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Atlas of Heart Disease

Among American Indians and Alaska Natives
Suggested Citation

Cobb N. 

Natives. Atlanta, GA: U.S. Department of Health and Human Services, Centers

for Disease Control and Prevention and Indian Health Service; 2005.

Cover photographs are copyrighted and were provided by the following sources:

E­mail: ccdinfo@cdc.gov

National Center for Chronic Disease Prevention

and Health Promotion

Atlas Project

4770 Buford Highway NE

MS K­47

Call:  1­888­232­2306 (toll free inside the United States)

Online

Acknowledgments

The authors would like to thank the following people

for their valuable contributions to the publication of

Labarthe for their continued support and enthusiasm;

for their initial vision and expertise in developing the

first three atlases of heart disease and stroke; Mark

Conner for his wonderful creativity and talent in developing the cover design; Mark Harrison for desktop

and her graciousness in assisting with analyses at a

critical time; Kan Zheng for his valued assistance

with data entry and quality control; and the following

reviewers for their helpful comments on earlier drafts:

Kurt J. Greenlund and H. 

Center for Chronic Disease Prevention and Health

Promotion (NCCDPHP), CDC, and Phil Smith,

Indian Health Service.

In addition, the authors would like to acknowledge

National Center for Health Statistics in maintaining the

rigorous and systematic surveillance work performed

state departments of health, producing this  Atlas of

would not be possible.

Casper ML, Denny CH, Coolidge JN, Williams GI Jr, Crowell A, Galloway JM,

Atlas of Heart Disease and Stroke Among American Indians and Alaska

Cover Photos

Jim  West and The Image Works (photographers Bob Daemmrich, EastcottMomatiuk, James Fossett, Willie Hill, Jack Kurtz, and David Lassman).

For Free Copies

Write:

Division of Adult and Community Health

Atlanta, GA 30341­3717

To view interactive maps of heart disease and stroke mortality or download

sections of this atlas, visit http://www.cdc.gov/cvh/maps.

this atlas: Janet Croft, George Mensah, and Darwin

Elizabeth Barnett, Joel Halverson, and Valerie Braham

publishing; Andrea Saddlemeir for her SAS expertise

Wayne Giles, National

the exceptional work performed by CDC staff in the

National Vital Statistics System, as well as that of

CDC staff in NCCDPHP in maintaining the Behavioral Risk Factor Surveillance System. Without the

by these staff members in close collaboration with

Heart Disease and Stroke  Among  American Indians

and Alaska Natives
l i

i i

l i

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention 

Indian Health Service

Michele L. Casper 

Clark H. Denny 

Jonathan N. Coolidge 

G. Ishmael Williams, Jr. 

Amanda Crowell 

James M. Galloway 

Nathaniel Cobb 

At as of Heart D sease 

and Stroke Among 

Amer can Ind ans 

and A aska Nat ves 

A Message from the Director of CDC 

As the nation’s prevention agency, the Centers for Disease Control and Prevention (CDC) is committed to reducing the burden of heart

disease and stroke, which are the first and third leading causes of death and major contributors to disability in the United States. These

two cardiovascular diseases are largely preventable, and targeted public health efforts can help reduce their impact. To meet this challenge, CDC works to monitor temporal and geographic trends in heart disease and stroke rates among different racial and ethnic groups,

to strengthen the delivery of primary and secondary preventive health services to all such groups, and to implement policy changes that

support the alleviation of disparities among all U.S. residents.

Among American Indians and Alaska Natives, heart disease and stroke are the first and sixth leading causes of death. I am pleased to

provide you with the Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives, which presents the mortality rates

and distribution of common risk factors for these diseases for this population in geographic units that allow communities to see where

they stand. This information is essential to helping health professionals and policy makers at local, state, and national levels identify

populations at greatest risk for cardiovascular disease and in greatest need of prevention efforts. This atlas provides county-level maps

of heart disease and stroke mortality, as well as state maps of the geographic patterns of common risk factors. The magnitude of the

burden of these risk factors also is compared for American Indians and Alaska Natives, Asians and Pacific Islanders, blacks, Hispanics,

and whites. The comprehensive information provided in this atlas will allow health officials to tailor their prevention efforts to specific

communities as needed.

This publication is the fourth in a series of CDC atlases related to cardiovascular disease. However, it is the first to focus on geographic

patterns of heart disease and stroke mortality and risk factors for a specific racial/ethnic group in the United States. I encourage you

to use these data to improve the delivery of preventive health services and to create heart-healthy and stroke-free living and working

environments for all American Indians and Alaska Natives.

Julie Louis Gerberding, MD, MPH

Director

Centers for Disease Control and Prevention

iii

A Message from the Director of IHS

The Indian Health Service (IHS), an agency of the U.S. Department of Health and Human Services (HHS), is the principal federal health

care provider and advocate for the health of American Indians and Alaska Natives. Employing a community-based system of care, the

IHS is the primary source of personal and public health care services for the majority of the nation’s estimated 2.4 million American

Indians and Alaska Natives. The IHS is the only source of care for the many American Indian and Alaska Native people who live on or

near a reservation in remote and poverty-stricken areas of the country where other sources of health care are less available.

Heart disease has become the leading cause of death among American Indians and Alaska Natives, and stroke is the sixth leading 

cause of death. The incidence of coronary heart disease among American Indians and Alaska Natives occurs at rates almost double 

that of non-Indian communities. In addition to the higher rates of cardiovascular disease compared with the general U.S. population, 

the burden of premature cardiovascular disease among the American Indian and Alaska Native population also appears greater than 

for other racial and ethnic populations in the United States.

The Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives provides insights into the geographic disparities 

in heart disease and stroke experienced by American Indians and Alaska Natives. Health information contained in publications such 

as this will support efforts at the community level—developed by the community and focused on the individual and the community 

as a whole—in conjunction with the support and collaborative efforts of public health institutions, federal and state agencies, universities, and service organizations, to eliminate cardiovascular disease among American Indians and Alaska Natives. 

The Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives provides information to assist in the successful 

implementation of efforts to reach the two overarching goals of Healthy People 2010, which are “. . . to increase the quality and years 

of healthy life and to eliminate health disparities,” and to support the successful implementation of HHS’s Steps to a HealthierUS 

Initiative. This publication is an important and significant step toward these goals. 

Charles W. Grim, DDS, MHSA

Assistant Surgeon General

Director, Indian Health Service

v

Foreword

I am pleased to present the Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives. The maps in this atlas

highlight the great diversity—in culture, language, history, and the burden of heart disease and stroke—that exists among American

Indian and Alaska Native populations of the United States.

This landmark document supports the elimination of health disparities, one of the two overarching goals of Healthy People 2010, and

addresses the important need to reduce the risk for heart disease and stroke among American Indians and Alaska Natives. The maps

in this atlas present county-by-county heart disease and stroke mortality rates, as well as state-specific prevelances of eight major risk

factors for heart disease and stroke. Public health professionals at local, state, and national levels will be able to use this information to

tailor prevention resources to the populations of American Indians and Alaska Natives who need additional services the most.

Mortality trends for heart disease and stroke indicate that the rate of decline among American Indians and Alaska Natives has been

relatively slow since the early 1970s. This observation is in stark contrast to the large declines in heart disease and stroke mortality

reported for the total U.S. population during the same period. These alarming trends underscore the importance of enhancing our efforts

to support innovative, community-based strategies for reducing the risk for heart disease and stroke among American Indians and

Alaska Natives. We can expect to achieve the greatest cardiovascular health benefits through prevention. The Atlas of Heart Disease

and Stroke Among American Indians and Alaska Natives indicates where prevention programs and policies are most needed and can

have the greatest benefit.

We hope that you will find this publication to be a valuable resource as you design programs and policies to prevent heart disease and

stroke in your communities.

Darwin R. Labarthe, MD, MPH, PhD

Acting Branch Chief, Cardiovascular Health Branch

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

Foreword vii

Contents

A Message from the Director of CDC . . . . . . . . . . . . . iii

A Message from the Director of IHS . . . . . . . . . . . . . . . v

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Section 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Section 2. National Maps of Heart Disease and Stroke Mortality Among American Indians and Alaska Natives . . . . . . . . . . . . . . . . . . .7

Section 3. Risk Factors for Heart Disease and Stroke Among American Indians and Alaska Natives, by State . . . . . . . . . . . . . . . . . . . .17

Appendix A. Risk Factors for Heart Disease and Stroke Among the Total U.S. Population, by State . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Appendix B. Methodological and Technical Notes . . . 61

Appendix C. Resources . . . . . . . . . . . . . . . . . . . . . . . . 71

About the Authors . . . . . . . . . . . . . . . . Inside Back Cover

Contents ix
Introduction 1

©Eastcott-Momatiuk/The Image Works
Introduction

During the last four decades, significant changes have occurred 

in the health of American Indian and Alaska Native (AI/AN) 

people. Although infectious diseases such as tuberculosis and 

gastroenteritis were rampant among Native Americans in the 

first half of the 20th century, they are no longer ranked in the 

leading causes of death and disability for this population.1

With many infectious diseases under control today, AI/AN 

people are living longer. Like many other Americans, they are 

now experiencing chronic diseases such as heart disease and 

stroke as dominant risks to their health and longevity.

Disease Burden 

Heart disease and stroke are the first and sixth leading causes 

of death, respectively, among AI/AN people,2 as well as major 

causes of disability. Mortality trends for heart disease indicate 

that the rate of decline among AI/AN people has been relatively slow since 1972, with virtually no decline from 1989 

through 1997.2 This trend is in stark contrast to the large 

declines in heart disease mortality reported for the total U.S. 

population since the early 1970s.2,3 Consequently, although 

heart disease death rates for AI/AN people were 21% lower 

than the total U.S. population in the early 1970s, they were 

20% higher by the late 1990s.2

A similar trend exists for stroke mortality. From 1972 through 

1985, stroke death rates for AI/AN people declined, but at a 

slower rate than that reported for the total U.S. population.2

From 1985 through 1997, virtually no decline in stroke death 

rates was reported for the AI/AN population. By the end of 

the 1990s, stroke death rates were 14% higher for AI/AN 

people than for the total U.S. population.2

Recent studies of individual AI/AN tribes and communities

highlight the heavy burden of heart disease among AI/AN

people.4,5 In 1999, the National Heart, Lung, and Blood

Institute (NHLBI) funded the Strong Heart Study, which

was conducted among 13 tribes. The study reported that the

incidence of coronary heart disease among American Indians

was nearly double that reported in the Atherosclerotic Risk in

Communities (ARIC) Study of atherosclerosis in four nonIndian communities.6 Other recent studies have reported that

both the prevalence of heart disease and the percentages of

premature deaths are higher among Native Americans than

among any other racial or ethnic group in the United States.7,8

Risk Factors 

During the past several decades, marked increases in the prevalence of many risk factors for heart disease and stroke have 

been reported among AI/AN people.4 These increases place 

AI/AN populations at increased risk for subsequent rises in 

death rates from heart disease and stroke. In 2003, the Centers 

for Disease Control and Prevention (CDC) reported that the 

prevalence of self-reported obesity among AI/AN people was 

23.9%, diabetes was 9.7%, cigarette smoking was 32.2%, and 

physical inactivity was 32.5%.9 All are risk factors for heart 

disease and stroke.

In addition, two recent studies that collected extensive data

on heart disease and stroke risk factors among specific AI/AN

communities found high prevalences of insulin resistance syndrome, renal injury, lower extremity arterial disease, hypertension, elevated cholesterol levels, and diabetes. These studies

included the Inter-Tribal Heart Project conducted collaboratively by CDC, the Indian Health Service (IHS), and tribal

leaders of the Menominee Reservation in Wisconsin and two

Chippewa Reservations in Minnesota,10–16 as well as the Strong

Heart Study conducted among 13 tribes in Arizona, Oklahoma,

North Dakota, and South Dakota.17–20

Diabetes is a particularly important risk factor for heart disease

and stroke among AI/AN people because diabetes prevalence

in this population is increasing so rapidly. Before World War

II, diabetes was uncommon in this population.21 Today, an

estimated 9.7% of the AI/AN population has diabetes, compared

with 5.7% of non-AI/AN populations in the United States.9 The

diabetes death rate was 52.8/100,000 among AI/AN people during 1996–1998, compared with 13.5/100,000 for all U.S. racial

and ethnic groups.2 In a study of people hospitalized for stroke in

2 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Arizona during 1990–1996, the prevalence of diabetes was nearly twice as high for AI/AN people (62%) as it was for Hispanics

(36%) and more than three times as high as for whites (17%).22

Data Limitations 

There is a paucity of data on the burden of heart disease 

and stroke among AI/AN people in the United States. Data 

that are collected as part of national surveys are limited by 

very small sample sizes. For example, the series of National 

Health and Nutrition Examination Surveys (NHANES I, II, 

and III), which collected information on medical histories, 

demographics, and behaviors related to health and nutrition 

for the civilian, noninstitutionalized population of the United 

States, did not report data for AI/AN populations because the 

sample sizes were too small. Data that are collected for individual tribes and communities do not necessarily represent the

overall Native American population because of the large variations in the prevalence of risk factors, as well as the disparities

in mortality observed among different tribes and communities

across the United States.9,23

Mortality data for AI/AN people are more readily available 

than survey data. CDC’s National Center for Health Statistics 

maintains a database of death certificates for all U.S. citizens. However, AI/AN people are sometimes misreported 

as “white” on death certificates, especially in areas distant 

from traditional AI/AN reservations.2 A 1996 study by the 

IHS found that the degree of misreporting varied from 1.2% 

in Arizona to 28% in Oklahoma and 30.4% in California.24 

Another report found that race was coded incorrectly on death 

certificates for 26.6% of AI/AN people nationwide.25

To address the problem of misreporting of AI/AN race on death

certificates, the death rates presented in the most recent edition

of Trends in Indian Health have been adjusted to account for

misreporting.2A recentstudy highlights how the misreporting of

AI/AN race hasled to underestimates of mortality ratesfor heart

disease and stroke among AI/AN people when the data were not

adjusted to account for this misreporting.26 The results of this

study indicate that after adjustment for misreporting, the mortality rates for heart disease and stroke among AI/AN people

(195.9 per 100,000) were substantially higher than those among

whites (159.1) or those among the total U.S. population (166.1)

and that the magnitude of these disparities is increasing over

time.26 Unfortunately, because adjustment factors are not available at the county level, the maps of heart disease and stroke

mortality rates in this atlas are based on data that have not been

adjusted for misreporting of race among AI/AN decedents.

Looking Ahead 

The data that are available for AI/AN people have increased

awareness among members of the public health community,

health care practitioners, and Native Americans of the significance and severity of heart disease and stroke among AI/AN

populations. Effectively preventing heart disease and stroke in

this population and reducing disparities in both the prevalence

of these conditions and the quality of care available requires

an innovative and multidimensional approach. Prevention

strategies should be more intensive to address the growing risk

factors, and they should be culturally appropriate, taking into

account the wide variations among tribes and communities.

These strategies should be developed in partnership with tribal

and AI/AN communities with input from individuals, their

families, and community organizations.

As part of CDC’s Racial and Ethnic Approaches to Community 

Health (REACH) 2010 project, eight AI/AN communities are 

establishing community coalitions, identifying priority concerns, and implementing programs and policies designed to 

reduce people’s risk for chronic diseases such as heart disease 

and stroke. During 2001–2002, the REACH 2010 Risk Factor 

Survey was conducted in 21 minority communities, including two AI communities. The study reported that American 

Indians had the highest prevalences of cardiovascular disease, 

obesity, current smoking, and diabetes.27 These results underscore the need for enhanced national efforts to eliminate the 

heavy burden of cardiovascular disease and its risk factors 

among AI/AN populations.

Introduction 3
Strong support from national public health agencies and 

institutions—such as that provided currently by IHS, CDC, 

and NHLBI—is also important. These agencies are part of 

the U.S. Department of Health and Human Services (HHS), 

which has established national health objectives for the next 

decade, including the overarching goals of increasing quality 

and years of healthy life and eliminating health disparities 

among racial and ethnic groups.28 By highlighting the burden 

of heart disease and stroke among Native Americans, this 

Atlas of Heart Disease and Stroke Among American Indians 

and Alaska Natives can help achieve these goals.

Indian Health Service 

The IHS is a subagency of HHS and is responsible for 

providing federal health services to AI/AN people.29 This 

responsibility is based on the special relationship between the 

federal government and the 560 Native American tribes that 

it recognizes. This government-to-government relationship is 

based on Article 1, Section 8, of the U.S. Constitution and has 

been given form and substance by numerous treaties, laws, 

Supreme Court decisions, and executive orders.

The IHS is the federal health care provider and health advocate for AI/AN people. Services are provided directly and 

through health programs contracted to and operated by individual tribes. The federal system consists of 36 hospitals, 61 

health centers, 49 health stations, and 5 residential treatment 

centers. Another 34 urban health projects provide a variety of 

health and referral services.

The agency strives to ensure that comprehensive, culturally

acceptable personal and public health services are available and

accessible to AI/AN people. Its mission is to work in partnership

with AI/AN people to raise the physical, mental, social, and

spiritual health of this population to the highest level possible.

In addition, the IHS is responsible for educating people 

who work in health delivery programs that AI/AN people 

are American citizens who are eligible for services from all 

federal, state, and local health programs. In addition, the IHS 

is the principal federal health advocate for building health 

coalitions, networks, and partnerships with tribal nations, 

other government agencies, and nonfederal organizations 

(e.g., academic medical centers, private foundations) for the 

benefit of AI/AN people.

The delivery of IHS health services is managed by local 

administrative units called service units, which serve the 

same function as county or city health departments. Some 

service units are responsible for several small reservations, 

while some large reservations are served by several different 

service units.

Service units also are grouped into larger management 

jurisdictions on the basis of cultural, demographic, and 

geographic characteristics of different tribes. These larger 

jurisdictions are administered by the following 12 area 

offices: Aberdeen, Alaska, Albuquerque, Bemidji, Billings, 

California, Nashville, Navajo, Oklahoma, Phoenix, Portland, 

and Tucson.

1. Young TK. The Health of Native Americans—Towards a Biocultural 

Epidemiology. New York: Oxford Press; 1994.

2. Indian Health Service. Trends in Indian Health, 2000–2001 Rockville, 

MD: U.S. Department of Health and Human Services; February 2004.

3. CDC. Decline in deaths from heart disease and stroke—United States,

1900–1999. Morbidity and Mortality Weekly Report 1999;48(30):649–56.

4. Galloway JM. The epidemiology of atherosclerosis and its risk factors

among Native Americans. Current Diabetes Reports 2002;2(3):274–81.

5. Sewell JL, Malasky BR, Gedney CL, Gerber TM, Brody EA, Pacheco 

EA, et al. The increasing incidence of coronary artery disease and 

cardiovascular risk factors among a Southwest Native American tribe: 

the White Mountain Apache Heart Study. Archives of Internal Medicine

2002;162(12):1368–72.

6. Howard BV, Lee ET, Cowan LD, Devereux RB, Galloway JM, Go OT, 

et al. Rising tide of cardiovascular disease in American Indians: the 

Strong Heart Study. Circulation 1999;99(18):2389–95.

7. CDC. Health status of American Indians compared with other racial/

ethnic minority populations—selected states, 2001–2002. Morbidity 

and Mortality Weekly Report 2003;52(47):1148–52.

4 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
8. CDC. Disparities in premature deaths from heart disease—50 states and 

the District of Columbia, 2001. Morbidity and Mortality Weekly Report

19. Lee ET, Howard BV, Savage PJ, Cowan LD, Fabsitz RR, Oopik AJ, 

et al. Diabetes and impaired glucose tolerance in three American Indian 

9. 

2004;53(6):121–5.

CDC. Surveillance for health behaviors of American Indians and Alaska 

Natives. Findings from the Behavioral Risk Factor Surveillance System, 20. 

populations aged 45–74 years: the Strong Heart Study. Diabetes Care

1995;18(5):599–610.

Howard BV, Lee ET, Cowan LD, Fabsitz RR, Howard WJ, Oopik AJ, 

10. 

1997–2000. Morbidity and Mortality Weekly Report 2003;52(SS-7).

Lamar Welch VL, Casper M, Greenlund K, Zheng ZJ, Giles W, 

Rith-Najarian S. Prevalence of lower extremity arterial disease defined 

et al. Coronary heart disease prevalence and its relation to risk factors 

in American Indians: the Strong Heart Study. American Journal of 

Epidemiology 1995;142:254–68.

11. 

by the ankle-brachial index among American Indians: the Inter-Tribal 

Heart Project. Ethnicity and Disease 2002;12(1):S1-63-7.

Greenlund KJ, Valdez R, Casper ML, Rith-Najarian SJ, Croft JB. 

21. Gohdes D. Diabetes in North American Indians and Alaska Natives. 

In: Diabetes in America. Bethesda, MD: National Institutes of Health, 

National Institute of Diabetes and Digestive Kidney Diseases; 1995. 

Prevalence and correlates of the insulin resistance syndrome among 

Native Americans. The Inter-Tribal Heart Project. Diabetes Care

1999;22(3):441–7.

22. 

NIH publication no. 95-1468.

Frey JL, Jahnke HK, Bulfinch EW. Differences in stroke between white, 

Hispanic, and Native American patients: the Barrow Neurological 

12. Fischer ID, Brown DR, Blanton CJ, Casper ML, Croft JB, Brownson 

RC. Physical activity patterns of Chippewa and Menominee Indians: the 

Inter-Tribal Heart Project. American Journal of Preventive Medicine

23. 

Institute stroke database. Stroke 1998;29(1):29–33.

Indian Health Service. Regional Differences in Indian Health, 2000–

2001. Rockville, MD: U.S. Department of Health and Human Services; 

13. 

1999;17(3):189–97.

Kasiske BL, Rith-Najarian SJ, Casper ML, Croft JB. American 

Indian heritage and risk factors for renal injury. Kidney International

24. 

2000.

Indian Health Service. Adjusting for Miscoding of Indian Race on State 

Death Certificates. Rockville, MD: U.S. Department of Health and 

14.

1998;54(4):1305–10.

CDC. The Inter-Tribal Heart Project: Results from the Cardiovascular

Health Survey. Atlanta: U.S. Department of Health and Human Services;

25. 

Human Services, Public Health Service; 1996.

Sorlie PD, Rogot E, Johnson NJ. Validity of demographic characteristics on the death certificate. Epidemiology 1992;3(2):181–4.

15. 

1996.

Casper ML, Rith-Najarian SJ, Croft JB, Giles W, Donehoo R, and the 

Inter-Tribal Heart Project Working Group. Blood pressure, diabetes 

26. Rhoades DA. Racial misclassification and disparities in cardiovascular disease among American Indians and Alaska Natives. Circulation

2005;111(10):1250–6.

and body mass index among Chippewa and Menominee Indians: the 

Inter-Tribal Heart Project preliminary data. Public Health Reports

1996;111(Suppl 2):37–9.

27. CDC. REACH 2010 Surveillance for Health Status in Minority 

Communities—United States, 2001–2002. Morbidity and Mortality 

Weekly Report 2004;53(SS-6).

16. Struthers R, Savik K, Hodge FS. American Indian women and

cardiovascular disease: response behaviors to chest pain. Journal 

of Cardiovascular Nursing 2004;19(3):158–63.

28. U.S. Department of Health and Human Services. Healthy People 2010. 

2nd edition. Two volumes. Washington, DC: U.S. Government Printing 

Office; 2000.

17. Howard BV, Lee ET, Yeh JL, Go O, Fabsitz RR, Devereux RB, et 

al. Hypertension in adult American Indians: the Strong Heart Study. 

Hypertension 1996;28(2):256–64.

29. Indian Health Service Web site. Available at http://www.ihs.gov.

18. Welty TK, Lee ET, Yeh JL, Cowan LD, Fabsitz RR, Le NA, et al. 

Cardiovascular disease risk factors among American Indians: the Strong 

Heart Study. American Journal of Epidemiology 1995;142(3):269–87.

Introduction 5
Natives

2 National Maps 

of Heart Disease 

and Stroke 

Mortality Among 

American Indians 

and Alaska 

©Syracuse Newspapers/David Lassman/The Image Works
Heart Disease Mortality: American Indians and Alaska Natives

American Indians and Alaska Natives 

American Indian and Alaska Native (AI/AN) people made up 

1.5% of the U.S. population ages 35 years and older in 2000. 

During 1996–2000, the age-adjusted heart disease death rate 

for AI/AN people in this age group was 352/100,000. 

The national map of age-adjusted, spatially smoothed heart 

disease death rates for all AI/AN people shows considerable geographic disparity across the 806 counties for which 

sufficient data existed to calculate rates. County death rates 

ranged from 65 to 2,606/100,000. The quintile ranking for 

each county is depicted on the national map, with the darkest color representing counties with the highest rates and the 

lightest color representing counties with the lowest rates. The 

map indicates that the highest heart disease death rates were 

located primarily in South and North Dakota, Wisconsin, 

and Michigan. Smaller concentrations of counties in the top 

quintile also were observed along the North Carolina–South 

Carolina border and in Mississippi and Oklahoma. Counties 

with the lowest rates were located largely in California and 

Florida, with groupings of low-rate counties also found in 

parts of Illinois, Texas, the Northeast, and the Southwest. 

Women and Men 

During 1996–2000, the age-adjusted death rate for heart disease was 278/100,000 for AI/AN women and 445/100,000 for 

AI/AN men ages 35 and older. The maps of age-adjusted, spatially smoothed heart disease death rates for AI/AN women and

men show considerable geographic disparity across the counties

for which sufficient data existed to calculate rates. For women,

county death rates ranged from 60 to 1,110/100,000. For men,

the range was 108 to 2,374/100,000.

The maps for women and men indicate slightly different 

geographic patterns than the patterns for the total population. 

This difference can be largely attributed to the small number 

of counties with sufficient data to calculate rates for women 

and men separately. The patterns for women and men are 

similar, with groups of counties with high rates in Oregon, 

northern California, and Arizona.

A Note on Methods 

Heart disease deaths were defined as those for which the 

underlying cause of death listed on the death certificate was 

diseases of the heart, defined according to the International 

Classification of Diseases (ICD-9 codes 390–398, 402, and 

404–429; ICD-10 codes I00–I09, I11, I13, I20–I51).1,2 Heart 

disease death rates were age-adjusted to the 2000 U.S. population and spatially smoothed using a spatial moving average. 

A detailed explanation of the methods used to generate the 

death rates and create the maps can be found in Appendix B.

A Cautionary Note 

Decedents of certain racial and ethnic minorities are sometimes misreported as “white” on death certificates; in particular, American Indians have been significantly underreported 

on death certificates.3–5 In a 1996 Indian Health Service study, 

misclassification of American Indians ranged from 1.2% 

in Arizona to 28% in Oklahoma and 30.4% in California.6

Consequently, the true heart disease death rates for AI/AN 

people were probably higher during 1996–2000 than indicated on the maps, and the magnitude of geographic disparity 

displayed on the maps may be biased.

1. U.S. Department of Health and Human Services. International Classification

of Diseases, 9th Revision, Clinical Modification. Washington, DC: Public

Health Service, Health Care Financing Administration; 1980.

2. World Health Organization. International Classification of Diseases and 

Related Health Problems, 10th Revision, Clinical Modification. Geneva: 

World Health Organization; 1992.

3. Frost F, Shy K. Racial differences between linked birth and infant 

death records in Washington state. American Journal of Public Health

1980;70(9):974–6.

4. Hahn RA, Mulinare J, Teutsch SM. Inconsistencies in coding of race 

and ethnicity between birth and death in US infants: a new look at infant 

mortality, 1983 through 1985. JAMA 1992;267(2):259–63.

5. Kennedy RD, Deapen RE. Differences between Oklahoma Indian infant 

mortality and other races. Public Health Reports 1991;106(1):97–8.

6. Indian Health Service. Adjusting for Miscoding of Indian Race on State 

Death Certificates. Rockville, MD: U.S. Department of Health and 

Human Services, Public Health Service; 1996.

8 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
National Maps of Heart Disease and Stroke Mortality 9

Number of

Counties

65–298

301–395

396–512

514–711

712–2,606

Insufficient Data

164

161

162

161

158

2,296

Smoothed County Heart Disease Death Rates

1996–2000

American Indians and Alaska Natives

Ages 35 Years and Older

* Heart disease death rates are spatially smoothed to enhance the stability of rates

 in counties with small populations. See Appendix B for details.

Age-Adjusted

Average Annual

Deaths per 100,000*
10 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives

60–244

245–310

311–389

390–547

548–1,110

Insufficient Data

88

84

84

85

81

2,680

Age-Adjusted

Average Annual

Deaths per 100,000*

Number of

Counties

Smoothed County Heart Disease Death Rates

1996–2000

American Indian and Alaska Native Women

Ages 35 Years and Older

* Heart disease death rates are spatially smoothed to enhance the stability of rates

 in counties with small populations. See Appendix B for details.
National Maps of Heart Disease and Stroke Mortality 11

108–412

413–540

541–686

688–894

895–2,374

Insufficient Data

109

109

109

110

107

2,558

Age-Adjusted

Average Annual

Deaths per 100,000*

Number of

Counties

Smoothed County Heart Disease Death Rates 

1996–2000

American Indian and Alaska Native Men

Ages 35 Years and Older

* Heart disease death rates are spatially smoothed to enhance the stability of rates

in counties with small populations. See Appendix B for details.
Stroke Mortality: American Indians and Alaska Natives

American Indians and Alaska Natives 

American Indian and Alaska Native (AI/AN) people made up 

1.5% of the U.S. population ages 35 years and older in 2000. 

During 1991–1998, the age-adjusted stroke death rate for 

AI/AN people in this age group was 79/100,000. 

The national map of age-adjusted, spatially smoothed stroke 

death rates for all AI/AN people shows considerable geographic disparity across the 303 counties for which sufficient 

data existed to calculate rates. County death rates ranged from 

29 to 272/100,000. The quintile ranking for each county is 

depicted on the national map, with the darkest color representing counties with the highest rates and the lightest color 

representing counties with the lowest rates. The map suggests

somewhat of a north–south gradient in stroke mortality among

AI/AN people. Counties with high rates were reported primarily

in the northern states of Alaska, Washington, Idaho, Montana,

Wyoming, South Dakota, Wisconsin, and Minnesota. Counties

with low rates were reported primarily in central Oklahoma

and southern California. Exceptions to the north–south gradient were high rates in counties along the North Carolina–South

Carolina border and along the southern tip of Louisiana.

Women and Men 

During 1991–1998, the age-adjusted death rate for stroke was 

77/100,000 for AI/AN women and 80/100,000 for AI/AN 

men ages 35 and older. The maps of age-adjusted, spatially

smoothed stroke death rates for AI/AN women and men show

considerable geographic disparity across the counties for which

sufficient data existed to calculate rates. For women, county

death rates ranged from 35 to 291/100,000. For men, the range

was 33 to 291/100,000.

The maps for women and men indicate slightly different 

geographic patterns than the patterns for the total population. 

This difference can be largely attributed to the small number 

of counties with sufficient data to calculate rates for women 

and men separately. The patterns for women and men are 

similar, with groups of counties with high rates in Oregon, 

northern California, and Arizona.

A Note on Methods 

Stroke deaths were defined as those for which the underlying

cause of death listed on the death certificate was cerebrovascular

disease, defined according to the International Classification of

Diseases, 9th Revision, Clinical Modification (codes 430–438).1

Stroke death rates were age-adjusted to the 2000 U.S. population and spatially smoothed using a spatial moving average. A

detailed explanation of the methods used to generate the death

rates and create the maps can be found in Appendix B.

A Cautionary Note 

Decedents of certain racial and ethnic minorities are sometimes misreported as “white” on death certificates; in particular, American Indians have been significantly underreported 

on death certificates.2–4 In a 1996 Indian Health Service study, 

misclassification of American Indians ranged from 1.2% 

in Arizona to 28% in Oklahoma and 30.4% in California.5

Consequently, the true stroke death rates for AI/AN people 

were probably higher during 1991–1998 than indicated on the 

maps, and the magnitude of geographic disparity displayed on 

the maps may be biased.

1. U.S. Department of Health and Human Services. International Classification

of Diseases, 9th Revision, Clinical Modification. Washington, DC: Public

Health Service, Health Care Financing Administration; 1980.

2. Frost F, Shy K. Racial differences between linked birth and infant 

death records in Washington State. American Journal of Public Health

1980;70(9):974–6.

3. Hahn RA, Mulinare J, Teutsch SM. Inconsistencies in coding of race 

and ethnicity between birth and death in US infants: a new look at infant 

mortality, 1983 through 1985. JAMA 1992;267(2):259–63.

4. Kennedy RD, Deapen RE. Differences between Oklahoma Indian infant 

mortality and other races. Public Health Reports 1991;106(1):97–8.

5. Indian Health Service. Adjusting for Miscoding of Indian Race on State 

Death Certificates. Rockville, MD: U.S. Department of Health and 

Human Services, Public Health Service; 1996.

12 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
National Maps of Heart Disease and Stroke Mortality 13

Smoothed County Stroke Death Rates

1991–1998

American Indians and Alaska Natives

Ages 35 Years and Older

* Stroke death rates are spatially smoothed to enhance the stability of rates

 in counties with small populations. See Appendix B for details.

Age-Adjusted

Average Annual

Deaths per 100,000*

Number of

Counties

61

61

61

60

60

2,799

29–62

63–97

98–131

132–171

172–272

Insufficient Data
14 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives

Smoothed County Stroke Death Rates

1991–1998

American Indian and Alaska Native Women

Ages 35 Years and Older

* Stroke death rates are spatially smoothed to enhance the stability of rates

 in counties with small populations. See Appendix B for details.

Age-Adjusted

Average Annual

Deaths per 100,000*

Number of

Counties

33

31

31

31

30

2,946

35–57

58–83

84–128

131–165

167–291

Insufficient Data
National Maps of Heart Disease and Stroke Mortality 15

Smoothed County Stroke Death Rates

1991–1998

American Indian and Alaska Native Men

Ages 35 Years and Older

* Stroke death rates are spatially smoothed to enhance the stability of rates

in counties with small populations. See Appendix B for details.

Age-Adjusted

Average Annual

Deaths per 100,000*

Number of

Counties

22

23

23

20

20

2,994

33–64

65–88

89–122

125–176

182–291

Insufficient Data
Ri

i

i

i

Al i

3 sk Factors for

Heart D sease

and Stroke

Among Amer can

Ind ans and

aska Nat ves,

by State

©Lynn Johnson
High Blood Pressure

Figure 1. 

Prevalence of 

Self-Reported 

High Blood 

Pressure Among 

Adults ≥18 Years 

by Race/Ethnicity, 

BRFSS, 2001 and 

2003 Combined 

High blood pressure (hypertension) is a major risk factor for 

heart disease and stroke. For every 20 mm Hg systolic or 10 

mm Hg diastolic increase in blood pressure, there is a doubling 

of deaths from both ischemic heart disease and stroke, according to the Seventh Report of the Joint National Committee on 

Prevention, Detection, Evaluation, and Treatment of High 

Blood Pressure (Hypertension 2003;42:1206–52).

The JNC7 report also notes that only 34% of Americans with

high blood pressure have it under control. Research shows that

even a 5 mm Hg decrease in diastolic blood pressure can reduce

heart disease risk by 21% (Arch Intern Med 2001;161:2657–

60). A systolic blood pressure <120 mm Hg and a diastolic

blood pressure <80 mm Hg is considered normal.

The IHS is working to better identify and reduce high blood

pressure among American Indian and Alaska Native (AI/AN)

people—for example, through electronic alerts to health care

providers and audits of patients’ charts. It also is administering

40 

36% 

35 

30 28% 27% 

25% 25 24%

20% 20 

15 

10 

5 

0 

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

numerous diabetes grants that include strategies to reduce high

blood pressure and other cardiovascular risk factors.

CDC funds state programs to assess the prevalence of high 

blood pressure, increase compliance with treatment guidelines among managed care organizations, and prevent high 

blood pressure in the United States, with special programs 

tailored to minority groups and inner-city residents.

Definition of High Blood Pressure 

We defined self-reported high blood pressure on the basis of 

the following Behavioral Risk Factor Surveillance System 

(BRFSS) question: “Have you ever been told by a doctor, 

nurse, or other health care professional that you have high 

blood pressure?” This question was only asked in oddnumbered years, so the data for this analysis are from 2001 

and 2003. Age-adjusted prevalences were calculated for 

adults ages ≥18 years.

Prevalence Variations 

We found substantial state-to-state differences in the prevalence of high blood pressure among AI/AN people (see facing

map and Table 1). A 1.8-fold difference existed between the

midpoint of the lowest quartile (20%) and that of the highest

quartile (35%).

The national prevalence among all AI/AN people was 28%. 

Prevalences were 26% for women and 29% for men. AI/AN 

people ranked second among U.S. racial/ethnic groups (see 

Figure 1). 

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of high blood pressure and are more representative of AI/AN people living in urban rather than rural areas 

or on reservations (see Appendix B for details).

18 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 19

American Indians and Alaska Natives

Ages 18 Years and Older Prevalence of Self-Reported High Blood Pressure

2001 and 2003 Combined

Prevalence of 

High Blood Pressure

Number of

States

10

11

11

11

7

16.4–23.3

23.5–29.1

29.2–30.4

31.5–38.8

Insufficient Data
Table 1. Prevalence of Self-Reported High Blood Pressure Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 76 38.8 27.5–50.1 36 ‡ 40 ‡ 26.9–56.8 

Alaska 1047 28.5 24.5–32.5 592 33.0 28.0–37.9 455 24.5 19.0–30.0 

Arizona 272 21.7 14.3–29.2 176 19.5 10.6–28.5 96 27.5 16.0–39.0 

Arkansas 107 35.1 26.8–43.4 62 29.4 22.2–36.7 45 ‡ 

California 86 23.0 14.0–31.9 58 18.0 8.9–27.0 28 ‡ 

Colorado 48 ‡ 15.1–34.9 32 ‡ 16 ‡ 

Connecticut 76 23.3 12.9–33.7 37 ‡ 39 ‡ 

Delaware 63 29.2 17.0–41.3 34 ‡ 29 ‡ 

23 ‡ 9 ‡ 14 ‡ 

Florida 102 30.3 18.3–42.3 53 30.3 14.6–45.9 49 ‡ 

Georgia 102 29.3 20.6–38.0 55 37.4 27.1–47.6 47 ‡ 

Hawaii 43 ‡ 21 ‡ 22 ‡ 

Idaho 124 27.9 19.7–36.2 76 28.7 17.5–39.8 48 ‡ 

Illinois 75 19.3 9.7–28.9 44 ‡ 31 ‡ 

Indiana 68 29.0 19.6–38.4 36 ‡ 32 ‡ 

Iowa 26 ‡ 16 ‡ 10 ‡ 

Kansas 89 23.2 14.1–32.4 51 24.1 12.1–36.1 38 ‡ 

Kentucky 71 29.4 17.2–41.5 28 ‡ 43 ‡ 

Louisiana 92 30.3 20.5–40.2 60 31.4 19.3–43.6 32 ‡ 

Maine 63 28.8 17.0–40.7 36 ‡ 27 ‡ 

Maryland 74 32.1 19.6–44.5 39 ‡ 35 ‡ 

Massachusetts 95 29.8 20.1–39.6 60 25.8 19.4–32.3 35 ‡ 

Michigan 56 29.4 17.7–41.2 31 ‡ 25 ‡ 

Minnesota 53 30.4 17.5–43.2 30 ‡ 23 ‡ 

Mississippi 45 ‡ 28 ‡ 17 ‡ 

Missouri 88 34.3 21.2–47.5 45 ‡ 43 ‡ 

Montana 744 32.2 27.1–37.3 449 33.5 27.6–39.3 295 31.7 24.3–39.1 

Nebraska 46 ‡ 27 ‡ 19 ‡ 

Nevada 84 22.9 16.1–29.7 40 ‡ 44 ‡ 

73 19.2 9.7–28.7 37 ‡ 36 ‡ 

95 28.8 16.4–41.1 54 27.6 15.1–40.2 41 ‡ 

District of Columbia 

New Hampshire 

New Jersey 

New Mexico 356 19.9 14.5–25.4 201 19.8 12.2–27.4 155 19.6 11.3–27.8 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

20 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

73 29.6 16.3–42.8 47 ‡ 26 ‡ 

298 29.8 22.5–37.0 193 34.6 25.0–44.1 105 24.5 13.7–35.3 

161 29.1 20.8–37.4 100 22.4 14.2–30.6 61 40.0 27.2–52.8 

Ohio 63 27.3 17.3–37.2 33 ‡ 30 ‡ 

Oklahoma 898 33.4 30.2–36.6 573 34.3 30.2–38.4 325 32.5 27.4–37.5 

Oregon 24.0 15.1–32.9 55 27.0 13.2–40.8 55 23.5 10.9–36.1 

Pennsylvania 37 ‡ 20 ‡ 17 ‡ 

69 23.5 14.4–32.5 36 ‡ 33 ‡ 

90 33.1 24.0–42.2 46 ‡ 44 ‡ 

491 29.9 25.6–34.1 317 30.4 25.3–35.5 174 29.4 22.3–36.4 

37 ‡ 21 ‡ 16 ‡ 

103 22.5 14.2–30.7 56 20.4 10.4–30.3 47 ‡ 

Utah 56 37.8 25.4–50.1 29 ‡ 27 ‡ 

77 26.5 14.7–38.2 35 ‡ 42 ‡ 

68 33.2 21.4–44.9 32 ‡ 36 ‡ 

392 31.9 24.7–39.1 210 28.9 20.3–37.5 182 33.1 22.6–43.7 

59 27.9 16.8–39.0 26 ‡ 33 ‡ 

Wisconsin 89 31.5 24.2–38.8 48 ‡ 41 ‡ 

101 16.4 9.0–23.8 61 13.3 4.5–22.1 40 ‡ 

7734 27.7 25.4–29.8 4491 26.1 23.3–28.9 3243 29.1 25.8–32.3 

Region§ Respondents % Respondents % Respondents % 

East 2206 29.1 25.6–32.6 1332 29.0 24.6–33.4 874 29.0 23.8–34.3 

New York 

North Carolina 

North Dakota 

110 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

United States 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 1835 29.8 25.5–34.1 1115 27.5 21.9–33.1 720 32.0 25.6–38.4 

Southwest 816 23.3 18.6–28.0 478 21.1 14.8–27.4 338 26.6 21.0–32.2 

Pacific Coast 712 24.8 17.9–31.6 399 19.8 12.3–27.4 313 31.4 20.0–42.7 

Alaska 1047 28.5 24.5–32.5 592 33.0 28.0–37.9 455 24.5 19.0–30.0 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?” Data are for adults >18 years, are age–adjusted 

to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996. 

Risk Factors for Heart Disease and Stroke 21
High Cholesterol

Figure 2. 

Prevalence of 

Self-Reported 

High Cholesterol 

Among Adults 

≥18 Years by 

Race/Ethnicity, 

BRFSS, 2001 and 

2003 Combined 

Studies have shown that people with blood cholesterol levels 

in the highest 10% of the population are four times more 

likely to die of heart disease and stroke than those with 

cholesterol levels in the lowest 10% (MMWR 1992;41[36]). 

Diet modification, physical activity, weight control, and medication can help to lower blood cholesterol levels, according 

to the American Heart Association.

Cholesterol is a fatty substance that the human body needs to

function properly. When there is too much cholesterol in the 

body, it deposits in arteries, causing them to narrow. People 

with blood cholesterol levels >240 mg/dL are considered to be 

at high risk for heart disease and stroke (National Cholesterol 

Education Program).

Prevalence of high cholesterol is increasing among American

Indian and Alaska Native (AI/AN) people (MMWR 2003;52

[47]1148–52). In response, the IHS has developed several programs to ensure appropriate screening and to improve control

of this risk factor. Sample activities include educating people

35 

31% 30% 30% 30 28% 28% 28% 

25 

20 

15 

10 

5 

0 

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

about the dangers of high cholesterol levels, implementing

electronic systems for quality assurance and reminders to

health care providers, and awarding diabetes and cardiovascular health grants to tribes and AI/AN communities.

CDC currently funds 32 states and the District of Columbia 

to develop strategies and implement programs that reduce the 

prevalence of heart disease and stroke and related risk factors, 

including high cholesterol.

Definition of High Cholesterol 

We defined self-reported high cholesterol on the basis of “yes”

answers to the following Behavioral Risk Factor Surveillance

System (BRFSS) question: “Have you ever been told by a

doctor or other health professional that your cholesterol is

high?” This question was only asked in odd-numbered years, so

the data for this analysis are from 2001 and 2003. Age-adjusted

prevalences were calculated for adults ages ≥18 years.

Prevalence Variations 

We found substantial state-to-state differences in the prevalence of high cholesterol among AI/AN people (see facing 

map and Table 2). A greater than 1.8-fold difference existed 

between the midpoint of the lowest quartile (23%) and that of 

the highest quartile (41%). Many of the states in the eastern 

half of the United States did not have sufficient data (i.e., <50 

BRFSS respondents) to calculate a stable prevalence.

The national prevalence for all AI/AN people was 30%. 

Prevalences were similar for women (29%) and men (31%). 

The prevalence for AI/AN people was similar to those for 

other U.S. racial/ethnic groups (see Figure 2).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of high cholesterol and are more representative of AI/AN people living in urban rather than rural areas or 

on reservations (see Appendix B for details).

22 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 23

American Indians and Alaska Natives

Ages 18 Years and Older Prevalence of Self-Reported High Cholesterol

2001 and 2003 Combined

Prevalence of 

High Cholesterol

Number of

States

9

9

9

9

14

20.4–26.1

26.2–28.7

29.0–33.1

33.5–47.4

Insufficient Data
Table 2. Prevalence of Self-Reported High Cholesterol Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 52 47.4 34.6–60.3 24 ‡ 28 ‡ 

Alaska 579 22.6 18.2–27.0 334 21.0 15.7–26.4 245 24.4 17.4–31.3 

Arizona 164 20.4 13.7 6.6–20.8 53 37.3 21.9–52.6 

Arkansas 76 27.5 18.8–36.2 50 26.8 17.4–36.2 26 ‡ 

California 68 40.6 28.8–52.3 44 ‡ 24 ‡ 

Colorado 36 ‡ 26 ‡ 10 ‡ 

Connecticut 59 28.7 17.2–40.2 25 ‡ 34 ‡ 

Delaware 53 26.2 14.1–38.2 29 ‡ 24 ‡ 

23 ‡ 9 ‡ 14 ‡ 

Florida 77 33.6 21.1–46.0 41 ‡ 36 ‡ 

Georgia 77 20.6 39 ‡ 38 ‡ 

Hawaii 37 ‡ 17 ‡ 20 ‡ 

Idaho 88 33.5 23.5–43.4 58 33.0 20.5–45.4 30 ‡ 

Illinois 51 29.2 16.6–41.8 30 ‡ 21 ‡ 

Indiana 48 ‡ 27 ‡ 21 ‡ 

Iowa 15 ‡ 9 ‡ 6 ‡ 

Kansas 69 25.1 15.6–34.6 41 ‡ 28 ‡ 

Kentucky 59 32.5 19.1–45.9 21 ‡ 38 ‡ 

Louisiana 68 33.8 21.4–46.1 44 ‡ 24 ‡ 

Maine 44 ‡ 26 ‡ 18 ‡ 

Maryland 64 26.9 16.2–37.6 35 ‡ 29 ‡ 

Massachusetts 76 34.7 24.2–45.1 48 ‡ 28 ‡ 

Michigan 44 ‡ 18.9–50.6 23 ‡ 21 ‡ 

Minnesota 40 ‡ 23 ‡ 17 ‡ 

Mississippi 27 ‡ 15 ‡ 12 ‡ 

Missouri 71 27.0 15.5–38.5 38 ‡ 33 ‡ 

Montana 485 26.1 20.7–47.3 305 28.9 21.3–36.4 180 23.1 16.1–30.0 

Nebraska 30 ‡ 20 ‡ 10 ‡ 

Nevada 59 40.6 26.2–54.9 27 ‡ 32 ‡ 

52 34.1 20.4–47.8 28 ‡ 24 ‡ 

74 30.8 20.0–41.7 44 ‡ 30 ‡ 

11.9–28.9 111 

District of Columbia 

11.2–29.9 

New Hampshire 

New Jersey 

New Mexico 233 24.9 19.3–30.4 136 22.3 15.8–28.9 97 27.0 17.7–36.3 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

24 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

52 32.5 18.1–46.8 35 ‡ 17 ‡ 

216 27.4 19.2–35.5 134 29.8 19.0–40.6 82 24.2 12.7–35.6 

107 29.0 19.8–38.2 67 30.9 20.0–41.9 40 ‡ 

Ohio 40 ‡ 22 ‡ 18 ‡ 

Oklahoma 639 24.2 20.8–27.7 409 25.9 21.2–30.6 230 22.8 17.6–28.1 

Oregon 76 26.9 16.3–37.5 42 ‡ 34 ‡ 

Pennsylvania 27 ‡ 14 ‡ 13 ‡ 

63 29.1 18.4–39.7 33 ‡ 30 ‡ 

68 27.0 16.2–37.7 38 ‡ 30 ‡ 

328 27.3 22.2–32.4 217 24.2 17.6–30.8 31.0 23.8–38.2 

31 ‡ 17 ‡ 14 ‡ 

83 33.1 23.9–42.3 44 ‡ 39 ‡ 

Utah 36 ‡ 21 ‡ 15 ‡ 

58 37.0 24.9–49.2 30 ‡ 28 ‡ 

59 29.8 16.8–42.8 29 ‡ 30 ‡ 

280 32.2 24.3–40.4 146 29.4 19.9–38.9 134 35.0 24.0–46.0 

45 ‡ 22 ‡ 23 ‡ 

Wisconsin 68 23.1 13.6–32.7 39 ‡ 29 ‡ 

72 24.5 15.1–33.9 43 ‡ 29 ‡ 

5346 30.0 27.3–32.7 3149 28.6 25.3–31.9 2197 31.1 27.1–35.1 

Region§ Respondents % Respondents % Respondents % 

East 1620 29.1 25.3–32.9 971 31.7 26.4–37.0 649 26.5 21.3–31.8 

1237 29.2 23.7–34.7 773 26.9 20.4–33.3 464 31.3 23.0–39.5 

Southwest 528 22.9 17.4–28.3 321 18.6 12.5–24.7 207 30.3 21.5–39.1 

512 37.8 28.9–46.8 290 29.3 19.0–39.7 222 47.0 34.0–60.0 

Alaska 579 22.6 18.2–27.0 334 21.0 15.7–26.4 245 24.4 17.4–31.3 

New York 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 

South Dakota 111 

Tennessee 

Texas 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

United States 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor or other health professional that your blood cholesterol is high?” Data are for adults >18 years, are age-adjusted to the 

2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996.

Risk Factors for Heart Disease and Stroke 25
Cholesterol Screening

Figure 3. 

Prevalence of 

Self-Reported 

Cholesterol 

Screening Among 

Adults ≥18 Years 

by Race/Ethnicity, 

BRFSS, 2001 and 

2003 Combined 

Screening for blood cholesterol levels in the general population is important because high cholesterol can be lowered with

medication and behavior change. Studies have shown that a 1%

decrease in cholesterol level can reduce the risk for heart disease

and stroke by 2% (MMWR 1992;41[36]). Cholesterol levels

<200 mg/dL are considered desirable (National Cholesterol

Education Program, http://hin.nhlbi.nih.gov/ncep.htm).

In 1998, about 67% of U.S. residents ages ≥20 years reported having their cholesterol level checked within the past

5 years (Healthy People 2010). Healthy People 2010 calls

for raising this proportion to 80%. National guidelines recommend that people ages ≥20 years have their cholesterol

measured at least once every 5 years (National Heart, Lung,

and Blood Institute).

The IHS is working to increase cholesterol screening among 

American Indian and Alaska Native (AI/AN) people. It is 

developing an electronic system to notify health care providers of current national guidelines, remind them to screen 

90 

80 75% 75% 74% 

71% 71% 

70 67%

60

50

40

30

20

10

0

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

patients, and track compliance. The IHS also is administering numerous diabetes and cardiovascular health grants that 

include strategies (e.g., cholesterol screening) to reduce cardiovascular risk factors.

CDC currently funds 32 states and the District of Columbia 

to 1) develop strategies, such as policy, environmental, and 

systems changes, that improve prevalence of cholesterol 

screening and 2) conduct activities to reduce the burden of 

heart disease and stroke.

Definition of Cholesterol Screening 

We defined self-reported cholesterol screening on the basis 

of “yes” responses to the following Behavioral Risk Factor 

Surveillance System (BRFSS) question: “Have you ever had 

your blood cholesterol checked?” This question was only 

asked in odd-numbered years, so the data for this analysis are 

from 2001 and 2003. Age-adjusted prevalences were calculated for adults ages ≥18 years.

Prevalence Variations 

We found state-to-state differences in cholesterol screening 

prevalence among AI/AN people (see facing map and Table 

3). A 1.3-fold difference existed between the midpoint of the 

lowest quartile (61%) and that of the highest quartile (82%).

The national prevalence for all AI/AN people was 71%. 

Prevalences were similar for women (72%) and men (71%). 

The prevalence for AI/AN people was higher than that for 

Hispanics, the same as Asians, and somewhat lower than 

other U.S. racial/ethnic groups (see Figure 3).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely higher than the 

true prevalence of cholesterol screening and are more representative of AI/AN people living in urban rather than rural 

areas or on reservations (see Appendix B for details).

26 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 27

American Indians and Alaska Natives

Ages 18 Years and Older

Prevalence of Self-Reported Cholesterol Screening

2001 and 2003 Combined

Prevalence of 

Cholesterol Screening

Number of

States

11

11

12

10

6

75.0–87.9

70.8–73.7

66.3–70.4

56.4–66.0

Insufficient Data
Table 3. Prevalence of Self-Reported Cholesterol Screening Among American Indians and Alaska Natives, 

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 75 66.4 55.3–77.5 35 ‡ 40 ‡ 49.9–77.6 

Alaska 992 59.6 55.4–63.7 560 59.0 53.8–64.3 432 60.2 53.9–66.6 

Arizona 268 59.8 52.0–67.7 175 61.5 51.6–71.4 93 56.8 45.1–68.6 

Arkansas 104 66.3 56.0–76.5 62 79.0 68.3–89.7 42 ‡ 

California 83 75.0 63.4–86.6 55 79.0 67.5–90.5 28 73.3 57.2–89.4 

Colorado 46 80.2 70.3–90.1 31 ‡ 15 ‡ 

Connecticut 72 82.1 71.4–92.9 35 ‡ 37 ‡ 

Delaware 63 81.8 72.5–91.1 34 ‡ 29 ‡ 

23 ‡ 9 ‡ 14 ‡ 

Florida 99 76.7 66.8–86.6 52 68.2 54.0–82.5 47 ‡ 

Georgia 96 72.7 64.5–81.0 52 67.7 59.2–76.2 44 ‡ 

Hawaii 43 ‡ 21 ‡ 22 ‡ 

Idaho 63.0 52.8–73.2 72 69.1 56.0–82.2 46 ‡ 

Illinois 72 60.2 47.3–73.1 42 ‡ 30 ‡ 

Indiana 66 71.2 61.2–81.1 34 ‡ 32 ‡ 

Iowa 26 ‡ 16 ‡ 10 ‡ 

Kansas 87 72.2 62.0–82.4 49 ‡ 38 ‡ 

Kentucky 67 79.1 68.4–89.8 27 ‡ 40 ‡ 

Louisiana 89 72.9 63.7–82.1 59 69.6 59.1–80.1 30 ‡ 

Maine 61 66.3 55.2–77.4 35 ‡ 26 ‡ 

Maryland 69 87.2 79.1–95.3 36 ‡ 33 ‡ 

Massachusetts 93 77.8 69.5–86.0 58 87.5 81.0–93.9 35 ‡ 

Michigan 56 66.8 56.9–76.7 31 ‡ 25 ‡ 

Minnesota 52 72.8 59.6–86.0 30 ‡ 22 ‡ 

Mississippi 44 ‡ 27 ‡ 17 ‡ 

Missouri 85 73.7 63.7–83.7 44 ‡ 41 ‡ 

Montana 725 65.6 61.0–70.2 438 69.6 64.2–75.0 287 61.6 54.1–69.1 

Nebraska 43 ‡ 26 ‡ 17 ‡ 

Nevada 82 69.6 58.0–81.3 38 ‡ 44 ‡ 

71 71.6 59.9–83.2 36 ‡ 35 ‡ 

91 72.2 59.1–85.3 52 86.6 76.5–96.8 39 ‡ 

District of Columbia 

118 

New Hampshire 

New Jersey 

New Mexico 351 66.0 60.3–71.8 197 69.6 61.8–77.3 154 62.4 53.9–70.9 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

28 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
by State, Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

72 70.8 62.1–79.6 46 ‡ 26 ‡ 

289 70.2 61.2–79.2 187 74.7 68.2–81.3 102 66.2 52.2–80.3 

160 66.6 58.8–74.3 100 64.9 55.3–74.4 60 69.2 57.2–81.3 

Ohio 61 56.4 45.8–67.0 32 ‡ 29 ‡ 

Oklahoma 867 70.1 66.8–73.5 553 69.0 64.7–73.4 314 71.6 66.6–76.6 

Oregon 104 70.4 61.6–79.2 53 82.3 72.0–92.7 51 62.9 50.2–75.6 

Pennsylvania 37 ‡ 57.5–89.4 20 ‡ 17 ‡ 

69 82.0 74.7–89.3 36 ‡ 33 ‡ 

87 73.6 64.5–82.7 43 ‡ 44 ‡ 

483 64.9 60.3–69.4 66.2 60.7–71.7 172 62.7 55.0–70.3 

38 ‡ 21 ‡ 17 ‡ 

100 79.1 71.1–87.2 54 69.4 58.6–80.3 46 ‡ 

Utah 54 64.9 50.4–79.4 29 ‡ 25 ‡ 

74 66.4 56.2–76.6 34 ‡ 40 ‡ 

68 87.9 79.6–96.3 32 ‡ 36 ‡ 

377 69.1 62.6–75.6 201 69.1 61.7–76.6 176 68.3 59.2–77.5 

59 63.3 52.3–74.4 26 ‡ 33 ‡ 

Wisconsin 89 71.8 60.2–83.4 48 ‡ 41 ‡ 

98 68.7 59.7–77.7 59 66.4 55.7–77.1 39 ‡ 

7498 71.0 68.7–73.3 4353 71.9 68.8–75.0 3145 70.6 67.4–73.8 

Region§ Respondents % Respondents % Respondents % 

East 2141 26.5 23.5–29.5 1289 27.2 23.6–30.8 852 25.9 21.4–30.4 

1798 30.6 26.0–35.3 1093 29.1 23.0–35.2 705 31.3 25.3–37.3 

Southwest 801 35.0 30.3–39.6 470 32.4 25.9–38.9 331 37.7 31.5–43.8 

682 72.4 64.0–80.9 381 77.3 67.8–86.9 301 69.6 58.5–80.7 

Alaska 992 40.4 36.3–44.6 560 41.0 35.7–46.2 432 39.8 33.4–46.1 

New York 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 

South Dakota 311 

Tennessee 

Texas 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

United States 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever had your blood cholesterol checked?” Data are for adults >18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the 

probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996. 

Risk Factors for Heart Disease and Stroke 29
Diabetes

Figure 4. 

Prevalence of 

Self-Reported 

Diabetes Among 

Adults ≥18 Years 

by Race/Ethnicity, 

BRFSS, 2001–2003 

Diabetes is the sixth leading cause of death in the United States,

accounting for more than 200,000 deaths each year. More than

18 million Americans have diabetes, and the disease costs

nearly $132 billion annually (http://www.cdc.gov/nccdphp/

aag/aag_ddt.htm). Surprisingly, about one-third of people with

diabetes are unaware that they have the disease (Diabetes Care

1998;21:518–24).

Adults with diabetes are 2–4 times more likely than those 

without diabetes to die of heart disease or stroke (http://www.

cdc.gov/diabetes). High blood pressure, high blood cholesterol, and obesity—all risk factors for heart disease and 

stroke—also are common among people with diabetes.

Diabetes was once rare among American Indian and Alaska

Native (AI/AN) people, but the prevalence is rising dramatically.

The IHS recently received a significant increase in funding to

prevent and control diabetes among AI/AN people. In addition, it has funded numerous community grants and prevention

efforts, as well as an agressive medical intervention program.

12 12% 12% 

11% 

10% 10 

8 

7% 

6% 6 

4 

2 

0 

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

In 2001, CDC and the National Institutes of Health conducted 

a landmark clinical trial that found that Americans at risk for 

diabetes can reduce this risk 58% with lifestyle changes in 

diet and exercise. CDC also supports 59 state and territorial 

diabetes prevention and control programs (http://www.cdc.

gov/diabetes/news/docs/dpp.htm).

Definition of Diabetes 

We defined self-reported diabetes on the basis of “yes” 

responses to the following Behavioral Risk Factor Surveillance 

System (BRFSS) question during 2001–2003: “Have you ever 

been told by a doctor that you have diabetes?” Age-adjusted 

prevalences were calculated for adults ages ≥18 years.

Prevalence Variations 

We found dramatic state-to-state differences in the prevalence 

of diabetes among AI/AN people (see facing map and Table 

4). A threefold difference existed between the midpoint of the 

lowest quartile (5.7%) and that of the highest quartile (18%).

The national prevalence for all AI/AN people was 12%. 

Prevalences were similar for women (12%) and men (11%). 

They also were highest in the Northern Plains (14%) and lowest in Alaska (5%) (see Table 4). The prevalence for AI/AN 

people was the same as that for blacks (see Figure 4).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of diabetes and are more representative of 

AI/AN people living in urban rather than rural areas or on 

reservations (see Appendix B for details).

30 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Prevalence of Self-Reported Diabetes American Indians and Alaska Natives

2001–2003 Ages 18 Years and Older

Risk Factors for Heart Disease and Stroke 31

Prevalence of 

Diabetes 

Number of 

States 

12 

14 

12 

1 

3.2–8.1 

8.2–10.6 

10.8–13.6 

13.7–21.5 

11 

Insufficient Data 
Table 4. Prevalence of Self-Reported Diabetes Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 10.6 3.9–17.3 59 13.6 2.2–25.1 59 10.2 1.4–18.9 

Alaska 1581 5.1 3.3–6.9 912 4.7 2.7–6.7 669 5.6 2.6–8.6 

Arizona 395 15.0 9.6–20.4 254 15.4 9.2–21.6 141 14.1 5.7–22.5 

Arkansas 168 7.8 94 8.8 3.6–14.0 74 6.4 0–12.9 

California 120 10.4 4.5–16.3 75 12.1 4.1–20.0 45 ‡ 

Colorado 80 10.4 0.9–19.8 53 8.2 0–17.4 27 ‡ 

Connecticut 102 6.6 51 4.9 51 7.6 0.9–14.3 

Delaware 86 13.7 6.1–21.2 46 ‡ 40 ‡ 

32 ‡ 5.6–20.9 14 ‡ 18 ‡ 

Florida 155 13.2 5.7–20.8 79 12.5 2.7–22.4 76 13.5 3.0–24.1 

Georgia 139 3.2 0.6–5.7 73 1.3 0–3.3 66 3.7 0.4–6.9 

Hawaii 82 6.6 45 ‡ 37 ‡ 

Idaho 189 12.0 6.9–17.1 14.9 7.6–22.1 74 8.4 2.4–14.5 

Illinois 10.1 5.1–15.0 68 10.7 3.8–17.6 49 ‡ 

Indiana 8.4 3.0–13.7 63 3.8–18.3 55 6.2 0–13.3 

Iowa 39 ‡ 25 ‡ 14 ‡ 

Kansas 137 8.0 3.6–12.3 80 12.1 4.2–20.0 57 5.6 0.8–10.4 

Kentucky 99 14.4 3.6–25.2 36 ‡ 63 9.0 0.7–17.2 

Louisiana 150 7.4 2.6–12.1 97 9.4 2.1–16.6 53 8.0 0–17.0 

Maine 90 9.2 2.9–15.6 50 2.9–19.1 40 ‡ 

Maryland 102 12.3 3.6–20.9 52 9.9 2.1–17.6 50 10.8 0.3–21.3 

Massachusetts 148 8.2 2.2–14.3 89 7.6 1.9–13.2 59 9.0 0–19.7 

Michigan 102 17.5 9.9–25.1 55 15.1 5.4–24.8 47 ‡ 

Minnesota 85 12.7 6.0–19.3 49 ‡ 36 ‡ 

Mississippi 63 21.5 10.9–32.1 42 ‡ 21 ‡ 

Missouri 159 6.3 2.6–10.1 77 5.4 82 8.2 2.8–13.7 

Montana 1088 12.8 10.2–15.4 659 12.8 9.4–16.3 429 13.2 9.4–17.0 

Nebraska 74 8.0 1.3–14.6 45 ‡ 29 ‡ 

Nevada 132 4.8 1.9–7.7 68 6.2 64 6.3 

126 8.1 3.2–13.0 58 6.1 0.3–12.0 68 9.5 2.4–16.6 

129 10.8 3.0–18.6 73 5.3 0–10.5 56 16.2 3.4–28.9 

118 

3.7–11.8 

1.4–11.8 0–11.5 

District of Columbia 

1.3–11.9 

115 

117 

118 11.0 

11.0 

0–11.3 

1.0–11.4 0.8–11.7 

New Hampshire 

New Jersey 

New Mexico 552 12.2 8.6–15.7 314 14.2 9.5–18.9 238 10.0 5.0–15.0 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

32 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

107 17.3 9.7–24.9 66 17.6 6.5–28.8 41 ‡ 

481 13.1 8.3–17.9 306 16.8 10.4–23.1 175 9.6 2.5–16.8 

250 12.7 7.2–18.2 156 13.1 6.4–19.8 94 12.8 3.2–22.4 

Ohio 98 17.8 9.2–26.4 46 ‡ 0.1–19.0 52 17.3 8.2–26.5 

Oklahoma 1372 13.6 858 13.7 514 13.4 10.0–16.8 

Oregon 164 12.8 7.1–18.5 89 3.8–18.7 75 14.4 6.0–22.8 

Pennsylvania 98 10.4 4.3–16.4 48 ‡ 50 13.2 3.3–23.0 

99 8.2 2.9–13.4 53 8.3 1.7–15.0 46 ‡ 

122 17.9 10.8–25.1 64 13.9 8.5–19.3 58 18.3 7.0–29.6 

670 18.5 14.7–22.4 426 17.3 12.8–21.7 244 20.3 14.0–26.6 

56 12.4 2.0–22.8 27 ‡ 29 ‡ 

164 10.8 5.0–16.5 95 9.1 3.2–15.1 69 13.4 2.5–24.2 

Utah 90 5.0 0–10.5 46 ‡ 44 ‡ 

10.0 4.4–15.6 48 ‡ 71 12.6 5.1–20.0 

101 10.1 3.1–17.2 47 ‡ 54 3.6–20.1 

475 10.8 6.8–14.8 256 16.7 9.5–23.9 219 6.1 2.2–10.0 

76 14.2 6.9–21.6 36 ‡ 40 ‡ 

Wisconsin 144 13.7 6.1–21.3 76 21.2 68 5.9 

144 13.7 7.6–19.8 84 18.3 9.9–26.6 60 7.1 0–14.9 

10.4–13.4 6697 12.4 10.3–14.5 4890 9.4–13.4 

Region§ Respondents % Respondents % Respondents % 

East 3406 13.0 10.7–15.4 2037 13.4 10.3–16.4 1369 12.7 9.1–16.3 

2714 13.6 10.9–16.4 1638 15.1 1076 12.2 8.3–16.1 

Southwest 1249 8.8–14.5 735 8.5–15.3 514 6.8–16.3 

948 6.5–15.5 535 13.0 6.6–19.4 413 7.7 3.1–12.4 

Alaska 1581 5.1 3.3–6.9 912 4.7 2.7–6.7 669 5.6 2.6–8.6 

New York 

North Carolina 

North Dakota 

11.5–15.6 11.2–16.1 

11.2 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 

Vermont 119 

Virginia 11.8 

Washington 

West Virginia 

11.0–31.4 0.7–11.1 

Wyoming 

United States 11587 11.9 11.4 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 11.3–18.9 

11.6 11.9 11.5 

Pacific Coast 11.0 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor that you have diabetes?” Data are for adults >18 years, are age-adjusted to the 2000 U.S. population, and are weighted 

for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996. 

Risk Factors for Heart Disease and Stroke 33
Cigarette Smoking

Figure 5. 

Prevalence of 

Self-Reported 

Cigarette 

Smoking Among 

Adults ≥18 Years 

by Race/Ethnicity, 

BRFSS, 2001–2003 

Cigarette smoking is a major cause of heart disease and

stroke, accounting for 30% of all U.S. deaths from coronary

heart disease (Circulation 1997;96:3243–7). Cigarette smokers are 2–4 times more likely than nonsmokers to develop

coronary heart disease (Reducing the Health Consequences

of Smoking: 25 Years of Progress; 1989) and twice as likely

to suffer a stroke (Circulation 1997;96:3243–7). For both

conditions, the smoking-related risk for death increases if other

CHD risk factors are present.

CDC provides national leadership for a comprehensive

approach to reducing tobacco use that includes preventing

young people from starting to smoke, eliminating human

exposure to secondhand smoke, promoting smoking cessation,

and eliminating disparities in tobacco use among different

populations. CDC also funds eight tribal tobacco control support centers, which provide resources for tobacco prevention

and cessation in American Indian and Alaska Native (AI/AN)

communities.

Tobacco control programs in AI/AN communities must 

distinguish between traditional ceremonial use and addictive 

40 38% 

35

30

25 24% 23% 22% 

20 18% 

15 13% 

10

5

0

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

abuse of tobacco. In ceremonial settings, small amounts of 

tobacco are used, and the potential for addiction or health 

problems is low (BMJ 1997;75:1690–3). IHS offers numerous

tobacco cessation programs, many of which were developed

with partners and other federal agencies. In areas with high

smoking prevalences, IHS actively promotes cessation through

clinic-based and community programs.

Definition of Cigarette Smoking 

We defined self-reported current cigarette smoking on the basis

of responses to two questions from the Behavioral Risk Factor

Surveillance System (BRFSS) during 2001–2003. The first

was, “Have you smoked at least 100 cigarettes in your entire

life?” Respondents who answered “yes” were then asked a

follow-up question: “Do you now smoke cigarettes every day,

some days, or not at all?” People who reported smoking at least

100 cigarettes in their lifetime and smoking now every day

or some days were defined as current smokers. Age-adjusted

prevalences were calculated for adults ages ≥18 years.

Prevalence Variations 

We found dramatic state-to-state differences in smoking prevalence among AI/AN people (see facing map and Table 5). A

twofold difference existed between the midpoint of the lowest quartile (21%) and that of the highest quartile (50%). The

national prevalence for all AI/AN people was 38%, with men

(42%) smoking more than women (34%). This gender difference is similar to that observed for the general U.S. population.

The Northern Plains (41.3%) and Alaska (41.1%) had the highest prevalence (41%), whereas the Southwest had the lowest

(21%) (see Table 5). AI/AN people had the highest smoking

prevalence among U.S. racial/ethnic groups (see Figure 5).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of cigarette smoking and are more representative of AI/AN people living in urban rather than rural areas or 

on reservations (see Appendix B for details).

34 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 35

American Indians and Alaska Natives

Ages 18 Years and Older Prevalence of Self-Reported Cigarette Smoking

2001–2003

Prevalence of 

Cigarette Smoking

Number of

States

12

12

13

12

1

13.8–34.8

35.2–39.0

39.3–44.3

44.4–55.1

Insufficient Data
Table 5. Prevalence of Self-Reported Cigarette Smoking Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 38.8 28.7–48.8 59 35.7 24.3–47.1 59 39.9 26.3–53.6 

Alaska 1573 41.1 37.4–44.7 904 37.3 32.9–41.8 669 45.3 39.7–50.9 

Arizona 396 13.8 9.6–18.0 255 12.8 7.7–17.9 141 15.1 8.3–21.9 

Arkansas 169 44.4 35.8–52.9 95 45.3 34.0–56.6 74 43.8 31.5–56.0 

California 120 36.7 27.1–46.2 75 31.3 20.2–42.4 45 ‡ 

Colorado 79 43.7 29.8–57.5 52 52.1 36.3–67.9 27 ‡ 

Connecticut 101 42.8 32.5–53.0 50 37.0 23.1–51.0 51 42.6 30.1–55.1 

Delaware 86 34.6 23.3–45.9 46 ‡ 40 ‡ 

31 ‡ 14 ‡ 17 ‡ 

Florida 156 42.7 32.0–53.5 80 41.1 30.5–51.6 76 39.8 24.3–55.4 

Georgia 139 46.2 36.0–56.4 73 33.5 20.1–46.8 66 53.3 38.6–67.9 

Hawaii 82 23.5 45 ‡ 37 ‡ 

Idaho 189 39.6 32.1–47.1 38.4 28.9–47.9 74 40.9 28.7–53.2 

Illinois 49.3 39.2–59.3 68 42.9 31.4–54.3 49 ‡ 

Indiana 44.3 34.6–54.0 63 37.5 25.0–49.9 56 53.2 39.5–67.0 

Iowa 39 ‡ 25 ‡ 14 ‡ 

Kansas 137 32.1 23.9–40.2 80 35.5 24.7–46.3 57 29.1 17.3–40.9 

Kentucky 99 38.5 27.5–49.4 36 ‡ 63 43.0 27.4–58.6 

Louisiana 150 37.4 29.0–45.7 97 34.5 24.0–45.0 53 38.4 25.7–51.2 

Maine 89 34.2 24.7–43.8 49 ‡ 40 ‡ 

Maryland 102 37.4 27.0–47.8 52 19.0 9.0–29.0 50 46.3 32.8–59.8 

Massachusetts 148 36.3 26.8–45.9 89 31.7 20.7–42.7 59 43.9 28.3–59.5 

Michigan 101 37.0 27.1–47.0 54 32.8 19.6–46.0 47 ‡ 

Minnesota 85 49.4 38.6–60.3 49 ‡ 36 ‡ 

Mississippi 62 39.0 26.4–51.6 41 ‡ 21 ‡ 

Missouri 158 48.9 39.5–58.4 77 33.6 22.1–45.0 81 54.1 42.5–65.6 

Montana 1089 42.5 38.3–46.8 659 45.7 40.2–51.3 430 38.7 32.3–45.2 

Nebraska 74 41.2 29.7–52.7 45 ‡ 29 ‡ 

Nevada 132 40.3 29.1–51.6 68 36.2 21.2–51.1 64 47.5 32.4–62.6 

126 32.3 23.6–41.1 58 40.3 26.8–53.8 68 26.9 17.1–36.7 

129 25.6 14.3–36.9 73 23.6 10.5–36.7 56 26.8 10.0–43.5 

118 

District of Columbia 

11.1–35.9 

115 

117 

119 

New Hampshire 

New Jersey 

New Mexico 552 17.1 12.6–21.7 314 9.9 6.3–13.4 238 24.7 16.8–32.6 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

36 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2000–2003*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

107 34.8 23.3–46.2 66 21.5 41 ‡ 

481 33.7 26.3–41.0 305 29.4 21.3–37.5 176 37.6 27.3–47.8 

250 48.4 41.6–55.2 156 58.1 49.5–66.6 94 35.3 25.6–45.0 

Ohio 97 53.7 41.9–65.6 45 ‡ 52 65.3 53.5–77.0 

Oklahoma 1371 37.9 34.7–41.0 858 33.9 30.2–37.6 513 42.3 37.4–47.3 

Oregon 164 39.7 31.6–47.9 89 39.0 26.8–51.2 75 42.8 32.7–52.8 

Pennsylvania 98 35.2 24.2–46.3 48 ‡ 50 35.3 21.6–49.0 

97 55.1 43.7–66.6 52 57.8 43.7–72.0 45 ‡ 

122 43.1 33.6–52.5 63 37.6 26.8–48.5 59 41.2 28.1–54.3 

670 44.6 40.0–49.2 426 42.4 37.1–47.7 244 49.0 41.5–56.5 

56 39.3 25.9–52.6 27 ‡ 29 ‡ 

164 43.1 34.8–51.3 95 45.0 33.8–56.2 69 41.3 28.9–53.7 

Utah 90 19.4 8.5–30.3 46 ‡ 44 ‡ 

45.6 36.4–54.9 48 ‡ 71 49.9 38.6–61.2 

101 31.0 20.0–41.9 47 ‡ 54 40.0 25.5–54.5 

476 38.1 31.1–45.2 255 34.2 25.2–43.2 221 41.2 31.1–51.3 

76 54.9 44.2–65.5 36 ‡ 40 ‡ 

Wisconsin 144 37.5 28.0–47.0 76 22.5 12.2–32.8 68 51.2 37.0–65.4 

145 53.5 44.5–62.5 85 49.1 37.4–60.9 60 57.5 44.2–70.8 

38.1 36.1–40.0 6683 33.6 31.3–35.9 4892 42.3 39.2–45.3 

Region§ Respondents % Respondents % Respondents % 

East 3401 38.9 35.8–42.1 2032 35.3 34.8–38.8 1369 42.0 36.9–46.9 

2716 41.3 37.4–45.2 1638 36.8 32.1–41.0 1078 46.2 40.0–52.3 

Southwest 1249 20.7 17.4–24.0 735 18.7 14.4–22.9 514 24.3 19.0–29.5 

949 36.8 30.1–43.6 534 32.1 24.0–40.2 415 42.1 31.3–52.8 

Alaska 1573 41.1 37.4–44.7 904 37.3 32.9–41.8 669 45.3 30.1–35.3 

New York 11.2–31.8 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 

Vermont 119 

Virginia 

Washington 

West Virginia 

Wyoming 

United States 11575 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 

* Data are based on “yes” responses to the following BRFSS question: “Have you smoked at least 100 cigarettes in your entire life?” Respondents who answered “yes” were then asked, “Do you now smoke every day, some days, or 

not at all?” People who reported smoking at least 100 cigarettes in their lifetime and smoking now every day or some days were defined as current smokers. Data are for adults >18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996. 

Risk Factors for Heart Disease and Stroke 37
Obesity

Figure 6. 

Prevalence of 

Self-Reported 

Obesity Among 

Adults ≥18 Years 

by Race/Ethnicity, 

BRFSS, 2001–2003 

Obesity and a sedentary lifestyle account for about $90

billion in direct health care costs each year

(http://www.cdc.gov/nccdphp/aag/aag_dnpa.htm). Obesity

also increases the nation’s prevalence of weight-related

risk factors for cardiovascular disease, including high blood

pressure, high blood cholesterol, and diabetes (Arch Intern

Med 2004;164:249–58).

Preventing or reducing these risk factors by eating a healthy

diet and increasing physical activity can lower a person’s risk

for heart disease and stroke. For example, losing at least 10 lbs

and maintaining that loss for 36 months can lower a person’s

blood pressure significantly (Ann Intern Med 2001;134:1–11).

CDC provides national leadership for obesity control through

programs that promote increased fruit and vegetable consumption (e.g., 5 A Day for Better Health) and physical activity (e.g.,

KidsWalk-to-School) among adults and children. CDC also

sponsors 12 state programs to help prevent obesity by improving nutrition and increasing physical activity in these states.

35 33% 

30 28% 

26%

25

22% 21% 

20 

15 

10 

6% 

5 

0 

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

The high prevalence of obesity among American Indian 

and Alaska Native (AI/AN) people is contributing to a high 

incidence of diabetes in this population. The IHS recently 

received a significant increase in funding to prevent and control diabetes among AI/AN people. It is implementing community and health care system programs as part of the IHS 

Director’s Prevention Initiative.

Definition of Obesity 

We defined self-reported obesity on the basis of questions from the Behavioral Risk Factor Surveillance System 

(BRFSS) that asked respondents their height and weight 

during 2001–2003. We used this information to calculate 

respondents’ body mass index (BMI). People with a BMI 

≥30.0 were considered obese. Age-adjusted prevalences were 

calculated for adults ages ≥18 years.

Prevalence Variations 

We found dramatic state-to-state differences in the prevalence 

of obesity among AI/AN people (see facing map and Table 

6). A twofold difference existed between the midpoint of the 

lowest quartile (17%) and that of the highest quartile (36%).

The national prevalence for all AI/AN people was 28%. 

Prevalences were similar for women (28%) and men (27%). 

AI/AN people ranked second among U.S. racial/ethnic 

groups, with only blacks having a higher prevalence (see 

Figure 6).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of obesity and are more representative of 

AI/AN people living in urban rather than rural areas or on 

reservations (see Appendix B for details).

38 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 39

American Indians and Alaska Natives

Ages 18 Years and Older Prevalence of Self-Reported Obesity

2001–2003

Prevalence of 

Obesity

Number of

States

12

12

13

12

1

12.6–20.9

21.2–26.3

26.7–30.1

31.7–39.3

Insufficient Data
Table 6. Prevalence of Self-Reported Obesity Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 29.4 20.6–38.2 57 35.8 20.6–51.1 59 27.6 17.5–37.7 

Alaska 1521 29.1 25.5–32.6 856 32.3 27.3–37.4 665 25.4 20.6–30.1 

Arizona 383 35.2 28.5–42.0 246 32.8 24.1–41.5 137 35.5 26.4–44.5 

Arkansas 164 20.1 13.8–26.4 91 22.0 13.5–30.5 73 18.2 8.8–27.4 

California 28.0 19.3–36.7 75 28.8 18.3–39.2 44 ‡ 13.7–40.4 

Colorado 76 28.9 16.9–40.8 49 ‡ 16.6–40.2 27 ‡ 

Connecticut 98 21.2 12.0–30.4 48 ‡ 50 27.9 14.4–41.3 

Delaware 80 16.8 8.5–25.2 40 ‡ 40 ‡ 

31 ‡ 13 ‡ 18 ‡ 

Florida 153 17.0 9.4–24.5 78 4.5–19.4 75 21.1 9.7–32.4 

Georgia 135 25.1 16.9–33.3 70 28.7 15.9–41.4 65 23.2 12.7–33.6 

Hawaii 80 34.2 18.7–49.8 44 ‡ 36 ‡ 

Idaho 177 29.5 22.0–37.1 104 39.1 28.1–50.1 73 18.9 9.7–28.1 

Illinois 19.2 10.8–27.7 65 20.6 10.9–30.2 45 ‡ 

Indiana 28.5 19.5–37.5 56 33.0 19.6–46.4 56 24.9 12.5–37.2 

Iowa 38 ‡ 24 ‡ 14 ‡ 

Kansas 130 26.2 18.2–34.2 74 21.4 56 33.2 21.0–45.4 

Kentucky 93 20.1 10.8–29.3 31 ‡ 62 28.5 13.2–43.8 

Louisiana 140 23.4 15.8–31.1 89 18.7 9.7–27.6 51 33.0 19.2–46.8 

Maine 80 19.1 10.9–27.3 41 ‡ 39 ‡ 

Maryland 99 12.6 5.8–19.4 49 ‡ 50 17.7 6.7–28.8 

Massachusetts 134 21.5 12.5–30.4 76 28.6 17.6–39.6 58 16.2 5.2–27.2 

Michigan 98 35.6 23.8–47.3 51 32.8 20.3–45.4 47 ‡ 

Minnesota 83 38.1 26.9–49.2 47 ‡ 36 ‡ 

Mississippi 59 39.3 25.1–53.6 38 ‡ 21 ‡ 

Missouri 153 24.8 16.7–32.9 72 24.3 13.4–35.2 81 24.5 14.1–34.9 

Montana 1061 38.0 33.7–42.3 634 35.3 29.3–41.2 427 41.5 35.4–47.6 

Nebraska 70 35.0 22.2–47.8 42 ‡ 28 ‡ 

Nevada 128 24.1 12.5–35.6 65 26.7 13.3–40.1 63 15.1 6.8–23.3 

120 20.6 13.3–27.9 53 14.5 5.3–23.6 67 24.4 14.2–34.5 

123 15.9 7.5–24.4 68 13.6 4.4–22.9 55 21.5 7.5–35.5 

116 

119 

District of Columbia 

11.9 

110 

112 

11.6–31.1 

New Hampshire 

New Jersey 

New Mexico 537 31.7 26.6–36.8 303 34.2 27.3–41.1 234 29.3 22.3–36.3 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

40 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

101 39.1 26.9–51.2 62 38.8 26.1–51.5 39 ‡ 

465 29.1 22.7–35.6 293 31.3 22.7–39.9 172 27.2 17.9–36.5 

244 36.0 28.1–43.9 151 34.0 24.3–43.8 93 37.1 25.1–49.2 

Ohio 94 18.2 10.3–26.1 43 ‡ 51 18.7 7.9–29.5 

Oklahoma 1319 29.7 26.9–32.6 29.9 26.2–33.5 508 29.6 25.1–34.0 

Oregon 155 29.3 21.2–37.5 80 22.5 13.2–31.8 75 34.5 22.3–46.6 

Pennsylvania 96 26.7 15.9–37.5 46 ‡ 50 21.1 10.9–31.4 

94 28.0 17.2–38.8 50 31.3 17.5–45.1 44 ‡ 

20.9 13.2–28.5 58 17.1 8.8–25.5 59 20.9 10.7–31.1 

656 36.4 31.8–40.9 33.4 28.2–38.7 245 39.3 32.1–46.6 

52 18.8 9.7–27.8 24 ‡ 28 ‡ 

160 25.9 18.3–33.5 92 26.6 16.1–37.1 68 27.5 14.8–40.2 

Utah 90 25.4 15.2–35.5 46 ‡ 44 ‡ 

23.3 14.4–32.3 41 ‡ 69 20.6 

99 28.0 17.4–38.5 45 ‡ 54 27.9 15.1–40.7 

455 30.1 23.4–36.7 238 32.6 24.1–41.0 217 28.6 19.3–37.9 

75 27.8 17.3–38.4 35 ‡ 40 ‡ 

Wisconsin 141 32.3 24.5–39.9 73 35.0 24.2–45.7 68 27.6 17.3–37.9 

143 24.0 16.2–31.8 84 24.7 14.7–34.6 59 20.7 9.8–31.5 

27.8 25.9–29.7 6332 28.3 25.7–30.9 4835 27.1 24.5–29.7 

Region§ Respondents % Respondents % Respondents % 

East 3262 26.7 23.9–29.6 1913 27.7 24.0–31.4 1349 25.9 21.8–30.0 

2646 35.1 30.7–39.5 1573 35.9 30.6–41.1 1073 33.1 27.1–39.2 

Southwest 1214 31.7 27.5–35.8 709 30.9 25.3–36.5 505 30.8 25.8–35.9 

906 29.0 22.7–35.4 497 30.0 21.8–38.1 409 27.9 18.7–37.0 

Alaska 1521 29.1 25.5–32.6 856 32.3 27.3–37.4 665 25.4 20.6–30.1 

New York 

North Carolina 

North Dakota 

811 

Rhode Island 

South Carolina 117 

South Dakota 411 

Tennessee 

Texas 

Vermont 110 11.0–30.3 

Virginia 

Washington 

West Virginia 

Wyoming 

United States 11167 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 

* Data are based on self-reported height and weight from the BRFSS, which was used to calculate body mass index (BMI). BMI >30.0 was considered obese. Data are for adults >18 years, are age-adjusted to the 2000 U.S. 

population, and are weighted for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996. 

Risk Factors for Heart Disease and Stroke 41
Physical Inactivity

Figure 7. 

Prevalence of 

Self-Reported 

Physical Inactivity 

Among Adults 

≥18 Years by 

Race/Ethnicity, 

BRFSS, 2001–2003 

Physical inactivity and unhealthy diets are leading causes

of preventable death in the United States (JAMA 2004;291:

1238–42). In addition to reducing a person’s risk for death,

increased physical activity can reduce the risk for chronic

diseases and conditions such as cardiovascular disease, diabetes,

obesity, and musculoskeletal conditions (Proceedings of the 1992 International Conference on Physical Activity, Fitness and Health; 1994).

CDC recommends at least 30 minutes of moderate-intensity

physical activity (e.g., walking briskly, mowing the lawn, dancing, swimming, bicycling) at least 5 days a week (Physical

Activity and Health: A Report of the Surgeon General; 1996).

Healthy People 2010 calls for reducing the proportion of the 

total U.S. population with no leisure-time physical activity to 

20%. It also seeks to increase the proportion of people who 

regularly participate in moderate physical activity to 30%.

45 

39% 40 

34% 35 

30% 30 

25% 25%

25 22% 

20

15

10

5

0

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

The IHS is implementing community-based programs that 

promote healthier diets and increased physical activity among 

American Indian and Alaska Native (AI/AN) people in the 

context of their traditional values and cultures.

Definition of Physical Inactivity 

We defined self-reported physical inactivity on the basis 

of “no” responses to the following Behavioral Risk Factor 

Surveillance System (BRFSS) question during 2001–2003: 

“During the past month, other than your regular job, did you 

participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?” 

Age-adjusted prevalences were calculated for adults ages ≥18 

years.

Prevalence Variations 

We found dramatic state-to-state differences in the prevalence of physical inactivity among AI/AN people (see facing 

map and Table 7). A 1.7-fold difference existed between the 

midpoint of the lowest quartile (23%) and that of the highest 

quartile (40%).

The national prevalence for all AI/AN people was 30%. The 

prevalence was higher for women (32%) than for men (28%). 

The prevalence for AI/AN people was lower than those for 

blacks and Hispanics and somewhat higher than those for 

other U.S. racial/ethnic groups (see Figure 7).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of physical inactivity and are more representative of AI/AN people living in urban rather than rural areas 

or on reservations (see Appendix B for more details).

42 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 43

American Indians and Alaska Natives

Ages 18 Years and Older Prevalence of Self-Reported Physical Inactivity

2001–2003

Prevalence of 

Physical Inactivity

Number of

States

12

12

13

12

1

21.1–25.0

26.0–29.3

29.4–32.9

33.0–46.6

Insufficient Data
Table 7. Prevalence of Self-Reported Physical Inactivity Among American Indians and Alaska Natives, by State,

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 35.2 24.0–46.4 59 34.7 22.0–47.4 59 37.6 22.4–52.9 

Alaska 1582 32.5 28.6–36.3 910 38.4 32.9–43.9 672 25.8 21.3–30.4 

Arizona 394 27.9 21.1–34.7 254 30.4 21.7–39.2 140 24.4 14.7–34.1 

Arkansas 169 32.9 25.0–40.8 95 33.9 23.2–44.6 74 29.7 18.8–40.6 

California 21.6 13.4–29.7 71 20.8 42 ‡ 

Colorado 80 21.1 9.9–32.4 53 22.4 9.6–35.1 27 ‡ 

Connecticut 102 46.6 35.3–57.8 51 46.7 33.5–59.9 51 41.7 27.4–56.0 

Delaware 86 35.4 22.2–48.7 46 ‡ 40 ‡ 

32 ‡ 14 ‡ 18 ‡ 

Florida 155 29.3 19.6–39.0 80 34.3 20.2–48.3 75 26.2 13.8–38.5 

Georgia 139 29.4 19.6–39.2 73 30.6 18.5–42.6 66 28.0 15.6–40.5 

Hawaii 82 25.0 13.8–36.2 45 ‡ 37 ‡ 

Idaho 188 23.1 16.2–29.9 19.9 74 26.0 15.9–36.1 

Illinois 33.0 23.8–42.3 68 33.5 21.5–45.4 49 ‡ 

Indiana 32.5 23.2–41.7 63 30.7 19.2–42.2 56 34.0 20.8–47.3 

Iowa 39 ‡ 25 ‡ 14 ‡ 

Kansas 137 28.6 20.2–36.9 80 22.2 12.2–32.3 57 32.2 20.3–44.1 

Kentucky 99 28.1 18.2–37.9 36 ‡ 63 33.2 22.2–44.1 

Louisiana 150 32.8 24.8–40.9 97 34.4 24.8–44.1 53 37.6 25.3–49.9 

Maine 90 27.0 17.3–36.6 50 24.7 14.4–34.9 40 ‡ 

Maryland 102 24.9 14.0–35.8 52 40.0 24.7–55.3 50 16.5 5.5–27.5 

Massachusetts 148 31.2 21.0–41.4 89 39.7 27.1–52.4 59 23.0 9.8–36.2 

Michigan 102 24.6 15.9–33.3 55 18.7 8.3–29.1 47 ‡ 

Minnesota 85 23.7 14.1–33.3 49 ‡ 36 ‡ 

Mississippi 63 38.0 24.4–51.5 42 ‡ 21 ‡ 

Missouri 159 31.0 23.4–38.6 77 26.2 15.3–37.0 82 36.8 26.6–47.0 

Montana 1088 31.5 27.2–35.7 658 31.3 25.6–37.0 430 32.2 26.2–38.1 

Nebraska 74 28.9 18.1–39.8 45 ‡ 29 ‡ 

Nevada 132 24.5 13.2–35.9 68 32.5 16.5–48.5 64 13.7 6.3–21.1 

126 21.9 14.6–29.2 58 26.3 14.1–38.4 68 18.5 9.9–27.1 

129 40.6 27.2–54.0 73 39.9 25.4–54.3 56 38.7 23.7–53.7 

118 

113 11.7–29.9 

District of Columbia 

114 11.4–28.4 

117 

119 

New Hampshire 

New Jersey 

New Mexico 552 23.7 19.3–28.1 314 26.5 20.7–32.4 238 20.2 14.3–26.1 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

44 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

106 34.5 23.5–45.5 65 42.6 29.4–55.7 41 ‡ 

483 38.1 30.9–45.3 307 37.2 28.8–45.6 176 39.0 27.6–50.4 

251 30.2 23.0–37.4 156 27.1 19.0–35.3 95 35.4 23.9–46.9 

Ohio 97 27.5 17.5–37.5 46 ‡ 51 32.4 18.6–46.2 

Oklahoma 1374 34.4 31.5–37.3 859 38.5 34.7–42.2 515 29.7 25.3–34.1 

Oregon 164 28.5 21.2–35.8 89 24.9 15.2–34.6 75 32.8 21.8–43.9 

Pennsylvania 96 28.4 16.8–40.0 48 ‡ 48 ‡ 

99 21.6 13.2–30.1 53 35.1 23.1–47.1 46 ‡ 

123 31.3 21.8–40.8 64 21.0 59 38.2 24.2–52.3 

671 31.6 27.1–36.1 426 30.3 24.9–35.7 245 33.6 26.6–40.6 

56 38.1 25.2–51.0 27 ‡ 29 ‡ 

164 28.8 21.2–36.3 95 35.4 25.0–45.9 69 20.7 10.2–31.2 

Utah 90 36.9 26.0–47.8 46 ‡ 44 ‡ 

23.9 15.7–32.1 48 ‡ 71 24.1 13.7–34.5 

101 32.4 22.4–42.4 47 ‡ 54 23.9 

475 26.8 20.3–33.3 255 30.3 21.4–39.2 220 24.6 15.9–33.4 

76 30.3 19.7–40.9 36 ‡ 40 ‡ 

Wisconsin 144 36.9 28.6–45.1 76 37.5 26.4–48.5 68 37.2 24.8–49.5 

145 26.0 18.5–33.5 85 28.0 18.1–37.9 60 24.9 13.5–36.3 

29.7 27.9–31.6 6692 31.6 29.1–34.0 4893 28.1 25.4–30.7 

Region§ Respondents % Respondents % Respondents % 

East 3408 32.5 29.6–35.4 2039 36.2 32.4–40.0 1369 29.1 24.8–33.4 

2718 29.9 26.4–33.4 1638 29.9 25.2–34.5 1080 30.4 25.3–35.5 

Southwest 1248 26.3 22.5–30.2 735 28.4 23.1–33.8 513 22.9 17.9–27.8 

940 23.1 17.2–29.0 529 22.0 15.0–28.9 24.3 14.9–33.7 

Alaska 1582 32.5 28.6–36.3 910 38.4 32.9–43.9 672 25.8 21.3–30.4 

New York 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 11.2–30.9 

South Dakota 

Tennessee 

Texas 

Vermont 119 

Virginia 11.1–36.8 

Washington 

West Virginia 

Wyoming 

United States 11585 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 411 

* Data are based on “yes” responses to the following BRFSS question: “During the past month, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or 

walking for exercise?” Data are for adults >18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996.

Risk Factors for Heart Disease and Stroke 45
Poor Health

Figure 8. 

Prevalence of 

Self-Reported 

Poor Health 

Among Adults 

≥18 Years by 

Race/Ethnicity, 

BRFSS, 2001–2003 

Self-perception of health is often used as a representative 

measurement of a range of factors that can affect a person’s 

general health and functional status. For example, studies 

show that a person’s perception of his general health can predict his risk for death and disability. Even after adjusting for 

socioeconomic (e.g., education) and health risk (e.g., number 

of physician visits) variables, people who report poor or fair 

health have an approximately twofold greater risk of death 

(Am J Epidemiol 1999;149:41–66).

People who report poor health also are more likely to think 

that they are at greater risk of having a heart attack (Behav 

Med 2000;26:4–13). In addition, self-perception of poor 

health has been linked to risk factors associated with heart 

disease and stroke, such as diabetes, smoking, high blood 

pressure, and physical inactivity (MMWR 1996;46:906–11).

To support the Healthy People 2010 goal of increasing 

Americans’ quality and years of healthy life, CDC developed 

30 30% 

26% 

25 

21% 

20 

15% 15 13% 

10% 10 

5 

0 

American Asian Black, Hispanic Native White, 

Indian/ non- (All races) Hawaiian/ nonAlaska Hispanic Pacific Hispanic 

Native Islander 

Prevalence 

the Healthy Days surveillance measure to monitor leading health indicators such as physical activity, obesity, and 

tobacco use (Measuring Healthy Days; 2000). The resulting 

data can guide policy changes designed to improve the health 

of the nation and decrease the number of people reporting 

poor general health.

Definition of Poor Health 

We defined self-reported poor health on the basis of “poor” 

responses to the following Behavioral Risk Factor Surveillance 

System (BRFSS) question during 2001–2003: “Would you 

say that in general your health is excellent, very good, good, 

fair, or poor?” Age-adjusted prevalences were calculated for 

adults ages ≥18 years.

Prevalence Variations 

We found substantial state-to-state differences in the prevalence of poor health among American Indian and Alaska

Native (AI/AN) people (see facing map and Table 8). A twofold difference existed between the midpoint of the lowest

quartile (18%) and that of the highest quartile (36%).

The national prevalence for all AI/AN people was 26%. The

prevalence was higher for women (28%) than for men (24%).

AI/AN people ranked second among U.S. racial/ethnic groups,

with only Hispanics having a higher prevalence (see Figure 8).

A Cautionary Note 

Prevalences are based on a sample of AI/AN people surveyed 

by telephone for the BRFSS. They are likely lower than the 

true prevalence of poor health and are more representative of 

AI/AN people living in urban rather than rural areas or on 

reservations (see Appendix B for more details).

46 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factors for Heart Disease and Stroke 47

American Indians and Alaska Natives

Ages 18 Years and Older

Prevalence of Self-Reported Poor Health

2001–2003

Prevalence of 

Poor Health

Number of

States

12

12

13

12

1

14.6–21.1

22.3–26.3

26.4–29.9

31.6–42.7

Insufficient Data
Table 8. Prevalence of Self-Reported Poor Health Among American Indians and Alaska Natives, by State, 

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

Alabama 35.6 26.5–44.6 59 40.5 31.3–49.7 59 34.0 21.6–46.4 

Alaska 1581 22.3 18.7–25.9 910 24.0 18.6–29.3 671 20.8 16.1–25.4 

Arizona 393 25.7 18.6–32.8 255 23.6 15.4–31.7 138 31.2 21.1–41.2 

Arkansas 166 32.7 24.9–40.5 93 29.7 20.2–39.2 73 36.3 24.3–48.2 

California 120 32.1 22.6–41.7 75 34.9 23.4–46.3 45 ‡ 

Colorado 80 33.1 25.1–41.1 53 34.6 24.7–44.5 27 ‡ 

Connecticut 101 16.6 8.4–24.9 50 19.6 7.7–31.5 51 13.7 4.3–23.0 

Delaware 86 28.4 17.2–39.5 46 ‡ 13.4–42.0 40 ‡ 

32 ‡ 3.2–23.4 14 ‡ 18 ‡ 

Florida 155 28.0 18.9–37.0 80 34.9 22.0–47.7 75 22.1 10.7–33.5 

Georgia 138 20.3 12.6–28.0 72 24.7 13.1–36.4 66 17.3 7.8–26.7 

Hawaii 82 18.9 6.7–31.1 45 ‡ 37 ‡ 

Idaho 188 25.0 18.1–31.8 28.8 19.8–37.9 73 20.0 10.7–29.3 

Illinois 25.2 17.2–33.2 67 29.2 78.5–39.8 49 ‡ 

Indiana 34.1 24.4–43.8 63 37.3 24.6–49.9 56 29.9 15.7–44.1 

Iowa 39 ‡ 25 ‡ 14 ‡ 

Kansas 137 19.0 80 22.5 12.2–32.9 57 15.1 6.5–23.7 

Kentucky 99 37.6 25.6–49.7 36 ‡ 63 34.2 23.0–45.4 

Louisiana 149 29.1 21.5–36.7 96 31.4 21.1–41.6 53 22.4 

Maine 89 26.6 16.9–36.3 50 29.8 16.8–42.8 39 ‡ 

Maryland 101 20.9 10.2–31.5 52 16.2 6.4–26.0 49 ‡ 

Massachusetts 148 32.1 21.8–42.4 89 33.9 22.8–44.9 59 28.3 13.5–43.0 

Michigan 102 20.0 55 24.5 47 ‡ 

Minnesota 85 29.8 20.1–39.5 49 ‡ 36 ‡ 

Mississippi 61 38.7 25.3–52.1 40 ‡ 21 ‡ 

Missouri 159 29.1 20.3–37.8 77 28.4 17.8–38.9 82 28.6 17.3–40.0 

Montana 1089 28.3 24.3–32.2 659 30.4 25.1–35.7 430 25.8 20.4–31.2 

Nebraska 74 19.7 9.3–30.0 45 ‡ 29 ‡ 

Nevada 132 36.6 25.9–47.2 68 39.9 26.4–53.5 64 25.8 12.5–39.1 

126 23.4 15.7–31.1 58 33.4 21.7–45.2 68 17.2 7.3–27.1 

129 14.6 5.7–23.6 73 3.0–19.1 56 17.1 3.9–30.4 

118 

District of Columbia 

115 

116 

119 

11.9–26.1 

11.4–33.5 

11.4–28.5 11.9–37.2 

New Hampshire 

New Jersey 11.1 

New Mexico 551 16.6 12.9–20.4 314 21.7 16.4–27.0 237 11.9 7.0–16.8 

Note: To compare these prevalances with those for the total U.S. population, see Appendix A. 

48 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003*

Total Population Women Men 

State Respondents % 95% C.I.† Respondents % 95% C.I.† Respondents % 95% C.I.† 

107 31.6 21.2–42.0 66 26.9 15.7–38.1 41 ‡ 

481 28.1 21.9–34.4 305 28.8 21.5–36.0 176 27.4 17.7–37.1 

250 29.9 22.7–37.1 156 31.8 23.0–40.6 94 28.2 16.4–39.9 

Ohio 98 26.3 16.3–36.3 46 ‡ 52 21.7 10.3–33.1 

Oklahoma 1370 24.1 21.6–26.6 858 26.3 23.1–29.6 512 21.7 17.7–25.6 

Oregon 163 26.4 19.5–33.3 89 23.4 14.6–32.3 74 27.8 17.6–38.0 

Pennsylvania 98 27.5 17.0–38.1 48 ‡ 50 28.4 14.9–41.8 

99 15.9 8.7–23.1 53 18.8 8.2–29.4 46 ‡ 

121 25.1 16.3–34.0 63 19.9 9.4–30.4 58 27.0 15.1–39.0 

667 22.7 18.7–26.6 423 24.1 19.4–28.7 244 21.1 14.9–27.2 

56 25.1 15.9–34.3 27 ‡ 29 ‡ 

164 26.4 19.0–33.7 95 29.0 18.9–39.1 69 21.4 

Utah 89 28.5 16.3–40.6 45 ‡ 44 ‡ 

31.6 22.1–41.2 48 ‡ 71 37.5 25.0–50.0 

101 21.1 12.8–29.4 47 ‡ 54 23.9 13.7–34.1 

477 22.6 16.8–28.4 256 27.2 19.1–35.2 221 19.8 12.0–27.6 

76 42.7 31.1–54.2 36 ‡ 40 ‡ 

Wisconsin 144 22.6 14.4–30.9 76 21.7 10.8–32.7 68 23.3 

144 19.8 12.6–26.9 85 26.4 16.7–36.1 59 8.7 1.9–15.5 

26.2 24.4–28.1 6685 28.0 25.5–30.5 4884 24.3 21.7–27.0 

Region§ Respondents % Respondents % Respondents % 

East 3398 26.6 23.9–29.3 2032 28.5 25.0–32.1 1366 24.4 20.6–28.3 

2713 24.8 21.3–28.2 1636 26 21.5–30.6 1077 23.8 18.9–28.7 

Southwest 1245 25.6 21.6–29.5 735 26.6 21.5–31.8 510 23.7 18.3–29.2 

948 29.2 22.4–36.0 535 32.2 23.7–40.7 413 25.3 15.4–35.2 

Alaska 1581 22.3 18.7–25.9 910 24 18.6–29.3 671 20.8 16.1–25.4 

New York 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 11.1–31.6 

Vermont 119 

Virginia 

Washington 

West Virginia 

11.0–35.6 

Wyoming 

United States 11569 

95% C.I. 95% C.I. 95% C.I. 

Northern Plains 

Pacific Coast 

* Data are based on people who answered “poor” to the following BRFSS question: “Would you say that in general your health is excellent, very good, good, fair, or poor?” Data are for adults >18 years, are age-adjusted to the 2000 

U.S. population, and are weighted for the probability of sampling. † Confidence interval. 

‡ Estimates for states with <50 respondents are considered unstable and are not reported. 

§ The Indian Health Service (IHS) provides services to American Indians and Alaska Natives in 35 states. Only these 35 states were used for the regional estimates. Regions are defined as follows: East = Alabama, Connecticut, Florida, 

Louisiana, Maine, Massachusetts, Mississippi, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Oklahoma, and Kansas. Northern Plains = Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North 

Dakota, South Dakota, Wisconsin, and Wyoming. Southwest = Arizona, Colorado, Nevada, New Mexico, and Utah. Pacific Coast = California, Idaho, Oregon, and Washington. Alaska = Alaska. These regional definitions were first 

used in CDC’s Health Behaviors of American Indians and Alaska Natives: Findings from the Behavioral Risk Factor Surveillance System, 1993–1996.

Risk Factors for Heart Disease and Stroke 49
Ri

i

l

l i

A sk Factors for

Heart D sease

and Stroke

Among the Tota

U.S. Popu at on,

by State

©Jack Kurtz/The Image Works
Table A-1. Prevalence of Self-Reported High Blood Pressure Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 6072 31.8 30.5–33.0 

Alaska 5470 23.7 22.1–25.3 

Arizona 6400 22.8 21.4–24.2 

Arkansas 7075 28.8 27.7–29.9 

California 8712 24.1 23.1–25.1 

Colorado 6048 21.6 20.5–22.7 

Connecticut 12799 22.9 22.2–23.7 

Delaware 7487 27.1 25.9–28.3 

3834 28.1 26.5–29.7 

Florida 9562 25.2 24.1–26.3 

Georgia 12052 28.7 27.7–29.7 

Hawaii 8751 23.0 22.0–24.0 

Idaho 9740 23.9 23.0–24.8 

Illinois 24.7 23.7–25.7 

Indiana 9394 26.0 25.1–26.9 

Iowa 8564 23.8 22.9–24.8 

Kansas 9109 23.1 22.2–23.9 

Kentucky 15073 29.5 28.5–30.5 

Louisiana 9978 28.7 27.8–29.7 

Maine 4750 24.3 23.1–25.5 

Maryland 8739 25.8 24.7–26.8 

Massachusetts 15883 22.8 22.0–23.5 

Michigan 7310 26.8 25.7–27.9 

Minnesota 7829 22.0 21.2–22.9 

Mississippi 7393 32.8 31.6–33.9 

Respondents 

Montana 7321 22.9 21.7–24.0 

Nebraska 8601 22.2 21.4–23.1 

Nevada 5519 24.4 22.9–26.0 

8959 22.6 21.7–23.5 

17000 24.9 24.1–25.6 

9067 20.6 19.7–21.5 

9277 25.1 24.2–26.1 

15513 27.7 26.7–28.7 

5468 23.2 22.1–24.3 

Ohio 7149 25.6 24.5–26.8 

Oklahoma 12091 27.5 26.6–28.4 

Oregon 6493 23.6 22.6–24.7 

Pennsylvania 7264 25.6 24.5–26.6 

8035 26.2 25.2–27.2 

8996 28.7 27.7–29.7 

10285 23.4 22.6–24.2 

5481 29.4 28.1–30.7 

26.2 25.4–27.0 

Utah 7654 22.9 21.8–24.1 

8465 21.8 21.0–22.7 

8274 25.4 24.3–26.4 

22709 24.1 23.4–24.9 

6403 30.9 29.8–32.1 

Wisconsin 7348 23.5 22.5–24.5 

6983 22.9 21.9–23.9 

District of Columbia 

7411 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 11851 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

Missouri 8357 26.1 25.0–27.3 United States 455998 25.5 25.3–25.7 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?” Data are for adults ≥18 years, are age-adjusted 

to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

52 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Table A-2. Prevalence of Self-Reported High Cholesterol Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 4766 31.1 29.5–32.6 

Alaska 3953 26.7 24.8–28.6 

Arizona 4957 28.9 27.3–30.6 

Arkansas 5390 28.1 26.8–29.4 

California 6801 29.7 28.5–31.0 

Colorado 4743 28.2 26.8–29.7 

Connecticut 10727 27.3 26.4–28.3 

Delaware 6236 29.9 28.5–31.3 

3241 28.3 26.5–30.1 

Florida 7816 28.7 27.4–30.0 

Georgia 9652 31.1 29.9–32.3 

Hawaii 6778 23.6 22.3–24.9 

Idaho 7146 27.1 25.9–28.2 

Illinois 5718 29.4 28.1–30.8 

Indiana 7292 29.0 27.9–30.1 

Iowa 6769 26.8 25.7–28.0 

Kansas 6947 26.3 25.2–27.4 

Kentucky 30.5 29.3–31.8 

Louisiana 7507 27.0 25.9–28.1 

Maine 3962 28.5 26.9–30.0 

Maryland 7348 30.5 29.1–31.8 

Massachusetts 13335 28.7 27.8–29.6 

Michigan 5989 32.4 31.1–33.8 

Minnesota 6399 27.6 26.5–28.8 

Mississippi 5531 29.3 28.0–35.1 

Respondents 

Montana 5543 25.2 23.7–26.6 

Nebraska 25.8 24.5–27.0 

Nevada 4140 33.0 31.0–35.1 

7526 29.7 28.6–30.9 

14235 29.2 28.3–30.2 

6799 23.1 22.0–24.2 

7590 30.1 28.9–31.3 

12524 28.9 27.7–30.0 

26.9 25.5–28.2 

Ohio 5579 29.9 28.8–31.4 

Oklahoma 9304 27.6 26.5–28.7 

Oregon 5002 28.6 27.2–29.9 

Pennsylvania 5798 29.6 28.4–30.9 

6836 30.9 29.6–32.2 

7410 28.2 27.1–29.4 

26.1 25.1–27.2 

4198 28.7 27.2–30.2 

30.4 29.4–31.4 

Utah 5558 26.8 25.4–28.5 

7025 27.4 26.3–28.5 

6801 29.5 28.2–30.8 

17950 28.2 27.3–29.1 

5168 33.2 31.8–34.7 

Wisconsin 5827 27.5 26.3–28.7 

5528 29.5 28.2–30.8 

District of Columbia 

11549 

6411 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 4211 

Rhode Island 

South Carolina 

South Dakota 7911 

Tennessee 

Texas 9011 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

Missouri 6404 28.7 27.3–30.2 United States 360841 29.3 29.1–29.6 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor or other health professional that your blood cholesterol is high?” Data are for adults ≥18 years, are age-adjusted to the 

2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

Appendix A: Risk Factors Among the Total U.S. Population 53
Table A-3. Prevalence of Self-Reported Cholesterol Screening Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001 and 2003 Combined* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 5919 73.0 71.7–74.2 

Alaska 5268 68.9 67.2–70.6 

Arizona 6254 71.1 69.4–72.7 

Arkansas 6826 69.6 68.4–70.9 

California 8581 71.5 70.4–72.6 

Colorado 5885 71.5 70.2–72.8 

Connecticut 12493 78.5 77.6–79.4 

Delaware 7347 77.8 76.5–79.0 

3744 81.2 79.6–82.7 

Florida 9356 77.0 75.7–78.2 

Georgia 75.5 74.4–76.5 

Hawaii 8599 73.3 72.1–74.5 

Idaho 9412 66.5 65.4–67.5 

Illinois 7249 70.5 69.3–71.7 

Indiana 9131 71.7 70.7–72.7 

Iowa 8308 70.0 68.9–71.2 

Kansas 8821 70.3 69.3–71.4 

Kentucky 14483 72.7 71.6–73.8 

Louisiana 9634 72.3 71.3–73.3 

Maine 4610 75.5 74.0–76.9 

Maryland 8529 78.6 77.5–79.7 

Massachusetts 15466 80.9 80.1–81.6 

Michigan 7107 74.1 72.9–75.2 

Minnesota 7549 75.6 74.6–76.7 

Mississippi 7059 70.6 69.4–71.8 

Respondents 

Montana 7136 68.2 66.8–69.7 

Nebraska 8353 66.7 65.6–67.9 

Nevada 5347 69.3 67.6–71.0 

8740 77.5 76.5–78.5 

16633 77.9 77.1–78.8 

8865 67.9 66.8–69.1 

9048 76.2 75.1–77.3 

15074 74.7 73.5–75.8 

5323 69.8 68.5–71.1 

Ohio 6951 72.0 70.8–73.3 

Oklahoma 70.6 69.6–71.7 

Oregon 6283 68.4 67.1–69.6 

Pennsylvania 7070 73.7 72.5–74.8 

7829 80.7 79.5–81.8 

8768 77.8 76.7–78.9 

9994 68.7 67.7–69.6 

5320 72.0 70.6–73.4 

70.3 69.4–71.2 

Utah 7391 69.2 68.0–70.5 

8241 75.4 74.4–76.5 

8065 76.2 75.0–77.5 

22014 71.3 70.5–72.1 

6208 74.2 73.0–75.5 

Wisconsin 7206 72.5 71.3–73.7 

6829 72.1 70.9–73.2 

District of Columbia 

11602 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 

11637 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 11565 

Vermont 

Virginia 

Washington 

West Virginia 

Wyoming 

Missouri 8114 70.9 69.6–72.2 United States 443236 73.3 73.1–73.6 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever had your blood cholesterol checked?” Data are for adults ≥18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the 

probability of sampling. 

† Confidence interval. 

54 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Table A-4. Prevalence of Self-Reported Diabetes Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 9149 8.8 8.2–9.4 

Alaska 8152 5.1 4.3–5.8 

Arizona 9600 6.2 5.6–6.9 

Arkansas 10947 7.3 6.8–7.9 

California 12924 7.4 6.8–8.0 

Colorado 10075 4.9 4.4–5.4 

Connecticut 18273 5.7 5.3–6.1 

Delaware 7.1 6.5–7.7 

6196 8.5 7.7–9.4 

Florida 15632 7.3 6.8–7.8 

Georgia 17057 7.7 7.3–8.2 

Hawaii 14688 6.3 5.7–6.8 

Idaho 14755 6.0 5.6–6.4 

Illinois 14481 7.0 6.5–7.4 

Indiana 15129 7.2 6.8–7.6 

Iowa 12210 5.9 5.4–6.3 

Kansas 13682 5.9 5.5–6.3 

Kentucky 22083 7.3 6.9–7.8 

Louisiana 14976 7.9 7.4–8.4 

Maine 7172 6.7 6.1–7.3 

Maryland 13081 7.0 6.4–7.5 

Massachusetts 23228 5.7 5.3–6.0 

Michigan 13203 7.6 7.1–8.1 

Minnesota 12319 4.9 4.5–5.3 

Mississippi 9.7 9.1–10.3 

Respondents 

Montana 5.2 4.8–5.7 

Nebraska 12962 5.6 5.2–6.0 

Nevada 8673 6.1 5.4–6.8 

13924 5.7 5.3–6.1 

23087 6.6 6.1–7.0 

13718 6.0 5.6–6.4 

13692 7.0 5.3–6.0 

22182 7.4 7.1–8.1 

8450 5.5 4.5–8.3 

Ohio 7.7 9.1–10.3 

Oklahoma 18836 7.0 6.6–7.4 

Oregon 9553 5.9 5.4–6.4 

Pennsylvania 20623 7.0 6.5–7.4 

6.0 5.6–6.5 

13468 8.6 8.0–9.1 

15055 6.2 5.8–6.6 

8660 8.4 7.8–9.1 

17909 7.9 7.4–8.3 

Utah 5.5 4.9–6.0 

12675 5.5 5.0–5.9 

12641 6.6 6.1–7.1 

27627 6.1 5.7–6.5 

9738 8.8 8.2–9.4 

Wisconsin 5.4 4.9–5.8 

10507 5.3 22.6–25.5 

11483 

District of Columbia 

11446 

11318 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 

11194 

Rhode Island 11823 

South Carolina 

South Dakota 

Tennessee 

Texas 

11723 

Vermont 

Virginia 

Washington 

West Virginia 

11683 

Wyoming 

Missouri 13054 6.7 6.1–7.2 United States 696716 7.0 6.9–7.1 

* Data are based on “yes” responses to the following BRFSS question: “Have you ever been told by a doctor that you have diabetes?” Data are for adults ≥18 years, are age-adjusted to the 2000 U.S. population, and are weighted 

for the probability of sampling. 

† Confidence interval. 

Appendix A: Risk Factors Among the Total U.S. Population 55
Table A-5. Prevalence of Self-Reported Cigarette Smoking Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 9146 24.7 23.7–25.8 

Alaska 8142 26.2 24.7–27.6 

Arizona 9597 22.2 20.8–23.5 

Arkansas 10928 26.1 25.1–27.1 

California 12910 16.6 15.8–17.4 

Colorado 10061 20.0 19.1–21.0 

Connecticut 18236 20.1 19.3–20.8 

Delaware 24.1 22.9–25.2 

6184 21.2 19.9–22.5 

Florida 15605 24.1 23.1–25.0 

Georgia 17016 22.8 22.0–23.7 

Hawaii 14710 19.7 18.9–20.6 

Idaho 14730 19.7 18.9–20.5 

Illinois 14457 23.2 22.4–24.0 

Indiana 15122 27.2 26.4–28.0 

Iowa 12192 22.9 22.0–23.8 

Kansas 13677 21.7 20.9–22.5 

Kentucky 22055 31.6 30.6–32.5 

Louisiana 14929 25.0 24.2–25.8 

Maine 7164 24.4 23.2–25.5 

Maryland 13046 20.9 20.0–21.9 

Massachusetts 23178 19.4 18.8–20.1 

Michigan 13194 25.4 24.5–26.3 

Minnesota 12295 21.6 20.8–22.5 

Mississippi 26.1 25.1–27.0 

Respondents 

Montana 21.2 20.2–22.3 

Nebraska 12948 21.7 20.8–22.6 

Nevada 8659 25.8 24.5–27.2 

13902 22.9 22.1–23.7 

23030 20.1 19.2–21.1 

13689 22.3 21.4–23.1 

13650 22.6 21.8–23.5 

25.6 24.7–26.5 

8438 21.8 20.8–22.8 

Ohio 26.8 25.8–27.8 

Oklahoma 18822 27.1 26.3–28.0 

Oregon 9535 21.5 20.5–22.5 

Pennsylvania 20593 25.6 24.8–26.5 

23.3 22.4–24.2 

13441 26.0 25.1–27.0 

15035 22.9 22.1–23.7 

8654 25.9 24.8–27.0 

17882 22.2 21.4–22.9 

Utah 12.4 

12649 21.2 20.4–22.0 

12615 22.8 21.8–23.8 

27557 21.1 20.3–21.8 

9729 29.0 28.0–30.1 

Wisconsin 23.2 22.3–24.2 

10495 23.5 22.6–24.5 

11476 

District of Columbia 

11419 

11299 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 22119 

North Dakota 

11174 

Rhode Island 11797 

South Carolina 

South Dakota 

Tennessee 

Texas 

11711 11.7–13.2 

Vermont 

Virginia 

Washington 

West Virginia 

11676 

Wyoming 

Missouri 13027 27.0 25.9–28.1 United States 695595 22.7 22.5–22.9 

* Data are based on “yes” responses to the following BRFSS question: “Have you smoked at least 100 cigarettes in your entire life?” Respondents who answered “yes” were then asked, “Do you now smoke every day, some days, 

or not at all?” People who reported smoking at least 100 cigarettes in their lifetime and smoking now every day or some days were defined as current smokers. Data are for adults ≥18 years, are age-adjusted to the 2000 U.S. 

population, and are weighted for the probability of sampling. 

† Confidence interval. 

56 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Table A-6. Prevalence of Self-Reported Obesity Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 8838 26.4 25.3–27.4 

Alaska 7891 23.3 21.9–24.7 

Arizona 9162 19.6 18.4–20.8 

Arkansas 10543 24.0 21.1–25.0 

California 12517 21.5 20.6–22.3 

Colorado 9723 15.8 14.9–16.6 

Connecticut 17266 18.2 17.5–18.9 

Delaware 10901 22.4 21.4–23.4 

5941 21.0 19.6–22.4 

Florida 14847 19.2 18.4–20.1 

Georgia 16328 23.8 22.9–24.7 

Hawaii 14312 17.2 16.3–18.1 

Idaho 14094 21.0 20.2–21.8 

Illinois 13701 22.2 21.3–23.0 

Indiana 14546 25.0 24.2–25.8 

Iowa 23.3 22.4–24.2 

Kansas 12994 22.6 21.8–23.4 

Kentucky 20933 24.9 24.0–25.8 

Louisiana 14250 25.1 24.3–25.9 

Maine 6824 19.8 18.8–20.9 

Maryland 12516 20.3 19.4–21.2 

Massachusetts 21917 17.2 16.6–17.8 

Michigan 12791 25.1 24.2–26.0 

Minnesota 21.7 20.9–22.5 

Mississippi 10928 27.5 26.5–28.5 

Respondents 

Montana 10856 18.8 17.8–19.8 

Nebraska 12287 22.7 21.8–23.6 

Nevada 8247 20.5 19.2–21.9 

13221 19.1 18.3–19.8 

21829 19.4 18.5–20.3 

13174 20.0 19.1–20.8 

13028 20.6 19.8–21.4 

20937 23.5 22.6–24.4 

22.8 21.8–23.8 

Ohio 10604 23.4 22.4–24.4 

Oklahoma 23.5 22.8–24.3 

Oregon 9124 20.8 19.9–21.8 

Pennsylvania 19791 23.1 22.3–23.9 

18.3 17.5–19.2 

12942 24.4 23.5–25.4 

14435 22.0 21.2–22.7 

8231 24.3 23.2–25.3 

16944 25.0 24.2–25.7 

Utah 20.1 19.1–21.1 

12189 18.6 17.8–19.4 

12131 22.0 21.1–23.0 

26365 20.6 19.9–21.3 

9350 27.0 26.0–28.0 

Wisconsin 21.6 20.7–22.5 

10223 19.8 18.9–20.6 

District of Columbia 

11679 

11951 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 8114 

17911 

Rhode Island 11198 

South Carolina 

South Dakota 

Tennessee 

Texas 

11341 

Vermont 

Virginia 

Washington 

West Virginia 

11275 

Wyoming 

Missouri 12562 23.5 22.5–24.5 United States 665702 22.1 21.9–22.3 

* Data are based on self-reported height and weight from the BRFSS, which were used to calculate body mass index (BMI) using the following formula: {[Weight in lbs. x 0.4536]/[(height in inches x 0.2540)2]} x 100. 

BMI ≥30.0 was considered obese. Data are for adults ≥18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

Appendix A: Risk Factors Among the Total U.S. Population 57
Table A-7. Prevalence of Self-Reported Physical Inactivity Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 9154 29.3 28.3–30.4 

Alaska 8156 21.9 20.5–23.3 

Arizona 9604 21.8 20.6–23.1 

Arkansas 10945 29.0 28.0–30.0 

California 12673 23.9 23.0–24.9 

Colorado 10075 18.7 17.8–19.7 

Connecticut 18286 22.1 21.4–22.9 

Delaware 26.4 25.3–27.4 

6196 22.8 21.5–24.2 

Florida 15639 27.2 26.2–28.2 

Georgia 17064 26.3 25.4–27.2 

Hawaii 14722 17.7 16.9–18.5 

Idaho 14752 19.8 19.0–20.5 

Illinois 14484 27.0 26.1–27.9 

Indiana 15135 26.7 225.9–27.5 

Iowa 12213 22.9 22.1–23.8 

Kansas 13697 24.9 24.1–25.7 

Kentucky 30.2 29.3–31.0 

Louisiana 14978 33.3 32.5–34.2 

Maine 7174 22.7 21.6–23.7 

Maryland 13090 23.0 22.0–23.9 

Massachusetts 23248 21.7 21.0–22.3 

Michigan 13213 23.0 22.1–23.9 

Minnesota 12333 16.1 15.4–16.9 

Mississippi 32.2 31.2–33.2 

Respondents 

Montana 20.1 19.1–21.1 

Nebraska 12966 24.4 23.5–25.3 

Nevada 8677 24.2 22.8–25.6 

13938 19.8 19.0–20.6 

23090 26.3 25.3–7.3 

13721 24.1 23.2–24.9 

13686 26.9 26.0–27.8 

22202 27.0 26.1–27.9 

8448 22.7 21.7–23.7 

Ohio 25.8 24.8–26.8 

Oklahoma 18852 31.1 30.3–32.0 

Oregon 9554 19.0 18.1–19.9 

Pennsylvania 20618 23.3 22.5–24.1 

24.0 23.1–24.9 

13465 24.8 23.9–25.7 

15051 23.2 22.4–24.0 

8673 32.7 31.5–33.8 

17920 28.3 27.5–29.1 

Utah 18.6 17.7–19.5 

12676 19.0 18.3–19.8 

12642 23.4 22.5–24.3 

27635 16.7 16.1–17.4 

9743 28.9 27.9–29.9 

Wisconsin 19.7 18.9–20.6 

10515 21.0 20.1–21.8 

11492 

District of Columbia 

22116 

11457 

11320 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 

11202 

Rhode Island 11834 

South Carolina 

South Dakota 

Tennessee 

Texas 

11719 

Vermont 

Virginia 

Washington 

West Virginia 

11690 

Wyoming 

Missouri 13054 25.8 24.8–26.8 United States 696787 25.1 24.9–25.3 

* Data are based on “no” responses to the following BRFSS question: “During the past month, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or 

walking for exercise?” Data are for adults ≥18 years, are age-adjusted to the 2000 U.S. population, and are weighted for the probability of sampling. 

† Confidence interval. 

58 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Table A-8. Prevalence of Self-Reported Poor Health Among the Total U.S. Population, by State, 

Behavioral Risk Factor Surveillance System (BRFSS), 2001–2003* 

State % 95% C.I.† State % 95% C.I.† Respondents 

Alabama 9136 20.0 19.2–20.9 

Alaska 8151 13.3 12.2–14.4 

Arizona 9555 15.6 14.5–16.7 

Arkansas 10928 18.8 18.0–18.6 

California 12925 15.9 15.1–16.7 

Colorado 10062 13.0 12.2–13.8 

Connecticut 18241 

Delaware 13.9 13.0–14.7 

6181 12.7 

Florida 15550 15.4 14.6–16.2 

Georgia 17021 16.7 16.0–17.4 

Hawaii 14710 

Idaho 14732 13.5 12.9–14.1 

Illinois 14471 14.6 13.9–15.2 

Indiana 15.7 15.0–16.3 

Iowa 12185 

Kansas 13666 12.5 

Kentucky 22069 22.6 21.8–23.3 

Louisiana 14910 17.2 16.5–17.9 

Maine 7151 13.6 12.7–14.4 

Maryland 13063 12.7 12.0–13.5 

Massachusetts 23177 12.5 

Michigan 13197 14.3 13.6–15.0 

Minnesota 12309 

Mississippi 23.2 22.4–24.1 

Respondents 

Montana 12.7 

Nebraska 12949 12.8 12.2–13.4 

Nevada 8677 16.2 15.0–17.4 

13903 10.6 

23005 14.8 14.0–15.6 

13704 17.0 16.3–17.8 

13619 16.4 15.6–17.2 

22147 18.9 18.1–197 

8419 12.7 

Ohio 13.7 13.0–14.5 

Oklahoma 18801 18.0 17.4–18.6 

Oregon 9541 15.5 14.7–16.4 

Pennsylvania 20594 14.2 13.5–14.8 

14.0 13.3–14.7 

13380 16.5 15.8–17.3 

15030 12.3 

8667 19.4 18.5–20.3 

17885 20.5 19.9–21.2 

Utah 10.9–12.4 

12651 10.9 

12621 13.6 12.8–14.3 

27604 13.2 12.7–13.8 

9712 23.1 22.2–24.0 

Wisconsin 10.8–12.2 

10482 

11.8 11.2–12.4 

11483 

District of Columbia 11.7–13.7 

11.8 11.1–12.5 

15111 

11.1 10.4–11.7 

11.9–13.1 

11.9–13.0 

11.1 10.5–11.7 

11414 

11299 11.9–13.4 

New Hampshire 10.1–11.2 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 11.9–13.4 

11179 

Rhode Island 11813 

South Carolina 

South Dakota 11.7–12.9 

Tennessee 

Texas 

11712 11.6 

Vermont 10.3–11.4 

Virginia 

Washington 

West Virginia 

11654 11.5 

Wyoming 11.9 11.2–12.5 

Missouri 13030 16.3 15.5–17.1 United States 695476 15.7 15.5–15.9 

* Data are based on people who answered “poor” to the following BRFSS question: “Would you say that in general your health is excellent, very good, good, fair, or poor?” Data are for adults ≥18 years, are age-adjusted to the 2000 

U.S. population, and are weighted for the probability of sampling. † Confidence interval. 

Appendix A: Risk Factors Among the Total U.S. Population 59
Methodological B Notes

and Technical 

©Bob Daemmrich/The Image Works
Mortality Data 

County Definitions 

We used Federal Information Processing Standard (FIPS)1 codes to link 

county definitions across multiple data sets in this atlas. To ensure accurate linking of counties across the data sets, the following modifications 

were made:

Independent Cities 

The following independent cities were retained in the geographic database

as discrete entities separate from adjacent counties.

Independent Original Modified

City State FIPS Code FIPS Code

Baltimore Maryland 24510 24007 

Missouri 29510 29191 

Nevada 32510 32025 

St. Louis 

Carson City 

Suffolk Virginia 51800 51123

Alaska 

Original Original County Incorporated into Modified 

County FIPS Code Adjacent County FIPS Code 

Yakutat 2282 Skagway-Yakutat-Angoon 2231 

2013 2010 

2016 2010 

2068 2290 

Kobuk 2140 2290 

Skagway-Hoonah-Angoon 2232 2231 

Aleutian Islands East Aleutian Islands 

Aleutian Islands West Aleutian Islands 

Denali Borough Yukon-Koyukuk 

Yukon-Koyukuk 

Skagway-Yakutat-Angoon 

Arizona 

Hawaii

Original Original County Incorporated into Modified 

County FIPS Code Adjacent County FIPS Code

Kalawao 15005 Maui 15009 

Virginia 

Virginia has 34 independent cities. We used the 1996 Area Resource File 

database2 to incorporate data from these cities into their adjacent counties, which is standard practice.

Independent Independent City Incorporated into Modified 

City FIPS Code Adjacent County FIPS Code

Bedford 51515 Bedford 51019 

Bristol 51520 

51530 Rockbridge 

Charlottesville 51540 Albemarle 51003 

51560 Allegheny 51005 

l ial i 51570 Chesterfield 51041 

Covington 51580 Allegheny 51005 

Danville 51590 Pittsylvania 

Emporia 51595 Greensville 51081 

Fairfax 51600 Fairfax 51059 

51610 Fairfax 51059 

Franklin 51620 

Fredericksburg 51630 Spotsylvania 

Galax 51640 Grayson 51077 

Harrisonburg 51660 Rockingham 

Hopewell 51670 

Lexington 51678 Rockbridge 

51680 Campbell 51031 

Manassas 51683 

51685 

Martinsville 51690 Henry 51089 

Washington 51191 

Buena Vista 51163 

Clifton Forge 

Co on He ghts 

51143 

Falls Church 

South Hampton 51175 

51177 

51165 

Prince George 51149 

51163 

Lynchburg 

Prince William 51153 

Manassas Park Prince William 51153 

Original Original County Incorporated into Modified 

County FIPS Code Adjacent County FIPS Code

Yuma 4027 LaPaz 4012

Continued on next page 

62 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Independent Independent City Incorporated into Modified 

City FIPS Code Adjacent County FIPS Code

Norfolk 51710

Norton 51720

Petersburg 51730

Portsmouth 51740

Radford 51750

Richmond 51760

Roanoke 51770

Salem 51775

South Boston 51780

Staunton 51790

Waynesboro 51820

Williamsburg 51830

Winchester 51840

Norfolk 51129 

Wise 51195 

Dinwiddie 51053 

Norfolk 51129 

Montgomery 51121 

Henrico 51087 

Roanoke 51161 

Roanoke 51161 

Halifax 51083 

Augusta 51015 

Augusta 51015 

James City 51095 

Frederick 51069 

Yellowstone National Park

Original Original County Incorporated into Modified 

County FIPS Code Adjacent County FIPS Code

Park 30067 

Yellowstone National 

Park (Part), Montana 30113 

Data Sources 

Heart Disease and Stroke Mortality Data 

We obtained death certificate data through the National Center for Health 

Statistics’ National Vital Statistics System, which is a compilation of 

statistics from all death certificates filed in the 50 states and the District 

of Columbia.3 Heart disease deaths were defined as those for which 

the underlying cause of death listed on the death certificate was diseases

of the heart, defined according to the International Classification of 

Diseases (ICD-9 codes 390–398, 402, and 404–429; ICD-10 codes 

I00–I09, I11, I13, I20–I51).4,5 Stroke deaths were defined as those for 

which the underlying cause of death listed on the death certificate was 

cerebrovascular disease (ICD-9-CM codes 430–438).4 For each decedent, underlying cause of death, age, race, ethnicity, gender, and county 

of residence at the time of death were abstracted from computerized 

death certificate files.

Population Data 

For heart disease mortality rates during 1996–2000, we used postcensal population estimates for 1996–1999 and a special “bridged-race” 

version of the 2000 census population estimates that allowed us to 

aggregate the data across 1996–2000. CDC’s National Center for Health 

Statistics has produced bridged-race versions of 2000 census data to 

allow comparisons between these data and earlier reports, which used 

fewer race/ethnicity categories (see the Definition of American Indians 

and Alaska Natives section on pages 64–65 of this appendix for a 

discussion of race/ethnicity categories used for federal data collection).6 

For stroke mortality rates during 1991–1998, we used postcensal estimates calculated by the U.S. Bureau of the Census through extrapolation 

of linear trends in population growth and intercounty migration patterns 

between the 1980 and 1990 censuses. 

Map Projections 

We used several different map projections to produce the county-level

maps in this publication. For the contiguous United States, an Albers

Conic EqualArea projection was used. ForAlaska, the Miller’s Cylindrical

projection was used. For the Hawaii map, we used geographic coordinates

(latitude and longitude). Neither Alaska nor Hawaii is in proper geographic scale relative to the continental United States on the national maps. The

combination of different projections and scales allowed for presentation of

a relatively familiar orientation of these geographic features.

The coordinate information for the contiguous 48 states was projected using the Albers Conic Equal Area projection with the following 

parameters:

Spheroid: Clarke 1866 Central Meridian: -96.000

1st Standard Parallel: 29.500 2nd Standard Parallel: 45.500

False Easting: 0.000 False Northing: 0.000

Reference Latitude: 37.500

Appendix B: Methodological and Technical Notes 63
The coordinate information for Alaska used the Miller’s Cylindrical 

projection with the following parameters:

Spheroid: Sphere Central Meridian: 0.000

Definition of American Indians 

and Alaska Natives 

The definition for American Indian and Alaska Native (AI/AN) people 

used in this publication is based on the definition established in 1977 by

Directive 15 of the Office of Management and Budget (OMB), which is 

the federal agency that defines standards for government publications.7

The categories are not based on biological or anthropological concepts. 

OMB developed categories for racial and ethnic groups in response to 

the need for standardized data for record keeping and data collection and 

presentation by federal agencies (e.g., to conduct federal surveys, collect 

decennial census data, and monitor civil rights laws).

In 1997, OMB issued new race and ethnicity categories following criticism

that the categories did not reflect the country’s increasing diversity. All federal agencies were instructed to begin collecting and analyzing data using

the new categories no later than January 1, 2003. However, the census and

vital statistics data used in this publication were collected before the 1997

directive was implemented. Consequently, the racial and ethnic categories

analyzed here are consistent with the 1977 directive.

The 1977 definition for American Indian or Alaska Native is as follows: 

A person having origins in any of the original peoples of North America 

and who maintains tribal affiliation or community attachment.

Spatial Geometry 

The geographic database used for the county-level maps in this publication came from the Environmental Systems Research Institute’s (ESRI) 

ArcUSA database, which includes spatial geometry and characteristics of all U.S. counties. ESRI modified the 1973 Digital Line Graph 

source data produced by the U.S. Geological Survey to update county 

boundaries through 1988. The geographic scale of the spatial geometry 

(i.e., linework) used is 1:2 million, which is sufficient to identify major 

county features. Mortality and population data were linked to county 

geography using FIPS codes.

Calculation of Spatially Smoothed 

and Age-Adjusted Death Rates 

Rationale for Spatial Smoothing 

Although county death rates provide a high degree of spatial specificity, rates in counties with small populations and few heart disease or 

stroke deaths can be unstable. This problem is particularly relevant when 

examining geographic disparities among AI/AN populations because 

many counties have small or nonexistent numbers of this population. We 

used two approaches to reduce the statistical instability of county death 

rates for heart disease and stroke: 1) temporal aggregation of the data 

(1996–2000 for heart disease, 1991–1998 for stroke) and 2) application 

of a statistical procedure known as spatial smoothing.

We chose to spatially smooth heart disease and stroke death rates using a 

spatial moving average. The number of deaths (numerators) and population counts (person-year denominators) for each county were combined 

with the deaths and population counts of the immediate neighboring 

counties (i.e., contiguous counties), and then divided to produce an average rate. We used the contiguity matrix for all U.S. counties from the 

1996 Area Resource File database to identify contiguous counties and 

to perform spatial smoothing. Thus, a single county’s heart disease or 

stroke mortality rate actually represents an average of the rates of that 

county and all of its contiguous neighbors.

Calculation of Death Rates 

Spatially smoothed and age-adjusted death rates were calculated at the 

county level for all AI/AN people and again for AI/AN women and 

men separately. Heart disease and stroke deaths were obtained from the 

National Vital Statistics System and included all deaths for which the 

underlying cause of death reported on the death certificates was diseases 

of the heart (ICD-9-CM codes 390–398, 402, or 404–429: ICD-10 codes 

I00–I09, I11, I13, or I20–I51) or cerebrovascular disease (ICD-9-CM

codes 430–438).4,5 Population data were obtained from the U.S. Bureau 

of the Census.

For each county, deaths(numerators) and population counts(denominators)

for 10-year age groups (i.e., ages 35–44, 45–54, 55–64, 65–74, 75–84, and

≥85 years) were summed across the years. County numerators and denomi64 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
nators were then combined with numerators and denominators of all neighboring counties. Neighboring counties were defined solely by contiguity

(as opposed to distance). The combined numerators were divided by the

combined denominators to produce spatially smoothed, age-specific (i.e.,

by 10-year age group) death rates. These spatially smoothed rates were then

directly age-adjusted to the 2000 U.S. population for 10-year age groups

starting at 35. These calculations were repeated separately by gender.

Two constraints were applied to the calculation of county death rates. A

stroke death rate was not calculated for any county for which the total

number of stroke deaths in that county plus its neighbors was fewer than

20 during 1991–1998.8 A heart disease death rate was not calculated for

any county for which the total number of heart disease deaths in that

county plus its neighbors was fewer than 20 during 1996–2000. To avoid

calculating rates for counties that had no AI/AN population but whose

neighboring counties had significant populations, rates were calculated

only for counties with a population count of 5 or more (i.e., person-years

were ≥5) during 1996–2000 for heart disease and 1991–1998 for stroke.

Unfortunately, death rates could not be adjusted to account for misreporting ofAI/AN people as “white” on death certificates(see the Introduction,

page 2, for a discussion of this issue). Although the Indian Health Service

(IHS) has established a series of weights that can be used to estimate more

accurate death rates for AI/AN populations, these weights are designed to

be applied to IHS areas, not U.S. counties.9 Because the weights were calculated on the basis of deaths from all causes combined, even the adjusted

heart disease and stroke death rates for AI/AN people may still be less

than the true rates for this population.10

Standard Population Weights 

Because we calculated directly age-adjusted heart disease and stroke 

death rates for people ages 35 years and older, but not for the entire age 

range of the population, we had to recalculate the standard weights for 

the 2000 U.S. standard population. New weights for age groups 35–44 

through ≥85 years were calculated using a two-step procedure. First, 

we calculated the sum of the original 2000 standard weights for 10-

year age groups 35–44 through ≥85 years. Second, for each age group, 

we divided the original weight by the sum of the weights for ages ≥35 

1.000000 

<1 0.013818 

1 0.013687 

2–4 0.041630 

5 0.014186 

6–8 0.042966 

9 0.015380 

0.030069 

12–14 0.042963 

15–17 0.043035 

18–19 0.029133 

20–24 0.066478 

25–29 0.064530 

30–34 0.071044 

35–39 0.080762 

40–44 0.081851 

45–49 

50–54 0.062716 

55–59 0.048454 

60–64 0.038793 

65–69 0.034264 

70–74 0.031773 

75–79 0.027000 

80–84 0.017842 

≥85 0.015508 

65–74 0.13 

70–84 0.09 

≥85 0.03 

≥

2000 U.S. Projected Standard 

Population Weights 

Age Group (yrs) Weight 

All ages 

10–11 

0.072118 

2000 U.S. Projected Standard 

Population Weights for Age 

Groups ≥35 Years 

Age Group (yrs) Weight 

years. The resulting quotients are the new standard population weights. 

The weights were rounded to two decimal places and used to calculate 

directly age-adjusted death rates for people ages 35 years.

35–44 0.32 

45–54 0.26 

55–64 0.17 

Appendix B: Methodological and Technical Notes 65
Contiguity Matrix for Alaska 

We used the contiguity matrix for all U.S. counties from the 1996 Area

Resource File database to perform spatial smoothing of heart disease

and stroke mortality rates for this publication. However, this database

did not include information for counties in Alaska, because Alaska was

considered to be a single geographic unit. Because we are interested in the

geographic patterns of heart disease and stroke mortality within the state,

we created the following contiguity matrix for the counties in Alaska:

1 2 3 4 5 6 7 8 

2010 2164 

2020 2170 2261 2122 

2050 2070 2270 2170 2164 2290 2122 

2060 2164 2070 

2070 2164 2060 2050 

2090 2290 2240 

2100 2231 

2100 2280 

2122 2020 2170 2050 2164 2150 2261 

2130 2201 2280 

2150 2122 2164 

2164 2060 2070 2050 2122 2010 

2170 2290 2240 2261 2020 2050 2122 

2180 2270 2290 2188 

2185 2188 2290 

2188 2185 2290 2180 

2201 2280 2130 

2220 2231 2280 

2231 2261 2100 2220 2280 

2240 2290 2090 2170 2261 

2261 2240 2170 2020 2231 2122 

2270 2290 2050 2180 

2280 2220 2201 2231 2130 

2290 2185 2188 2270 2050 2170 2240 2090 2180 

FIPS Codes 

for Alaska’s 

23 Counties 

FIPS Codes for Neighboring Counties* 

2110 

2110 

2110 

* Each county can be bordered by as few as one or as many as eight neighboring counties. 

66 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Risk Factor Data

Data Source Telephone Coverage 

We obtained data for eight important risk factors for heart disease and A recent study indicates that about 17% of AI/AN people do not have 

stroke from the Behavioral Risk Factor Surveillance System (BRFSS). telephones in their homes.15 This percentage is higher than that of any 

BRFSS data are collected monthly by state departments of health through other U.S. racial/ethnic group. The percentages within this population 

telephone interviews of noninstitutionalized adults aged 18 years or vary sharply depending on where people live; only 47% of AI/AN peoolder. The states use a multistage design for stratified random sampling ple living on reservations have telephones compared with 75% of those 

of the telephone numbers dialed. Complete details of the BRFSS meth- who live in rural areas and 88% of those who live in urban areas.15,16

odology have been published elsewhere.11–13

Other studies have found that AI/AN people who live in households 

The BRFSS includes a set of core questions that are asked every year in without telephones are more likely to be physically inactive and to 

all states, as well as a set of rotating core questions that are asked every smoke cigarettes.17–19 Therefore, the findings reported in this atlas are 

other year. This publication presents prevalence data for the following more likely to represent AI/AN people who live in urban areas and not 

risk factors included in the annual core questions: diabetes, cigarette on reservations, and they likely underestimate the prevalence of some 

smoking, obesity, physical inactivity, and poor health. From the rotating risk factors for heart disease and stroke.

questions that are asked in odd-numbered years, it presents data on high 

blood pressure, high blood cholesterol, and cholesterol screening.

BRFSS core questions are available in English and Spanish. If the 

interviewer determines that the respondent is not proficient in either 

language, the interviewer does not administer the survey and notes that 

the interview was ended because of a language barrier.

Once the monthly state data are collected, they are sent to CDC to be edited

and checked for accuracy. CDC staff members aggregate the monthly data

files for each state to create annual totals. These totals are then weighted

according to the respondents’ probability of being sampled, given the race,

age, and gender of the population from which they were selected. Weighting

is based on the most current census data for each state. The prevalence of

each risk factor for each state is calculated from the weighted data.

Because of the small number of AI/AN respondents in the BRFSS, we 

combined data for 2001–2003 to increase the precision of our estimates. 

Prevalence estimates for states that reported fewer than 50 AI/AN 

respondents were considered unreliable and are not presented in this 

publication.14

Appendix B: Methodological and Technical Notes 67
Definition of Risk Factors 

For this publication, we defined eight risk factors for heart disease and 

stroke on the basis of specific questions from the BRFSS during 2001–

2003. As of 1996, state health departments also can ask about regular

aspirin use, prior history of heart disease, and prior history of stroke on 

their BRFSS questionaires. However, only a few states do so, and many 

of these states do not have large enough AI/AN populations to generate 

stable estimates. Therefore, data for these heart disease and stroke risk 

factors are not included in this atlas.

Map Projection 

We combined two map projections to produce the risk factor maps in 

this publication. For the contiguous United States, an Albers Conic 

Equal Area projection was used. For Alaska, the Miller’s Cylindrical 

projection was used. Neither Alaska nor Hawaii is in proper geographic 

scale relative to the continental United States on the risk factor maps. 

The combination of different projections and scales allowed for presentation of a relatively familiar orientation of these geographic features.

Definition of American Indians 

and Alaska Natives 

Respondents to the BRFSS were asked to select a race of origin from 

the following list: White, Black or African American, Asian, Native 

Hawaiian or Other Pacific Islander, American Indian/Alaska Native, 

or Other (Specify). Only those respondents selecting American Indian/

Alaska Native were included in this atlas. 

Spatial Geometry 

The geographic database used for the risk factor maps in this publication came from the Environmental Systems Research Institute’s (ESRI) 

ArcUSA database, which includes spatial geometry and characteristics 

of all U.S. counties. The geographic scale of the spatial geometry used 

is 1:42,874,983, which is sufficient to identify state features. 

Definition 

Pressure l l

High 

Cholesterol 

Cholesterol 

Screening 

Diabetes 

Cigarette 

Smoking 

foll i i

l i i i

lif

ll

l i l i in 

ir lif i i

fi

Obesity foll i l l i f i

( I) f lf i i {[ i

in l ]/[( i in i )2]} 

Physical 

Inactivity 

foll i i i

l j i icii i l iviti i i

li i lf i lki f i

Poor 

Health 

l foll i

i l i l l is 

ll fai

Risk Factor 

High Blood Based on “yes” responses to the following question: “Have 

you ever been to d by a doctor, nurse, or other hea th 

professional that you have high blood pressure?” 

Based on “yes” responses to the following question: “Have 

you ever been told by a doctor or other health professional 

that your blood cholesterol is high?” 

Based on “yes” responses to the following question: “Have 

you ever had your blood cholesterol checked?” 

Based on “yes” responses to the following question: “Have 

you ever been told by a doctor that you have diabetes?” 

Based on “yes” responses to the ow ng quest on: 

“Have you smoked at east 100 c garettes n your ent re 

e?” Respondents who answered “yes” were then asked, 

“Do you now smoke every day, some days, or not at a ?” 

Peop e who reported smok ng at east 100 c garettes 

the et me and smok ng now every day or some days 

were de ned as current smokers. 

Based on the ow ng ca cu at on o body mass ndex 

BM rom se -reported he ght and we ght: we ght 

bs. x 0.4536 he ght nches x 0.2540 x 100. 

BMI ≥30.0 was considered obese. 

Based on “no” responses to the ow ng quest on: “Dur ng 

the past month, other than your regu ar ob, d d you part

pate n any phys ca act es or exerc se such as runn ng, 

ca sthen cs, go , garden ng, or wa ng or exerc se?” 

Based on peop e who answered “poor” to the ow ng 

quest on: “Wou d you say that n genera your hea th 

exce ent, very good, good, r, or poor?” 

68 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Calculation of Prevalence Estimates 

Because of the complex survey methodology used to produce prevalence

estimates for this publication, we used SUDAAN statistical software to

calculate standard errors and 95% confidence intervals. The prevalences

reported in this atlas are weighted according to the respondents’ probability of being sampled, given the race, age, and gender of the state population from which they were selected. No statistical tests were performed

for comparison, so the findings of this publication should be considered

descriptive in nature.

1. National Institute of Standards and Technology. Federal Information Processing 

Standards Publication 55-3: Codes for Named Populated Places, Primary County 

Divisions, and Other Locational Entities of the United States, Puerto Rico, and the 

Outlying Areas. Gaithersburg, MD: U.S. Department of Commerce; 1994. Available 

at http://www.itl.nist.gov/fipspubs/fip55-3.htm.

2. Bureau of Health Professions. Area Resource File. Rockville, MD: U.S. Department 

of Health and Human Services, Health Resources and Services Administration; 1996. 

Available at http://www.arfsys.com.

3. CDC. National Vital Statistics System Web site. Available at

http://www.cdc.gov/nchs/nvss.htm.

4. U.S. Department of Health and Human Services. The International Classification 

of Diseases, 9th Revision, Clinical Modification. Washington, DC: Public Health 

Service, Health Care Financing Administration; 1980. HHS publication no. (PHS) 

80-1260.

5. World Health Organization. International Classification of Diseases and Related 

Health Problems, 10th Revision, Clinical Modification. Geneva: World Health 

Organization; 1992.

6. CDC. National Center for Health Statistics Web site. U.S. Census Populations with 

Bridged Race Categories: Bridged-Race Population Estimates for April 1, 2000. 

Available at http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm.

7. Wallman KK, Hodgdon J. Race and ethnic standards for federal statistics and administrative reporting. Statistical Reporter 1977;77(10):450–454.

8. Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 

1999. National Vital Statistics Reports 2001;49(8):110.

9. Indian Health Service. Adjusting for Miscoding of Indian Race on State Death 

Certificates. Rockville, MD: U.S. Department of Health and Human Services, Public 

Health Service; 1996.

10. Rhoades DA. Racial misclassification and disparities in cardiovascular disease 

among American Indians and Alaska Natives. Circulation 2005;111(10):1250–6.

11. CDC. Technical Information and Data: BRFSS User’s Guide. Atlanta: U.S. 

Department of Health and Human Services; 1998. Available at http://www.cdc.gov/

brfss/technical_infodata/usersguide.htm.

12. Holtzman D. Analysis and interpretation of data from the U.S. Behavioral Risk Factor

Surveillance System (BRFSS). In: McQueen DV, Puska P, et al. Global Behavioral Risk

Factor Surveillance. New York: Kluwer Academic/Plenum Publishers; 2003:35–46.

13. Mokdad AH, Stroup DF, Giles WH. Public health surveillance for behavioral risk 

factors in a changing environment: recommendations from the Behavioral Risk 

Factor Surveillance Team. Morbidity and Mortality Weekly Report 2003;52(RR-9).

14. CDC. 2000 BRFSS Summary Prevalence Report. Atlanta: U.S. Department of Health 

and Human Services; May 2001:9. Available at http://www.cdc.gov/brfss/pubrfdat.

htm.

15. National Telecommunications and Information Administration. Falling Through the 

Net: Defining the Digital Divide. Washington, DC: U.S. Department of Commerce; 

1999.

16. Bureau of the Census. Housing of American Indians on reservations—equipment and 

fuels. Bureau of the Census Statistical Brief 1995. Publication no. SB/95-11.

17. Pearson D, Cheadle A, Wagner E, Tonsberg R, Psaty BM. Differences in sociodemographic, health status, and lifestyle characteristics among American Indians by 

telephone coverage. Preventive Medicine 1994;23(4):461–4.

18. Cheadle A, Pearson D, Wagner E, Psaty BM, Diehr P, Koepsell T. Relationship 

between socioeconomic status, health status, and lifestyle practices of American 

Indians: evidence from a Plains reservation population. Public Health Reports

1994;109(3):405–13.

19. Peterson DE, Remington PL, Kuykendall MA, Kanarek MS, Diedrich JM, Anderson 

HA. Behavioral risk factors of Chippewa Indians living on Wisconsin reservations. 

Public Health Reports 1994;109(6):820–3.

Appendix B: Methodological and Technical Notes 69
Resources C©Eastcott-Momatiuk/The Image Works
American Indian and Alaska Native 

Health Organizations 

Native American Women’s Health Education Resource Center

PO Box 572, Lake Andes, SD 57356-0572 

Phone: 605-487-7072 

Web site: http://www.nativeshop.org/nawherc.html

The Native American Women’s Health Education Resource Center 

is operated by the Native American Community Board (NACB). The 

NACB was formed in 1985 by a group of Native Americans living on 

or near the Yankton Sioux Reservation in South Dakota to address 

pertinent issues of health, education, land and water rights, and 

economic development of Native American people.

National Indian Health Board 

1385 S. Colorado Blvd, Suite A707, Denver, CO 80222 

Phone: 303-759-3075, Fax: 303-759-3674 

Web site: http://www.nihb.org

The National Indian Health Board (NIHB) represents Tribal

Governments that operate their own health care delivery systems

through contracting and compacting, as well as those that receive

health care directly from the Indian Health Service. The NIHB is

a nonprofit organization that conducts research, policy analysis,

program assessment and development, national and regional meeting

planning, project management, and training and technical assistance

programs. These services are provided to Tribes, Area Health Boards,

Tribal organizations, federal agencies, and private foundations.

Association of American Indian Physicians 

1225 Sovereign Row, Suite 103, Oklahoma City, OK 73108 

Phone: 405-946-7072, Fax: 405-946-7651 

Web site: http://www.aaip.com

The Association of American Indian Physicians was founded to 

pursue excellence in Native American health care by promoting 

education in the medical disciplines; honoring traditional healing 

practices; and restoring the balance of mind, body, and spirit.

Association of Native American Medical Students

1225 Sovereign Row, C-9, Oklahoma City, OK 73108

Phone: 405-946-7072 

Web site: http://www.aaip.com/anams/anams.html

The Association of Native American Medical Students was founded 

to provide support and a resource network for all Native Americans 

enrolled in the various allied health professions schools, to increase 

the number of Native American students in medicine and other 

health professions, and to promote its exposure and recognition on a 

national level throughout the medical community.

Indians into Medicine 

University of North Dakota 

School of Medicine and Health Science 

PO Box 9037, Grand Forks, ND 58202-9037 

Phone: 701-777-3037, Fax: 701-777-3277 

Web site: http://www.med.und.nodak.edu/depts/inmed/home.htm

Indians into Medicine addresses three major problem areas: 1) too 

few health professionals in American Indian communities, 2) too few 

American Indian health professionals, and 3) the substandard level 

of health and health care in American Indian communities.

Indian Health Service Headquarters

The Reyes Building

801 Thompson Avenue, Suite 440

Rockville, MD 20852-1627 

Phone: 301-443-1083, Fax: 301-443-4794 

Web site: http://www.ihs.gov 

The Indian Health Service (IHS) is an agency within the U.S. 

Department of Health and Human Services that is responsible for 

providing federal health services to American Indians and Alaska 

Natives. The IHS is the principal federal health care provider and 

health advocate for these populations, and its goal is to ensure that 

comprehensive, culturally acceptable personal and public health 

services are available and accessible to American Indians and 

Alaska Natives. 

72 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
National Council of Chief Medical Officers, 

Indian Health Service 

Chief Medical Officer 

Indian Health Service (IHS)

801 Thompson Avenue, Suite 440

Rockville, MD 20852

Aberdeen Area IHS

Federal Building, 115 4th Avenue, S.E.

Aberdeen, SD 57401

Alaska Area IHS

4141 Ambassador Drive

Anchorage, AK 99508

Albuquerque Area IHS

5300 Homestead Road, N.E.

Albuquerque, NM 87110

Bemidji Area IHS

522 Minnesota Avenue, N.W.

Bemidji, MN 56601

Billings Area IHS 

PO Box 36600

Billings, MT 59107

California Area IHS

650 Capitol Mall, Suite 7-100

Sacramento, CA 95814

Nashville Area IHS

711 Stewarts Ferry Pike

Nashville, TN 37214-2634

Navajo Area IHS

PO Box 9020

Window Rock, AZ 86515

Oklahoma Area IHS

Five Corporate Plaza

3625 N.W. 56th Street

Oklahoma City, OK 73112

Phoenix Area IHS

Two Renaissance Square

40 N. Central Avenue, Suite 600

Phoenix, AZ 85004-4424

Portland Area IHS

1220 S.W. Third Avenue

Portland, OR 97204-2892

Tucson Area IHS

7900 South J Stock Road

Tucson, AZ 85746-9352

Federal Government Agencies 

Indian Health Service Headquarters

The Reyes Building

801 Thompson Avenue, Suite 440

Rockville, MD 20852-1627 

Phone: 301-443-1083, Fax: 301-443-4794 

Web site: http://www.ihs.gov 

The Indian Health Service (IHS)is an agencywithin the U.S. Department

of Health and Human Services that is responsible for providing federal

health services to American Indians and Alaska Natives. The IHS is the

principal federal health care provider and health advocate for these

populations, and its goal is to ensure that comprehensive, culturally

acceptable personal and public health services are available and accessible to American Indians and Alaska Natives.

Appendix C: Resources 73
Office of the Associate Director for Minority Health

Centers for Disease Control and Prevention (CDC) 

1600 Clifton Road, MS D-39, Atlanta, GA 30333 

Phone: 404-639-7210 

Web site: http://www.cdc.gov/od/admh 

The mission of the Office of the Associate Director for Minority 

Health is to improve the health of African American, Asian American 

and Pacific Islander, Hispanic American, and Native American and 

Alaska Native citizens and, where appropriate, members of similar 

ethnic/racial subgroups both in and outside the United States, 

through policy development and program analysis at the CDC and 

the Agency for Toxic Substances and Disease Registry. 

Office of Women’s Health 

Centers for Disease Control and Prevention 

1600 Clifton Road, MS D-51, Atlanta, GA 30333 

Phone: 404-639-7230, Fax: 404-639-7331 

Web site: http://www.cdc.gov/od/owh 

The Office of Women’s Health is dedicated to in-depth research

and dissemination of information and public policy regarding

women’s health.

Office of Minority Health 

Division of Information and Education 

Rockwall II Building, Suite 1085

5515 Security Lane, Rockville, MD 20852 

Phone: 301-443-5224, Fax: 301-443-1426 

Web site: http://www.omhrc.gov 

The Office of Minority Health, which operates under the U.S. 

Department of Health and Human Services, works to improve collection and analyses of data on the health of racial and ethnic minority 

populations, and it monitors efforts to achieve Healthy People 2010 

goals for minority health. 

The Office of Minority Health Resource Center 

Division of Information and Education 

Rockwall II Building, Suite 1000

5600 Fishers Lane, Rockville, MD 20857 

Phone: 1-800-444-6472 

Web site: http://www.omhrc.gov 

The Office of Minority Health Resource Center was established to 

assist in the exchange of information and analyses of minority health 

issues. The center collects and distributes information on a wide 

variety of health topics and facilitates the exchange of information 

on minority health issues. 

Office of Research on Women’s Health 

National Institutes of Health

Building 1, Room 201, Bethesda, MD 20892 

Web site: http://www4.od.nih.gov/orwh/index.html

The goal of the Office of Research on Women’s Health is to ensure 

that research conducted and supported by the National Institutes of 

Health addresses issues of women’s health, and that there is appropriate inclusion of women in clinical research. 

National Heart, Lung, and Blood Institute 

National Institutes of Health 

Building 31, Suite 4A10, MSC 2480

31 Center Drive, Bethesda, MD 20892

Web site: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

The National Heart, Lung, and Blood Institute is a national program 

dedicated to research related to the causes, prevention, diagnosis, 

and treatment of heart, blood vessel, lung, and blood diseases, as 

well as sleep disorders.

74 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
National Center of Minority Health and Health Disparities 

Office of Research on Minority Health 

6707 Democracy Blvd., Suite 800

Bethesda, MD 20892-5465

Phone: 301-402-1366, Fax: 301-480-4049 

The Office of Research on Minority Health (ORMH) was founded in 

1999 by the National Institutes of Health to help solve research questions that result from the disparity of health status among Americans. 

The ORMH’s mission is to support and promote biomedical research 

aimed at improving the health status of minority Americans across 

the life span and programs aimed at expanding the participation 

of under-represented minorities in all aspects of biomedical and 

behavioral research. 

Agency for Healthcare Research and Quality 

Center for Cost and Financing Studies 

2101 East Jefferson Street, Suite 500

Rockville, MD 20852 

Phone: 301-594-1406, Fax: 301-594-2166 

Web site: http://www.ahrq.gov

The Agency for Healthcare Research and Quality (AHRQ) was established in 1989 as the Agency for Health Care Policy and Research.

Reauthorizing legislation passed in November 1999 established

AHRQ as the lead federal agency on quality research. AHRQ operates

under the U.S. Department of Health and Human Services and is the

lead agency charged with supporting research designed to improve the

quality of health care, reduce its cost, and broaden access to essential services. AHRQ’s broad programs of research bring practical,

science-based information to medical practitioners and to consumers

and other health care purchasers.

State and Territorial Agencies 

Cardiovascular Health Council of 

the Association of State and Territorial 

Chronic Disease Program Directors 

Jack Hataway

Director, Chronic Disease Prevention Division

Alabama Department of Public Health

201 Monroe Street, RSA Tower, Suite 964

Montgomery, AL 36104

Phone: 334-206-5610, Fax: 334-206-5609

E-mail: jhataway@adph.state.al.us

Jason Eberhart-Phillips

Cardiovascular Health Program

Alaska Division of Public Health

PO Box 241623, Anchorage, AK 99524-1623

Phone: 907-269-8447, Fax: 907-562-7802

E-mail: Jason_eberhart-phillips@health.state.ak

Margaret Tate

Chief, Office of Nutrition and Chronic Disease 

Prevention Services

Arizona Department of Health Services

150 North 18th Avenue, Suite 310, Phoenix, AZ 85007

Phone: 602-542-2829, Fax: 602-542-1890

E-mail: mtate@hs.state.az.us

Jan Bunch

Chronic Disease Service Unit

Arkansas Department of Health

4815 West Markham Street, Slot 41

Little Rock, AR 72205

Phone: 501-661-2150, Fax: 501-661-2055

E-mail: jbunch@healthyarkansas.com

Appendix C: Resources 75
Kathleen H. Acree

Chief, Chronic Disease Control Branch

California Department of Health Services

PO Box 942732, MS-7208

Sacramento, CA 94234-7320

Phone: 916-552-9900, Fax: 916-552-9729

E-mail: kacree@dhs.ca.gov

Normie Morin-Voilleque

Director, Chronic Disease Section-A5

Colorado Department of Public Health and Environment

4300 Cherry Creek Drive South

Denver, CO 80246-1530

Phone: 303-692-2505, Fax: 303-691-7721

E-mail: normie.morin@state.co.us

Rosa M. Biaggi

Director, AIDS and Chronic Disease Division

Connecticut Department of Public Health

410 Capitol Avenue, MS-11 APV

PO Box 340308, Hartford, CT 06134

Phone: 860-509-7801, Fax: 860-509-7855

E-mail: rosa.biaggi@po.state.ct.us

Gregory Roane

Chronic Disease Director

Delaware Division of Public Health

PO Box 637, Dover, DE 19904-0637

Phone: 302-741-2900, Fax: 302-741-2910

E-mail: gregory.roane@state.de.us

Karen Barry

Chief, Bureau Chronic Disease

District of Columbia Department of Health

825 North Capitol Street, N.E. #3147

Washington, D.C. 20002

Phone: 202-442-9366, Fax: 202-442-4825

E-mail: kbarry@dehealth.com

Jennie A. Hefelfinger

Florida Department of Health

Bureau of Chronic Disease 

4052 Bald Cypress Way, Bin #A18

Tallahassee, FL 32399-1744

Phone: 850-245-4330, Fax: 850-414-6625

E-mail: jennie_a_hefelfinger@doh.state.fl.us

Carol Steiner

Director, Cancer Control Section

Georgia Department of Human Resources

2 Peachtree Street, Room 16-293, Atlanta, GA 30303

Phone: 404-657-6606, Fax: 404-657-6316

E-mail: cbsteiner@dhr.state.ga.us

Barbara Yamashita

Chief, Community Health

Hawaii State Department of Health

1250 Punchbowl Street, Room 218

Honolulu, HI 96801-3378

Phone: 808-586-4126, Fax: 808-586-4791

E-mail: bayamash@mail.health.state.hi.us

Elke Shaw-Tulloch

Chief, Bureau of Community and Environmental Health

Idaho Division of Health

450 W. State Street, 6th Floor, Boise, ID 83720-0036

Phone: 208-334-5950, Fax: 208-334-6573

E-mail: shawe@idhw.state.id.us

Chandana Nandi

Chief, Office of Health Promotion

Illinois Department of Public Health

535 West Jefferson Street, Springfield, IL 62761

Phone: 217-782-3300, Fax: 217-782-1235

E-mail: cnandi@idph.state.il.us

76 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Sue Percifield

Director

Indiana State Department of Health

2 North Meridian Street, Suite 6-A

Indianapolis, IN 46204-3003

Phone: 317-233-7816, Fax: 317-233-7805

E-mail: spercifi@isdh.state.in.us

Jill Myers-Geadelmann

Chief, Cancer Prevention and Control Bureau

Iowa Department of Public Health

321 E. 12th Street, Des Moines, IA 50319-0075

Phone: 515-242-6067, Fax: 515-281-4535

E-mail: jgeadelm@idph.state.ia.us

Paula F. Marmet

Director

Kansas Department of Health and Environment

1000 S.W. Jackson, Suite 230, Topeka, KS 66612-1274

Phone: 785-296-8916, Fax: 785-296-8059

E-mail: pmarmet@kdhe.state.ks.us

Curtis Rowe

Manager, Chronic Disease Prevention and Control

Kentucky Department for Public Health

275 East Main Street, HSIC-B, Frankfort, KY 40621

Phone: 502-564-7996 (ext. 1), Fax: 502-564-4667

E-mail: curtis.rowe@mail.state.ky.us

Vicki Scanlon-Leishman

Program Manager, Community Health Promotion and 

Chronic Disease

Louisiana Department of Health and Hospitals

PO Box 60630, New Orleans, LA 70160

Phone: 504-599-1087, Fax: 504-568-7005

E-mail: vsleishm@dhh.state.la.us

Barbara A. Leonard

Director, Division of Community Health Promotion

Maine Department of Health and Human Services

11 State House Station

286 Water Street, 4th Floor, Augusta, ME 04333

Phone: 207-287-5387, Fax: 207-287-4631

E-mail: barbara.a.leonard@maine.gov

Patricia Boehm

Chief, Chronic Disease Prevention Teams

Maryland Department of Health and Mental Hygiene

300 West Preston Street, Suite 200, Baltimore, MD 21202

Phone: 410-767-5590, Fax: 410-333-7411

E-mail: boehmp@dhmh.state.md.us

Cynthia Boddie-Willis

Director, Division of Community Health Promotion

Massachusetts Department of Public Health

250 Washington Street, 4th Floor, Boston, MA 02108

Phone: 617-624-5467, Fax: 617-624-5075

E-mail: cynthia.boddie-willis@state.ma.us

Carol Callaghan

Director, Division of Chronic Disease and Injury Control

Michigan Department of Community Health

3423 N. Martin Luther King Jr. Blvd.

PO Box 30195, Lansing, MI 48909

Phone: 517-335-8379, Fax: 517-335-9397

E-mail: callaghanc@michigan.gov

Mary Manning

Chief, Center for Health Promotion

Minnesota Department of Health

PO Box 9441, Minneapolis, MN 55414

Phone: 651-676-5201, Fax: 651-676-5057

E-mail: mary.manning@state.mn.us

Appendix C: Resources 77
Victor Sutton

Director, Health Promotion

Mississippi State Department of Health

PO Box 1700, 570 East Woodrow Wilson

Jackson, MS 39215-1700

Phone: 601-576-7725, Fax: 601-576-7497

E-mail: vsutton@msdh.state.ms.us

Paula Nickelson

Director, Division of Community Health

Missouri Department of Health and Senior Services

920 Wildwood, PO Box 570

Jefferson City, MO 65102-0570

Phone: 573-522-6252, Fax: 573-552-5348

E-mail: nickep@dhss.mo.gov

Todd Harwell

Chief, Chronic Disease and Health Promotion Bureau

Montana Department of Public Health and Human Services

Cogswell Bldg., 1400 Broadway, Room C-317

Helena, MT 59620

Phone: 406-444-1437, Fax: 406-444-7465

E-mail: tharwell@state.mt.us

Roméo Guerra

Deputy Director for Health Services

Nebraska Department of Health and Human Services System

301 Centennial Mall South

PO Box 95044, Lincoln, NE 68509-5044

Phone: 402-471-6038, Fax: 402-471-9449

E-mail: romeo.guerro@hhss.state.ne.us

Richard Whitley

Chief

Nevada State Health Division

505 East King Street, Room 103, Carson City, NV 89701

Phone: 775-684-5958, Fax: 775-684-5998

E-mail: rwhitley@nvhd.state.nv.us

Margaret Murphy

Acting Director

New Hampshire Department of Health and Human Services

6 Haven Drive, Suite 2 East

Concord, NH 03301

Phone: 603-271-4524, Fax: 603-271-0539

E-mail: mmurphy@dhhs.state.nh.us

Doreleena Sammons-Posey

Program Manager, Cancer and Reproductive Health

New Jersey Department of Health and Senior Services

50 East State Street, 6th Floor

PO Box 364, Trenton, NJ 08625-0364

Phone: 609-292-8540, Fax: 609-292-9599

E-mail: Doreleena.Sammons-Posey@doh.state.nj.us 

David Vigil

Chief, Chronic Disease Prevention and Control

New Mexico Department of Health 

625 Silver, S.W. #200, Albuquerque, NM 87102

Phone: 505-841-5836, Fax: 505-841-5685

E-mail: davidv@doh.state.nm.us

Mark S. Baptiste

Director, Division of Chronic Disease Prevention 

and Adult Health

New York State Department of Health

Corning Tower Building, Empire State Plaza, Room 515

Albany, NY 12237-0675

Phone: 518-474-0512, Fax: 518-473-2853

E-mail: msb02@health.state.ny.us

Marcus Plescia

Section Chief, Chronic Disease and Injury

North Carolina Department of Health and Human Services

1915 Mail Service Center, Raleigh, NC 27699-1915

Phone: 919-715-0215, Fax: 919-715-3153

E-mail: Marcus.Plescia@ncmail.net

78 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Sherri Paxon

Director, Division of Chronic Disease

North Dakota Department of Health

600 E. Boulevard Avenue, Bismarck, ND 58505- 0200

Phone: 701-328-2698, Fax: 701-328-2036

E-mail: spaxon@state.nd.us

Frank S. Bright

Chief, Bureau of Health Promotion and Risk Reduction

Ohio Department of Health

246 North High Street, PO Box 118

Columbus, OH 43266-0118

Phone: 614-466-2144, Fax: 614-564-2409

E-mail: fbright@gw.odh.state.oh.us

Adeline M. Yerkes

Chief, Chronic Disease Service

Oklahoma State Department of Health

1000 North East 10th Street

Oklahoma City, OK 73117-1299

Phone: 405-271-4072 (ext. 57123), Fax: 405-271-3615

E-mail: adeliney@health.state.ok.us

Jane M. Moore

Manager, Health Promotion and Chronic Disease Prevention

Oregon Department of Health Services

800 N.E. Oregon Street, Suite 730

Portland, OR 97232

Phone: 503-731-4273, Fax: 503-731-4082

E-mail: jane.m.moore@state.or.us

Leslie Best

Director, Bureau of Chronic Disease and Injury Program

Pennsylvania Department of Health

Health and Welfare Bldg., Room 1000, Harrisburg, PA 17120

Phone: 717-787-6214, Fax: 717-783-5498

E-mail: Ibest@state.pa.us

Ann Thacher

Chief, Office of Health Promotion and 

Chronic Disease Prevention

Rhode Island Department of Health

3 Capitol Hill, Room 409

Providence, RI 02908-5097

Phone: 401-222-7637, Fax: 401-222-4415

E-mail: AnnT@doh.state.ri.us

Michael D. Byrd

Director

South Carolina Department of Health and Environmental Control

2600 Bull Street, Columbia, SC 29201

Phone: 803-545-4481, Fax: 803-545-4921

E-mail byrdmd@dhec.sc.gov

Norma Schmidt

Team Leader, Chronic Disease Prevention

South Dakota Department of Health

615 East Fourth Street, Pierre, SD 57501-1700

Phone: 605-773-5728, Fax: 605-773-5509

E-mail: norma.schmidt@state.sd.us

Donna Henry

Acting Director, Health Promotion Division

Tennessee Department of Health

Cordell Hull Building, 6th Floor

425 5th Avenue North, Nashville, TN 37247-7366

Phone: 615-253-5800, Fax: 615-253-8478

E-mail: donna.henry@state.tn.us

Philip Huang

Director

Texas Department of Health

1100 W. 49th Street, Austin, TX 78756-7446

Phone: 512-458-7200, Fax: 512-458-7618

E-mail: Philip.Huang@tdh.state.tx.us

Appendix C: Resources 79
Ladene Larsen

Director, Bureau of Health Promotion

Utah Department of Health

288 North 1460 West, PO Box 142107

Salt Lake City, UT 84114-2107

Phone: 801-538-62201, Fax: 801-538-9495

E-mail: ladenelarsen@utah.gov 

Karen Garbarino

Chronic Disease Director

Vermont Department of Health

PO Box 70, Burlington, VT 05402

Phone: 802-951-4004, Fax: 802-651-1634

E-mail: kgarbar@vdh.state.vt.us

Ramona D. Schaeffer

Director, Chronic Disease Prevention and Control

Virginia Department of Health

109 Governor Street, 10th Floor, Richmond, VA 23219

Phone: 804-864-7877, Fax: 804-864-7880

E-mail: Ramona.Schaeffer@vdh.virginia.gov

Mary Frost

Director, Chronic Disease Prevention and Risk

Washington State Department of Health 

PO Box 47855, Olympia, WA 98504-7855

Phone: 360-236-3628, Fax: 360-236-3646

E-mail: mary.frost@doh.wa.gov

Tom Sims

Director, Division of Health Promotion and Chronic Disease

West Virginia Bureau for Public Health

350 Capitol Street, Room 319

Charleston, WV 25301-3715

Phone: 304-558-0644, Fax: 304-558-1553

E-mail: tomsims@wvdhhr.org

Millie Jones

Director, Bureau of Community Health and Prevention 

Wisconsin Division of Public Health

1 West Wilson Street, Room 230

PO Box 2659, Madison, WI 53701-2659

Phone: 608-266-2684, Fax: 608-267-3824

E-mail: jonesmj@dhss.state.wi.us

Linda L. Chasson

Chief, Chronic Disease Section

Wyoming Department of Health

Qwest Building, Suite 259A

6101 N. Yellowstone Road

Cheyenne, WY 82002

Phone: 307-777-3579, Fax: 307-777-8604

E-mail: lchass@state.wy.us

Heart Disease and Stroke Prevention 

Program Managers 

Janice Cook

Alabama Department of Public Health

201 Monroe Street, RSA Tower, Suite 962

Montgomery, AL 36104

Phone: 334-206-5610, Fax: 334-206-5609

E-mail: jcook@adph.state.al.us

Carol White

Section of Community Health and EMS

Alaska Department of Health and Social Services

PO Box 110616, Juneau, AK 99811-0616

Phone: 907-465-8670, Fax 907-465-2770

E-mail: carol_white@health.state.ak.us

Linda Faulkner

Arkansas Department of Health

4815 W. Markham Street, Slot 11

Little Rock, AR 72205-3867

Phone: 501-661-2956, Fax: 501-661-2070

E-mail: lfaulkner@healthyarkansas.com

80 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Gloria Latimer Julie Harvill

CVH Program Manager Illinois Department of Public Health

Colorado Department of Public Health and Environment 535 West Jefferson Street, 2nd Floor

4300 Cherry Creek Drive S., A-5 Springfield, IL 62761

Denver, CO 80246-1530 Phone: 217-782-3300, Fax: 217-782-1235

Phone: 303-692-2562, Fax: 303-691-7721 E-mail: jharvill@idph.state.il.us

E-mail: gloria.latimer@state.co.us

Misty Jimerson

Chris Andresen Kansas Department of Health and Environment

Connecticut Department of Public Health 1000 S.W. Jackson, Suite 230

410 Capitol Avenue, MS-11 HLS Topeka, Kansas 66612-1274

PO Box 340308, Hartford, CT 06134-0308 Phone: 785-296-3921, Fax: 785-296-8059

Phone: 860-509-7828, Fax: 860-509-7855 E-mail: mjimerson@kdhe.state.ks.us

E-mail: chris.andresen@po.state.ct.us

Brian Boisseau

Vance Farrow Division of Adult and Child Health

District of Columbia Department of Health Kentucky Department of Public Health

825 North Capital Street N.E. 275 East Main Street, HS 1C-B

Washington, D.C. 20002 Frankfort, KY 40621

Phone: 202-442-5891 Phone: 502-564-7996 (ext. 3823), Fax: 502-564-4667

E-mail: vance.farrow@dc.gov E-mail: Brian.Boisseau@ky.gov

Linda Greis Tara Doskey

Bureau of Chronic Disease Prevention Louisiana Department of Health and Hospitals

Florida Department of Health 325 Loyola Avenue, Room 212

4052 Bald Cypress Way, Bin #A18 New Orleans, LA 70112

Tallahassee, FL 32399-1744 Phone: 504- 568-7562, Fax: 504 568-7005

Phone: 850-245-4444 (ext. 3800), Fax: 850-414-6625 E-mail: tdoskey@dhh.la.gov

E-mail: Linda_Greis@doh.state.fl.us

Debra A. Wigand

Carol B. Steiner Maine Department of Human Services

Cardiovascular Health Initiative Health Promotion 11 State House Station, Key Bank Plaza, 4th Floor

Georgia Department of Human Resources Augusta, ME 04333-0011

2 Peachtree Street N.W., 29th Floor Phone: 207-287-4624, Fax: 207-287-4631

Atlanta, GA 30303-3142 E-mail: debra.a.wigand@maine.gov

Phone: 404-657-6606, Fax: 404-657-6631

E-mail: cbsteiner@dhr.state.ga.us

Appendix C: Resources 81
Kathy Foell

Massachusetts Department of Public Health

250 Washington Street, 4th Floor

Boston, MA 02108 

Phone: 617-624-5469, Fax: 617-624-5075

E-mail: kathy.foell@state.ma.us

Khatidja Dawood

Center for Health Promotion

Minnesota Department of Health

PO Box 64882, St. Paul, MN 55101

Phone: 651-281-9838, Fax: 651-215-8959

E-mail: khatidja.dawood@health.state.mn.us

Tennille Howard

Mississippi State Department of Health

PO Box 1700, 570 East Woodrow Wilson

Jackson, MS 39215-1700

Phone: 601-576-7783, Fax: 601-576-7444

E-mail: thoward@msdh.state.ms.us

Judy Alexiou

Section for Chronic Disease Prevention 

and Health Promotion

Missouri Department of Health and Senior Services

920 Wildwood Drive, PO Box 570

Jefferson City, MO 65102-0570

Phone: 573-522-2868, Fax: 573-522-2898

E-mail: alexij@dhss.mo.gov

Crystelle Fogle

Cardiovascular Health Program

Montana Department of Public Health and Human Services 

PO Box 202951, Helena, MT 59620-2951

Phone: 406-947-2344, Fax: 406-444-7465

E-mail: cfogle@mt.gov

Jamie Hahn

Nebraska Department of Health and Human Services System

301 Centennial Mall South

PO Box 95044, Lincoln, NE 68509-5044

Phone: 402-471-3493, Fax: 402-471-6446

E-mail: jamie.hahn@hhss.ne.gov

Deborah A. Spicer

Healthy Heart Program

New York State Department of Health

Riverview Center, 3rd Floor West

150 Broadway, Albany NY 12204

Phone: 518-474-6683, Fax: 518-474-3356 

E-mail: das09@health.state.ny.us

Elizabeth (Libby) Puckett

Division of Public Health

North Carolina Department of Health and Human Services

1915 Mail Service Center

Raleigh, NC 27699-1915

Phone: 919-715-3342, Fax: 919-715-0433

E-mail: Libby.Puckett@ncmail.net

Susan M. Mormann

North Dakota Department of Health

600 E. Boulevard Avenue, Dept. 301

Bismarck, ND 58505-0200

Phone: 701-328-2305, Fax: 701-328-2036

E-mail: smormann@state.nd.us

Barbara Pryor

Ohio Department of Health 

246 North High Street, PO Box 118

Columbus, OH 43266-0118

Phone: 614-644-6963, Fax: 614-644-7740

E-mail: bpryor@odh.ohio.gov

82 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Adeline M. Yerkes Joan Ware

Oklahoma State Department of Health Bureau of Health Promotion

1000 North East 10th Street Utah Department of Health

Oklahoma City, OK 73117-1299 PO Box 142107, Salt Lake City, UT 84114-2107 

Phone: 405-271-4072 (ext. 57123), Fax: 405-271-5181 Phone: 801-538-6228, Fax: 801-538-9495

E-mail: adeliney@health.state.ok.us E-mail: JWARE@utah.gov

Nancy G. Clarke Laura Wimmer

Oregon Department of Health Services Division of Chronic Disease Prevention and Control

800 N.E. Oregon Street, Suite 730 Virginia Department of Health

Portland, OR 97232-2162 109 Governor Street, 10th Floor, Room 132

Phone: 503-731-4082, Fax: 503-731-4082 Richmond, VA 23219

E-mail: nancy.g.clarke@state.or.us Phone: 804-864-7884, Fax: 804-864-7880

E-mail: laura.wimmer@vdh.virginia.gov

Dory Masters

Division of Cardiovascular Health Miriam Patanian

South Carolina Department of Health Coordinator, Heart Disease and Stroke Prevention Program 

and Environmental Control Washington State Department of Health

1777 St. Julian Place, Heritage Building 7211 Cleanwater Lane, Bldg. 15

Columbia, SC 29201 PO Box 47836, Olympia, WA 98504-7836

Phone: 803-545-4498, Fax: 803-545-4492 Phone: 360-236-3792, Fax: 360-236-3708

E-mail: masterdm@dhec.sc.gov E-mail: Miriam.patanian@doh.wa.gov

Frances A. Walls Amy Carte

Community Services Section West Virginia Bureau for Public Health

Tennessee Department of Health 350 Capitol Street, Room 206

Cordell Hull Building, 6th Floor Charleston, WV 25301-3715

425 5th Avenue North, Nashville, TN 37247-5210 Phone: 304-558-0644, Fax: 304-558-1553

Phone: 615-741-0390, Fax: 615-532-8478 E-mail: amycarte@wvdhhr.org

E-mail: frances.walls@state.tn.us

Mary Jo Brink

Jennifer Smith Chronic Disease Prevention Unit

Cardiovascular Health and Wellness Program Wisconsin Division of Public Health

Texas Department of Health 1 West Wilson Street, Room 218

1100 W. 49th Street, T-406, Austin, TX 78756 Madison, WI 53701-2659

Phone: 512-458-7111 (ext. 2209), Fax: 512-458-7618 Phone: 608- 266-3702, Fax: 608-266-8925

E-mail: jennifer.smith@dshs.state.tx.us E-mail: brinkmj@dhfs.state.wi.us

Appendix C: Resources 83
Minority Health Organization 

Minority Health Professions Foundation 

3 Executive Park Drive NE, Suite 100, Atlanta, GA 30329 

Phone: 404-634-1993, Fax: 404-634-1903 

Web site: http://www.minorityhealth.org 

The Minority Health Professions Foundation is a nonprofit educational, scientific, and charitable organization that provides support 

for professional education, research, and community services that 

promote optimum health among poor and minority people. 

Heart Disease and Stroke Organizations 

American Heart Association, National Center

7272 Greenville Avenue, Dallas, TX 75231

Web site: http://www.americanheart.org

The American Heart Association is a not-for-profit, voluntary health 

organization funded by private contributions. Its mission is to reduce 

disability and death from cardiovascular diseases and stroke.

American Stroke Association, National Center 

7272 Greenville Avenue, Dallas, TX 75231 

Web site: http://www.americanheart.org 

The American Stroke Association is a division of the American Heart 

Association, which is a not-for-profit, voluntary health organization 

funded by private contributions. Its mission is to reduce disability 

and death from cardiovascular diseases and stroke.

Brain Attack Coalition 

National Institute of Neurological Disorders and Stroke 

Building 31, Room 8A-16, 31 Center Drive, MSC 2540, 

Bethesda, MD 20892 

Phone: 301-496-5751, Fax: 301-496-0296 

Web site: http://www.stroke-site.org 

The Brain Attack Coalition is a group of professional, voluntary, 

and governmental entities dedicated to reducing the occurrence of 

and the disabilities and death associated with stroke. The goal of the 

coalition is to strengthen and promote the relationships among its 

member organizations in order to help people who have had a stroke 

or are at risk for a stroke. 

Centers for Disease Control and Prevention (CDC) 

National Center for Chronic Disease Prevention 

and Health Promotion 

Division of Adult and Community Health 

4770 Buford Highway NE, MS K-47

Atlanta, GA 30341-3717

Phone: 770-488-2424, Fax: 770-488-2564 

Web site: http://www.cdc.gov/nccdphp/cvd 

CDC has established cardiovascular health programs in 32 states and

the District of Columbia. These programs are committed to reducing

the burden of heart disease and stroke by promoting heart-healthy

and stroke-free working and living environments. In addition, the

Cardiovascular Health Branch at CDC performs extensive monitoring

ofrecent trendsin cardiovascular disease and conducts applied research

to prevent cardiovascular disease.

Health Care Financing Administration 

Centers for Medicare & Medicaid Services 

7500 Security Blvd., Baltimore, MD 21244-1850 

Phone: 410-786-3000 

Web site: http://www.cms.hhs.gov 

The mission of the Centers for Medicare & Medicaid Services is to 

serve Medicare and Medicaid beneficiaries. The goal is to launch 

and enhance the Medicare education campaign to help beneficiaries and their caregivers become active and informed participants in 

their health care decisions. 

InterAmerican Heart Foundation 

American Heart Association, National Center 

7272 Greenville Avenue, Dallas, TX 75231 

Phone: 214-706-1218, Fax: 214-373-0268 or 972-562-3807 

Web site: http://www.americanheart.org

The goals of the InterAmerican Heart Foundation are to promote an 

environment throughout North, Central, and South America and the 

Caribbean conducive to the prevention of heart diseases and stroke; 

84 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
to facilitate the development and growth of heart foundations; and to 

foster partnerships between health professionals and other sectors of 

society, including business and government, for the accomplishment 

of its mission.

National Institute of Neurological Disorders and Stroke 

NIH Neurological Institute 

PO Box 5801, Bethesda, MD 20824 

Phone: 800-352-9424 

Web site: http://www.ninds.nih.gov 

The goal of the National Institute of Neurological Disorders and 

Stroke is to reduce the burden of neurological disease—a burden 

borne by every age group, by every segment of society, and by people 

all over the world. 

National Stroke Association 

9707 E. Easter Lane, Englewood, CO 80112 

Phone: 303-649-9299 or 1-800-STROKES (787-6537) 

Fax: 303-649-1328 

Web site: http://www.stroke.org

The mission of the National Stroke Association is to reduce the incidence and impact of stroke, to save lives, and to improve the quality 

of care among stroke survivors.

Patient Resources 

National Heart, Lung, and Blood Institute 

National Institutes of Health 

Building 31, 31 Center Drive, Bethesda, MD 20892 

Web site: http://www.nhlbi.nih.gov/index.htm 

The National Heart, Lung, and Blood Institute can supply a wealth 

of information regarding heart, blood, and lung diseases for patients. 

Resources are available on the Internet as well as via telephone and 

direct mail. 

American Heart Association, National Center

7272 Greenville Avenue, Dallas, TX 75231

Web site: http://www.americanheart.org

The American Heart Association offers resources for heart disease 

patients regarding health, fitness, and dietary guidelines. Information 

can be obtained through the Internet, by telephone, or by direct mail.

American Stroke Association, National Center 

7272 Greenville Avenue, Dallas, TX 75231 

Web site: http://www.strokeassociation.org 

The American Stroke Association is a division of the American 

Heart Association, which offers resources for heart disease patients 

regarding health, fitness, and dietary guidelines. Information may be 

obtained via the Internet, telephone, or direct mail.

Centers for Disease Control and Prevention (CDC) 

1600 Clifton Road, Atlanta, GA 30333 

Phone: 404-639-7000 

Web site: http://www.cdc.gov 

CDC is a government agency dedicated to the promotion of health

and quality of life by preventing and controlling disease, injury, and

disability. The CDC Web site provides information about a variety of

health topics, including women’s, cardiovascular, and minority health.

Appendix C: Resources 85
86 Atlas of Heart Disease and Stroke Among American Indians and Alaska Natives
Michele L. Casper is an epidemiologist in the Cardiovascular Health Branch of the Centers for Disease Control

and Prevention (CDC). She received her PhD in epidemiology from the University of North Carolina School of

Public Health. Her research focuses primarily on the geographic, racial, and ethnic disparities in cardiovascular

disease.

Clark H. Denny is an epidemiologist in the Cardiovascular Health Branch of CDC. He received his PhD in

Jonathan N. Coolidge

, is a Geographic Information Systems (GIS) analyst in the Cardiovascular Health

James M. Galloway

Nathaniel Cobb is the principal chronic disease epidemiologist for IHS. He received his MD from Harvard

Medical School. He did his residency at the University of New Mexico and then a fellowship in epidemiology at

CDC.

About the Authors

sociology from Emory University, specializing in demography. He has 8 years of experience studying the health

behaviors of American Indians and Alaska Natives.

was an Association of the Schools of Public Health fellow working in the Cardiovascular

Health Branch of CDC in 2004. He is now attending Albany Medical College. He received his MPH from Emory

University, concentrating in epidemiology, and his BA in biology from the College of the Holy Cross.

G. Ishmael Williams, Jr.

Branch of CDC. He received his MA in anthropology from the University of Arkansas and has more than 15 years

of experience in GIS research, spanning archeology, environmental management, and public health.

Amanda Crowell is a writer­editor in the National Center for Chronic Disease Prevention and Health Promotion

of CDC. She attended the University of Alabama, majoring in English.

, MD, FACP, FACC, is the senior cardiologist for the Indian Health Service (IHS) and

is based at the University of Arizona. His primary focus is the optimal prevention, detection, and control of

cardiovascular disease among American Indians and Alaska Natives.
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