in terms of contributing to chronic conditions and overall poor physical health. [xxx] Since the 1980s energy intake has climbed and energy expenditure has declined, leading to a growing energy imbalance that closely mirrors the obesity rates. [xxxi] There is increasing evidence illustrating the importance of environment in the obesity epidemic and the need for changes in social and physical environments in order to better facilitate lifestyle changes. [xxxii]
The prevalence of obesity among adults in the United States has increased over the past four years to reach 29.6% in 2015, with a momentary dip in 2013 to 27.6%.

Odds Ratio—Fair or Poor Health Status

The odds of self-reporting fair or poor health status among the obese population was 2.2 compared to the non-obese population (adjusted OR=2.0, controlling for other unhealthy behaviors in the model).

Obesity Prevalence by State (BRFSS 2014)








PHYSICAL INACTIVITY

Public Health Impact

Physical inactivity increases the risk of developing cardiovascular disease, type 2 diabetes, hypertension, obesity, certain cancers, depression, and premature death. [xxxiii–xxxiv] Only 21.0% of adults meet 2008 physical activity guidelines. [xxxv] Non-Hispanic white adults report more aerobic and muscle strengthening physical activity than non-Hispanic black and Hispanic adults. [xxxv] Increasing physical activity, especially from a baseline absence of activity, prevents numerous chronic diseases and aids in their management. [xxxvi] It is estimated that physical inactivity is responsible for almost one in 10 deaths annually. [xxviii] Physical inactivity is associated with many social and environmental factors including low educational attainment, socioeconomic status, violent crime, and poverty. [xi] Socioeconomic status and education moderate the relationship between race and physical inactivity; [xxxviii] adults with higher education or those with higher incomes are more likely to be physically active than those with low education or low income. [xxix]
Since 2012, there has been a decrease on average in the prevalence of physical inactivity or a sedentary lifestyle among adults in the United States (26.2% in 2012 to 22.6% in 2015).

Odds Ratio—Fair or Poor Health Status

The odds of self-reporting fair or poor health status among the physically inactive population compared to the physically active outside of work population was 3.3 (adjusted OR=2.9, controlling for other unhealthy behaviors in the model).
Physical Inactivity Prevalence by State (BRFSS 2014)

INSUFFICIENT SLEEP

Public Health Impact

Insufficient sleep has become a public health epidemic over the last two decades. [xxxix] An estimated 70 million US adults suffer from chronic sleep and wakefulness disorders. [xl] Sleep is an important determinant of overall health and well-being. Adequate sleep is necessary for optimal sugar metabolism and functioning of the immune system. CDC’s surveillance of sleep behavior has expanded to include data on outcomes associated with sleep insufficiency such as motor vehicle crashes and occupational errors. [xxxix] An estimated 1,500 fatal car accidents and 40,000 non-fatal injuries annually are the result of drowsy drivers. [xxxix] Adults who average fewer than seven hours of sleep nightly are more likely to have chronic illnesses including obesity, diabetes, cancer, hypertension, and depression; they are also more likely to have a reduced quality of life and productivity. [xli]
Insufficient sleep prevalence among adults in the United States decreased slightly from 35.3% to 34.2% over 2014-2015.

Odds Ratio—Fair or Poor Health Status

The odds of self-reporting fair or poor health status among the population with insufficient sleep compared to the population with 7 or more hours of sleep was 1.9 (adjusted OR=1.7, controlling for other unhealthy behaviors in the model).
Insufficient Sleep Prevalence by State (BRFSS 2014)



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