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Protective Behaviors Among Youth Youth Healthy Eating Habits Chronic • Protective Behaviors Vermont Youth Risk Behavior Survey • 2015 Vermont Youth Risk Behavior Survey • 2015 % of students in grades 9–12 who meet recommendations % of students in grades 9–12 who meet recommendations • What are protective behaviors? Regular physical activity and good nutrition are behaviors that protect against overweight and , plus a number of other chronic conditions. 34% Fruit - 2 or more per day While the benefits are clear, behavior is Vegetables - 3 or more per day complicated and change is not easy for anyone. 23% 18% Vermonters with the least resources too often by Race/Ethnicity — have the fewest opportunities for healthy behaviors. Not enough money, time or access, 37% combined with the daily stressors brought on by Asian/Pacific Islander Meet physical Eat fruit Eat vegetables 28% lack of money, time and access, means that more activity at least twice at least three immediate needs take priority over a guidelines a day times a day 45% and regular exercise. Black 22% • Elements of a Healthy Diet 41% Hispanic As a measure of good nutrition, a healthy diet Youth Physical Activity 26% includes two servings of fruit and three servings Vermont Youth Risk Behavior Survey • 2015 35% of vegetables every day. By this measure, most Native American/Alaska Native Vermonters do not have the best nutrition, a trend % of students in grades 9–12 who meet guidelines 21% that has changed little over time. Youth of color 33% are more likely to eat the recommended number White, non-Hispanic of servings compared to white youth. Adults with Asian/Pacific Islander 18% 17% higher income and education are more likely to Black 30% 35% eat the recommended number of servings. Multi-racial By another measure, the news is good: most Hispanic 24% 19% Vermonters do not drink more than one sugar- Native American/Alaska Native 28% 35% sweetened beverage a day. Other/unknown 21% White, non-Hispanic 23% • The Problem with Food Insecurity Multi-racial 22% Food insecurity means not having enough food to eat, and not having enough money to buy food. Other/unknown 22% Adults who do not have food security must often compromise quality, buying less nutritious but lower cost foods for themselves and their families.

28 • State Health Assessment 2018 healthvermont.gov/wellness Adult Healthy Eating Habits Protective Behaviors Among Adults • Are healthy foods within reach? Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Behavioral Risk Factor Surveillance System • 2016 Communities that provide easy access to afford- % of adults who meet recommendations (age-adjusted) % of adults who meet recommendations (age-adjusted) able food within a reasonable distance promote health by making it easier for residents to have a 59% healthy diet. Still, some areas of of the state can seem to be a , especially during the Fruit - 2 or more per day long winter months. Vegetables - 3 or more per day 32% Vermonters with lower incomes who live in a rural by Federal Poverty Level — agricultural area may live in a food desert if they 20% can’t afford to buy nutritious foods from a local market or neighbors. With limited or unreliable 34% 250% FPL and higher transportation to a grocery store, it’s easier to stock 23% up on shelf-stable, but less healthful foods. 33% Meet physical Eat fruit Eat vegetables 185–249% FPL activity at least twice at least three For people with , getting a ride to the 18% guidelines a day times a day grocery store is a lower priority for transportation 29% services, which may mean having to schedule 100–184% FPL rides far in advance. Our partners said that they 16% Adult Physical Activity may want to eat healthy, but it takes a lot of work. Vermont Behavioral Risk Factor Surveillance System • 2016 23% 0–99% FPL 16% • Differences in Physical Activity Adults who meet aerobic activity guidelines Overall, 59% of adult Vermonters meet guidelines for physical activity (30 minutes a day), but they tend to become less active as they age. Adults age by Education — 57% 59% 60% 59% 65+ are much less likely than younger adults to be 38% active in their leisure time. Likewise, adults age 45 College Graduate to 64 are less likely than those age 18 to 44 to be 29% active in their leisure time. 33% Some College Age 18–24 25–44 45–64 65+ 21% For youth, physical activity should add up to at least 60 minutes a day. Among students in grades 25% 9-12, there is no difference when comparing white, High School or less 12% 14% 12% 20% non-Hispanic students to all students of color. 30% Adults with NO leisure time physical activity

Vermont Department of Health • 29 Chronic Disease • Risk Behaviors Physical Activity & Nutrition Risks Tobacco, Alcohol & Marijuana Use Risks Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Behavioral Risk Factor Surveillance System • 2016 n n • What influences our behavior? Adults age 65+ People of color n n Behavior is not driven by our personal preferences Adults with depression Adults with depression n n and choices alone, but is greatly influenced by Adults with disabilities Adults with disabilities n n the conditions, communities, systems and social Those at low socio-economic status Living below 250% of Federal Poverty Level n structures in which we live. The need to belong to * = age-adjusted LGBT adults * = age-adjusted a group that shares common values and habits (% VT overall) (% VT overall) is another powerful influence on behavior. And — obese — 62% many policies have kept already disadvantaged 18% 26 % — overweight— 66 % 27 % 37 % 68 % groups from having equal opportunities for health. Over healthy weight * Currently smoke 30 % 41 % 74 % 37 % 34 % 68 % cigarettes * 28 % • 3-4-50: Risk Behaviors & Chronic Disease 18% 28 % Poor nutrition, lack of physical activity and tobacco 30 % No leisure time 28 % use are 3 behaviors that contribute to develop- physical activitiy * 31 % 18% 32 % ment and severity of 4 chronic that cause 26 % more than 50% of the deaths of all Vermonters. But 17% Binge drinking 18 % 12 % in the last 30 days 13 % focusing on changing behavior person by person One or more sugar- 20 % 18 % is not the solution for preventing disease in the sweetened beverages/day 24 % 28 % 28 % population. Vermont communities can be powerful agents of change. Simple changes in local policies 25% 57 % 12% or programming can help create conditions for * 31 % 22 % 37 % Marijuana use 21 % everyone to have an equal chance to be healthy. 33 % 18 % in the last 30 days 16 % 34% 28 % • Who is most at risk for chronic disease? 49 % Lower income Vermonters, those who have a High cholesterol 40 % 48 % high school education or less, have depression or 38 % disabilities, people of color, LGBT and older adults have a higher of risk behaviors and Tobacco, Weight & Tooth Loss Vermont Behavioral Risk Factor Surveillance System • 2016 chronic illnesses. And some risks can be circular: Vermonters who are obese or smoke have more Vermonters who use tobacco or who are obese are more likely to have tooth loss, even when accounting tooth loss, making it harder to eat healthy foods. for other factors such as differences in education, income, dental visits, and age: Poor diet and sugar-sweetened beverages are If you use tobacco every day, the odds of losing all your teeth are 15x greater than someone who has never used. linked to , which are risks for obesity. These disparities are at least partly a result of not If you previously used tobacco but quit, the odds of losing all your teeth are 5x greater. having fair and just opportunities. If you are obese, the odds of losing all your teeth are 2x greater than those who are at a healthy weight or underweight.

30 • State Health Assessment 2018 healthvermont.gov/3-4-50 Adult Smoking Adult Smoking & Quit Attempts • Adult Smoking & Quit Attempts Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Behavioral Risk Factor Surveillance System • 2016 Half of all adult smokers have attempted to quit (age-adjusted) % of current smokers (age-adjusted) in the past year. Both smoking and quit attempts among adults have stayed relatively unchanged 18% of Vermonters smoke cigarettes 40% by Federal over the past 10 years. In 2016, 18% of all adult Poverty Level 25% 23% Vermonters smoked. Smoking rates vary by population. As income and education rises, fewer 11% have tried to quit – people smoke. Males are more likely to smoke 15% 21% than females. Vermonters of color are more likely 0–99% 100–184% 185–249% 250% + to smoke than white, non-Hispanic Vermonters, but FPL FPL FPL FPL they are also more likely to make a quit attempt (59% compared to 49%). Female Male 32% by Education • Youth Tobacco Use 16% 27% 18% In 2015, one-quarter of high school students 6% have tried to quit – reported using a tobacco product (cigarette, cigar, High School Some College smokeless tobacco or e-vapor) in the past month. People of Color White, non-Hispanic or less College Graduates Of the 35 states that collect data on e-cigarette/ vapor use, Vermont is currently the lowest, at 15%. West Virginia is highest, at 31%. Youth Tobacco Use, by Product Youth Smoking, Alcohol & Marijuana Vermont Youth Risk Behavior Survey • 2011–2015 Vermont Youth Risk Behavior Survey • 2015 Frequency of use varies by product. Among cigarette users, 37% smoked on 20+ days in the % of students in grades 9-12 who use tobacco % of students in grades 9-12 who use tobacco + alcohol past month, similar to smokeless tobacco users. or marijuana Cigar and e-vapor users were more likely to use E-vapor Those who, in the these products rarely or occasionally. Only 13% of products last 30 days— cigar or e-vapor users reported frequent use. 15% cigarettes 15% & currently use alcohol 17 % Did not use tobacco & binge drank 6 % 13% & currently use marijuana 10 % • Tobacco & Other Risk Behaviors 13% Use of multiple tobacco products is linked with cigar products 11% Used 1 form of tobacco 62 % 35 % other risks. Vermont high school students who product 52 % 8% 8% 10% used one or more tobacco products in the past Used 2 forms of tobacco 75 % 50 % month were much more likely to use marijuana, smokeless 7% products % 64 alcohol, and to binge drink compared to students Used 3 or more different 91 % 74 % who do not use tobacco. For students who have 2011 | 2013 | 2015 tobacco products 80 % , the use of tobacco, alchol and marijuana may make asthma symptoms worse.

Vermont Department of Health • 31 Chronic Disease • Risk Behaviors Current Alcohol, Tobacco & Use Alcohol/Drug Use (Age 12+) Vermont Behavioral Risk Factor Surveillance System • 2016 National Survey on Drug Use & Health/Vermont • 2004–2015 Vermont Youth Risk Behavior Survey • 2015 Alcohol (past 30 days) • Why do people use alcohol and ? n Marijuana (past 30 days) There are many reasons why people use alcohol, People of Color n Non-medical use of pain relievers (past year) tobacco and other drugs: to relieve physical or White, non-Hispanic Heroin use in 2015: 0.8% psychological pain, to counter stress, to alter * = age-adjusted 61% traumatic experiences or feelings of hopelessness. Among adults, age 18 + 58% Prioritizing future health over immediate needs Drink alcohol 55% is especially difficult in the face of multiple daily 65% stressors and pervasive marketing that can make it Binge drink alcohol 26% seem as if alcohol or drugs will make life easier. 18%

Smoke cigarettes * 27% Addiction is not a choice or a moral failing. Some 18% 15% people are genetically prone to addiction, and this 9% Use marijuana 22% in itself is a risk factor in developing a substance use 11% 5% 3% disorder. As a chronic illness, addiction becomes 2005 2007 2009 2011 2013 2015 Ever used Rx without a prescription 8% a physiological and psychological need. Quitting 7% or seeking treatment is never easy, and relapse is Perception of Harm Among Youth common. Adding to the stress of behavior change Vermont Youth Risk Behavior Survey • 2005–2015 is the feeling of isolation that may come from avoiding friends or situations that may trigger Among Students Grades 9–12 % of students in grades 9–12 who think it is wrong smoking, drinking or drug use. or very wrong for someone their age to: Drink alcohol 29% 30% • Perception of Harm Matters Smoke cigarettes Use marijuana Binge drink alcohol 17% Perceptions of risk and community acceptance 16% Drink alcohol strongly influence behavior. In Vermont, more Smoke cigarettes * 16% people drink alcohol and use marijuana compared 10% 78% to the U.S. population overall. For Vermonters age 75% 12+, alcohol is by far more commonly used than Use any tobacco products 29% 24% 61% 56% marijuana or any other drug. 53% Use e-cigarettes 19% 44% 15% More than three-quarters of high school students think it is wrong or very wrong for someone their Use marijuana 26% 22% age to smoke cigarettes, yet only a little over half think it is wrong or very wrong to use marijuana or Ever used Rx without a prescription 17 % 10 % to drink. 2005 2007 2009 2011 2013 2015

32 • State Health Assessment 2018 healthvermont.gov/alcohol-drugs Binge Drinking • Youth & Adult Drinking Patterns Vermont Youth Risk Behavior Survey • 2005–2016 The age when a young person starts drinking Vermont Behavioral Risk Factor Surveillance System • 2005–2016 strongly predicts alcohol dependence later in life. % of Vermonters who binge drank in the last month By middle school, 2% of students in Vermont binge drink, defined as having five or more drinks on one occasion. By high school, 16% of students binge drink. The percentage of high school students who are current drinkers, having one or more drinks in the past month, has decreased Adults age 18-24 significantly – from 42% in 2005 to 30% in 2015. 32% 33% As adults, one in three of those age 18 to 24 binge 25% drink, and 5% of older adults age 65+ binge drink. High School Students 16% • What is risky drinking for older adults? Adults age 65 + 5% 4% Older adults are more susceptible to health risks 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 of alcohol due to physiological changes, a chronic disease they may have, or medications they take. Excessive alcohol use can increase the risk for dementia. High Risk Drinking Among Older Adults Vermont Behavioral Risk Factor Surveillance System • 2016 One in four (25%) Vermonters age 65+ engage in % of adults age 65+ who drink at a level of risk = 2+ drinks for females/3+ drinks for males on one occasion in the past month: risky alcohol use, higher than the U.S. average of 19%. Risky drinking for this age group is two or 30% more drinks on one occasion for females, three or 28% more for males. In contrast to other risk behaviors, 23% older adults with higher incomes and education are 19% more likely to engage in risky drinking compared 17% to those with lower incomes and less education. 14% 12% • Alcohol Use Disorder Problem drinking that becomes severe is given the of alcohol use disorder– 0–99% 100–184% 185–249% 250%+ High School Some College College Grad FPL FPL FPL FPL and above a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over intake, and a negative emotional state when not using. By percentage of Federal Poverty Level By educational level attained An estimated 33,000 Vermonters are in need, but have not received treament for alcohol use disorder.

Vermont Department of Health • 33 Chronic Disease • Risk Behaviors Marijuana Use Among High School Students Vermont Youth Risk Behavior Survey • 2015 % of students in grades 9–12 who used marijuana in the past 30 days, % of students in grades 9–12 who used marijuana, • Is marijuana use a community norm? by county by frequency of use Most Vermonters do not use marijuana. Still, the prevalence of marijuana use is higher than other Grand Isle Franklin Orleans Ever Used Marijuana states. The percentage of Vermonters who have 15% 20% 20% Essex 21% 37% tried marijuana for the first time at an early age is Lamoille also higher than the U.S. overall. Chittenden 23% Caledonia 21% 16% Washington Used in last 30 days 24% 22% Marijuana use is widely accepted, and this may be of which... Addison due to a number of influences: the perception that 20% Orange 23% it is less harmful than alcohol or other drugs, ease of access, and the policy shift toward legalization. higher rate 31% used 1-2 times Rutland But early and continuous use of marijuana is linked 21% Windsor with lower academic achievement in youth, and 24% State Average 22% 37% used 3-19 times lower income as an adult. These factors are gener- 33% used 20 or more times ally associated with worse health outcomes. Bennington lower rate 24% Windham 26% • Marijuana Use Among Youth More than one-third (37%) of high school students in Vermont report ever using marijuana, and 6% Marijuana Use Among High School Students have tried marijuana before age 13. By the time Vermont Youth Risk Behavior Survey • 2015 they graduate, half (49%) have tried marijuana. % of students in grades 9–12 who use marijuana, by various populations

Marijuana use varies across the state, by gender, race and socioeconomic status. Windham County high school students report more marijuana use than students in the rest of the state. Students who identify as LGB are much more likely to use marijuana compared to heterosexual students. White students are more likely than students of 36% 37% color, students with mothers who did not graduate 26% 27% 21% 22% 19% 21% from high school are more likely than those with mothers who did, and students with average or LGB Heterosexual Students White, A & B C/D/F High School Some College failing grades are more likely to use marijuana, of Color non-Hispanic Diploma or Less or a Degree compared to those who earn As or Bs. Gender Orientation Race Grades in School Mother’s Education

34 • State Health Assessment 2018 healthvermont.gov/alcohol-drugs Student Driving Under the Influence • Driving Under the Influence Vermont Youth Risk Behavior Survey • 2015 Alcohol is a risk or contributing factor to almost % of students in grades 9–12 who drove under the influence in the past 30 days every category of injury, including injuries from falls, assaults and motor vehicle crashes.

of all Vermont high school students who drive have driven under the influence 7% have done so under the influence of alcohol 15% of of marijuana Among all Vermont high school students who drive, 7% have driven after drinking and 15% have 27 % driven after using marijuana. Males are more likely 24 % than females, people of color are more likely than white students, and those who identify as LGB are 18 % more likely than heterosexual students to drive 15 % 14 % 15 % 14 % under the influence of alcohol or marijuana. 12 % 9 % 7 % And among adults who used marijuana, three in 5 % 6 % 10 drove within three hours of using.

Female Male Students of Color White, non-Hispanic LGB Heterosexual • Drug-Related Deaths In 2016, 148 deaths in Vermont were drug-related, and most were due to opioids. This is an increase Drug-related Deaths, by Population Drug-related Deaths, by Intention from 108 drug-related deaths in 2015, and nearly Vermont Vital Statistics • 2016 Vermont Vital Statistics • 2010–2016 double the number of deaths in 2010. # deaths, per 100,000 people # deaths and manner of death in 6 years Most deaths were the result of unintentional n Opioid-involved n Other 148 n Unintentional n Undetermined n Homicide n Suicide overdoses, rather than suicide or homicide, and most were due to a combination of drugs, rather Female 11.7 /4.4 109 108 than a single drug – e.g. prescription opioids and Male 24.3 7.1 97 98 cocaine, or benzodiazepines and alcohol. 81 People of Color 2.3/2.3 75 Nearly all of the drug-related deaths are among White, non-Hispanic 19.1 6.0 white, non-Hispanic adults. Two-thirds are among males. People age 30 to 50 accounted for most of Age 30 < 9.0 /0.9 the deaths. The average age at death is 43. Age 30–39 51.8 14.0 Age 40–49 36.1 8.0 50 and older 10.9 7.0 2010 2011 2012 2013 2014 2015 2016

Vermont Department of Health • 35 Chronic Disease • Mental Health Adults Diagnosed with Depression Vermont Behavioral Risk Factor Surveillance System • 2016 % of Vermont adults who report having ever been told they have a depressive disorder • Chronic Stress & Depressive Disorders Stress is a risk to health that is difficult to quantify, 26% but anyone who lives with great stress from day 26% 26% 25% to day knows the toll it can take on one’s energy, 22% 23% VT overall 22% mental outlook and quality of life. 18% 18% U.S. overall 17% 16% • What is depression? A depressive disorder is not a passing blue mood, but rather persistent feelings of sadness and worthlessness. According to the National Institute of Mental Health, depression is a common but serious mood disorder. It causes severe symptoms Female Male 18–24 25–44 45–64 65+ High School Some College that affect how you feel, think and handle daily life: College interacting with others, sleeping, eating, or work- by Age by Education ing. To be diagnosed with depression, symptoms must be present for at least two weeks. Adults in Mental Health Treatment Children in Mental Health Treatment Substance Abuse & Mental Health Services Administration National Survey of Children’s Health/Vermont • 2016 • Who has depression? Vermont Behavioral Health Barometer • 2013–2016 In 2016, among Vermont children age 3 to 17, % of Vermont children who – about 11% had a diagnosis of anxiety, and 3% % of Vermont adults with any mental health condition who had a diagnosis of depression. Over the past are receiving treatment or counseling (5-year averages) 3% 17% 16% n decade, the percentage of adults who have been Saw a mental health professional 3% 4% diagnosed with depression has remained 57% 58% unchanged, at 20% to 23%. 54% 56% n Needed, but did not see a mental health professional • Mental Health Treatment n About half of all adults who have been diagnosed 97% 79% 80% Did not need to see a mental health with a mental health condition are not in treat- professional ment or counseling. For children, a small percent- age who need to see a mental health professional are not in care. For those age 6 and older, about 3–5 6–11 12–17 half who sought care had a diagnosable condition. years old years old years old 2008-12 2009-13 2010-14 2011-15

36 • State Health Assessment 2018 mentalhealth.vermont.gov Adverse Family Experiences Adverse Family Experiences, by Age • Family Strengths & Adversities National Survey of Children’s Health/Vermont • 2016 National Survey of Children’s Health/Vermont • 2016 About half (47%) of Vermont’s children live in % of Vermont children age 6–17 living in households % of Vermont children living with 0-3 or more Adverse Family families that are stressed due to one or more of with Adverse Family Experiences (AFE) Experiences (AFE) these types of experiences: divorce or separation, financial hardship, unstable housing, alcohol or drug problems, mental health issues, incarceration, violence or death. These stressors accumulate as 64% 49% 47% Divorce / separation 32 % children grow up and they carry their experience into adulthood.

Family income hardship 23 % n No Adverse Family Experiences Among adults age 18 to 44, one-quarter grew up 33% 37% in a household with a parent or caregiver who was n 1 or 2 AFEs Moved 4 or more times 20 % 32% severely depressed, suicidal or had another mental n 3 or more AFEs health condition. 4% 19% 16% Alcohol / drug problems 16 % < 5 6–11 12–17 Despite these early childhood stressors, parents’ years old years old years old responses to the National Survey of Children’s Mental health / suicide / 13 % Health show that the youngest Vermonters are severe depression generally flourishing. One area of concern is Early Signs of Thriving or Flourishing resilience: one in three children under age 6 have Incarceration 8 % National Survey of Children’s Health/Vermont • 2016 difficulty “bouncing back” or managing emotions Responses from Vermont parents of children age <6 when faced with a frustration. Among those age 6 to 17, about half have difficulty staying calm and Domestic violence 6 % in control when challenged. Definitely True Somewhat True

5 % The Stigma of Mental Illness Death Child is affectionate • 95% 5% Anyone can be affected by mental illness, but those who are brave enough to admit they have a Neighborhood violence 4 % Child smiles / laughs 95% 5% problem are often blamed for their condition. The stigma applied by society to people who Child is interested / experience mental illness can lead to exclusion or curious 97% 3% discrimination within social circles or the work- Children in families with 3 or more 17 % of the above AFEs Child is resilient / place. Some groups of people may be especially bounces back 72% 28% resistant to seeking care due to stigmatization in their own communities. To remove the stigma, our partners wished for more outreach about mental health, and greater access to welcoming, culturally and linguistically competent care.

Vermont Department of Health • 37 Chronic Disease • Morbidity Overweight & Obesity, by Population Weight & Chronic Diseases Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Behavioral Risk Factor Surveillance System • 2016 % of adults age 20+ who are over a healthy weight (age-adjusted) % of adults with chronic diseases by weight category • The Burden of Chronic Disease Of all adult Vermonters, 64% had at least one chronic disease in 2016. In addition to the 8 % obese overweight Obese 18 % physical and social burden of illness, medical care 18 % 12 % for chronic diseases cost the state $2.17 billion Vermont 28% 62 % that same year. U.S. 30% 61% 9 % What does ‘over healthy weight’ mean? Overweight 12 % • (not obese) 7 % The terms ‘overweight’ and ‘obese’ describe weight 7 % ranges above what is medically considered to be healthy. Obesity is a complex, multi-faceted Vermont - Female 27% 52% 6 % condition but, simply put, it is most often the Vermont - Male 28% 71% NOT overweight disease 12 % result of poor nutrition and physical inactivity. or obese 3 % 6 % As a , obesity increases one’s risk for other serious illnesses and conditions – such as high blood pressure, high cholesterol, diabetes, Asian/Pacific Islander 17% 41% Overweight & Obesity Trend heart disease, , gallbladder disease, osteo- Vermont Behavioral Risk Factor Surveillance System • 2016 , and some . Black 25% 71% % of adults age 20+ who are over a healthy weight (age-adjusted) • A Growing Trend toward Obesity Hispanic 26% 64% Vermonters, like other Americans, are becoming Native American/Alaska Native 39% 71% more overweight. In 2016, two-thirds of adults were overweight or obese. Compared to the White, non-Hispanic 25% 61% 62% 56% U.S., Vermont adults have a lower rate of obesi- Multiracial 31% 63% ty (28% compared to 30%), but a similar rate of Overweight overweight. This growing trend affects males and Other/unknown 26% 66% females, and people of all races, incomes and education levels, but especially Vermonters at 28% the lower end of the socioeconomic ladder. And 21% just as we are more likely to become less active Obese as we age, we are also more likely to gain weight. Adults age 65+ are more likely to be overweight 2006 | 2008 | 2010 | 2012 | 2014 | 2016 compared to those age 20 to 44. Adults age 45 to 64 are likewise more likely to be overweight than those age 20 to 24.

38 • State Health Assessment 2018 healthvermont.gov/wellness Chronic Diseases, by Population Adults with Multiple Chronic Conditions • Obesity & Chronic Disease Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Behavioral Risk Factor Surveillance System • 2016 Adults who are obese are more likely than those % of adults who have chronic diseases among – Estimated total # by disease/condition (rounded to nearest 1,000) who are overweight or at a healthy weight to have cancer, lung disease, diabetes or cardiovascular disease. These four chronic diseases are the cause n Adults age 65+ additional chronic conditions present for Vermonters in each group: of more than half of all deaths in Vermont. n Adults with depression 141,000 128,000 n none n Adults with disabilities n 1 Older adults are more likely to have one or more n Those at low socio-economic status n 2 chronic conditions. Beyond age, adults who have n LGBT adults n 3 or more disabilities, depression, or who are of low socio- (% VT overall) economic status face a greater burden of disease.

8% 51,000 43,000 • Multiple Chronic Diseases 19 % 39,000 38,000 10 % Chronic conditions are common: six in 10 adult Cancer 15 % 8 % Vermonters have at least one chronic disease or 6 % condition, and 14% have two or more. 13% Arthritis Obesity Asthma Diabetes CVD Cancer 15 % 23 % Depending on the condition – obesity, diabetes, Lung Disease 26 % cardiovascular disease, asthma or arthritis – two- 22 % Hospitalizations & Emergency Dept. Visits thirds to nine in 10 adults who have one or more 23 % Vermont Uniform Hospital Discharge Data Set • 2015 8% of these conditions also have at least one other. 18 % # hospitalizations & ED visits per 10,000 people with primary 12 % Diabetes 18 % diagnosis of these chronic conditions: As an example, of the128,000 Vermonters who 14 % are obese, 35% have no other chronic conditions, 9 % n Emergency Dept visit n Hospitalizations and 16% have three or more. This is in contrast 8% 20 % to 38,000 Vermonters who have diabetes, 11% of 11 % 116.1 whom have no other conditions, and 37% have Cardiovascular Disease 19 % 15 % three or more other conditions. 8 % 76.3 • Hospital & Emergency Department Visits Vermonters who have chronic diseases are going to the emergency department or being hospital- 39.8 39.1 ized to treat heart disease, stroke, asthma, cancer 16.1 or diabetes, but generally only if their illness is 11.2 4.3 6.1 life-threatening. For asthma and cancer, the rates of emergency department visits are much higher Cardiovascular Asthma Cancer Diabetes than the rates of hospitalization. Disease (age-adjusted)

Vermont Department of Health • 39 Chronic Disease • Cancer Most Common Cancers Among Vermonters Cancer Stage at Time of Diagnosis Vermont Cancer Registry • 2010–2014 Vermont Cancer Registry • 2010–2014 Stage of progression when major cancers are first diagnosed • Cancer is Not One Disease, but Many Cancer is not a single disease, but a group of more Female than 100 different diseases that often develop n In Situ n Localized n Regional n Distant gradually as the result of a complex mix of genetic, Breast 2% behavioral and environmental factors. 4% 6% 4% All other 16% sites 29% 17% 20% 23% • Cancer Incidence & Risk Factors 35% 17% 54% Cancer affects thousands of Vermonters and is a 47% 34% leading cause of death. Cancer occurs in people 14% of all ages, but risk increases significantly with age. 6% Lung 56% 8% Melanoma 8% 77% Approximately four in 10 of all males and females 67% 25% in the U.S. will develop cancer in their lifetime. Colon and Rectum 40% Uterus 47% 20% 21% Some types of cancer are more prevalent among 3% Vermonters compared to the U.S. population. For Melanoma Prostate Breast Cervix Colon and Lung females, the incidence of breast cancer, cancers of (female) rectum the lung/, uterus, urinary bladder, and melanoma of the skin is worse than in the U.S. For males, the incidence of melanoma of the skin, Male urinary bladder cancer, non-Hodgkins lymphoma Cancer and esophageal cancer is worse than in the U.S. Prostate Vermont Behavioral Risk Factor Surveillance System • 2014 All other 22% sites % of adults who get the screening recommended for them Nearly two-thirds of cancer deaths in the U.S. can 35% (age-adjusted) be linked to tobacco use, poor nutrition, lack of 15% Lung physical activity, and obesity. Not all cancers can cervical cancer 92% be prevented, but risk for many can be reduced 5% 8% 86% 8% 8% 84% through a healthy lifestyle. Non-Hodgkin breast cancer 79% Lymphoma Melanoma 70% 71% Colon and Rectum colorectal cancer • Cancer is Survivable Urinary / Cancer is most survivable when found and treated Bladder early, before it has spread. That’s why it’s important for everyone to have the recommended cancer screenings. 2000 2002 2004 2006 2008 2010 2012 2014

40 • State Health Assessment 2018 healthvermont.gov/wellness/cancer Tobacco & Obesity-Associated Cancers Cancer Rates, by Risk • Obesity-Associated Cancers Vermont Cancer Registry • 2010–2013 Vermont Cancer Registry • 2010–2013 Being over a healthy weight increases a person’s # of new cases, per 100,000 Vermonters (age-adjusted) # of new cases, per 100,000 people risk of developing a number of different cancers. Nearly one-third of cancers diagnosed in the U.S. n Vermont are linked to excess weight. Cancer patients and Obesity-related n U.S. survivors who are overweight or obese also have 209.9 201.9 211.2 194.4 higher rates of complications from treatment, 204.4 Tobacco-associated 189.7 recurrence of cancer, and death. 189.1 195.5 cancers 187.0 177.8 Obesity-associated 167.8 • Tobacco-Associated Cancers Tobacco-related cancers 170.8 Smoking can cause cancer almost anywhere in the body. One-third of cancers diagnosed in the U.S. UV-associated cancers 31.5 are associated with tobacco; nine out of 10 cases (Melanoma) 20.7 of lung cancer are caused by smoking. Vermont HPV-associated 10.8 adults with non-skin cancer smoke at a higher rate 2010 2011 2012 2013 cancers 11.9 than those without cancer (25% vs. 18%), which can worsen the odds of survival.

• HPV-Associated Cancers Cancer Survivors — Health Status & Dental Care Cervical cancer is the most common cancer Vermont Behavioral Risk Factor Surveillance System • 2016 associated with the human papilloma or HPV. Oral and throat cancers are common HPV- associated cancers in males. The majority of these n n % of adults who report good to excellent health n % who have visited a dentist or cancers can be prevented with the HPV vaccine. dental clinic within past year (age adjusted) • Melanoma 79% 80% Ultraviolet radiation exposure from the sun, sun 71% lamps and tanning beds is the greatest risk factor associated with melanoma. Melanoma is largely 57% 59% preventable by protecting the skin from UV rays. 46% 53% 70% 96%

sample • Quality of Life for Cancer Survivors too small As quality of life measures, the percentage of to include cancer survivors who report they are in good or 0–99% 100– 184% 185–249% 250%+ High School Some College College Grad FPL FPL FPL FPL or less and above excellent health, and who have visited a dentist or dental clinic within the past year, generally by percentage of Federal Poverty Level by education level attained corresponds with higher income and education.

Vermont Department of Health • 41 Chronic Disease • Mortality Years Lost to Premature Death Chronic Lower Respiratory Disease Deaths Vermont Vital Statistics • 2015 Vermont Vital Statistics • 2004–2015 In 2015 there were an estimated 35,215 # of deaths, per 100,000 people • Mortality & Years of Potential Life Lost total years of life lost to Vermonters Vermonters today are more likely to die from a due to causes such as: Years lost largely preventable chronic disease than from Chronic Diseases– infectious disease. Seven of the top 10 causes of Cancer 9,506 56.9 death in the state are chronic diseases (page 11). Heart Disease 5,285 Years of potential life lost is a measure of premature Lower Respiratory 1,363 44.3 death (before age 75). Cancer, heart disease, and Stroke 809 lower respiratory disease ( and asthma) Diabetes 657 are chronic diseases that are among the top five contributors to years of life lost. Other– Unintentional injury 6,112 • Cancer Intentional self-harm 2,641 Since the 1960s, cancer and heart disease have Influenza and 192 been the leading causes of death. Vermont’s | 2005 | 2007 | 2009 | 2011 | 2013 | 2015 overall cancer is higher than the U.S. White, non-Hispanic Vermonters (166.1 per 100,000) are about twice as likely to die from Cardiovascular Disease Deaths cancer than Vermonters of color (86.1 per 100,000). Vermont Vital Statistics • 2000–2015 Males have a higher risk compared to females, and # of deaths, per 100,000 people (age-adjusted) risk increases signficantly as adults age. 180 174.5 • Heart Disease & Stroke Deaths from heart disease and stroke have been 150 Coronary Heart Disease declining steadily over the past decade. Vermont- ers are significantly less likely to die from stroke 120 114.8 than Americans overall. 90 • Lung Disease Deaths from chronic lower respiratory disease – 60 bronchitis, emphysema, asthma – is the #3 cause 55.1 Stroke 36.4 of death, and there has been no change over time. 30 Nearly all of these deaths occur among adults age 45+. The death rate increases with age, and is higher among white, non-Hispanic Vermonters. | 2001 | 2003 | 2005 | 2007 | 2009 | 2011 | 2013 | 2015

42 • State Health Assessment 2018 healthvermont.gov/wellness Diabetes-related Deaths Alzheimer’s Disease Deaths • Diabetes Vermont Vital Statistics • 2006–2015 Vermont Vital Statistics • 2004–2015 In 2015, diabetes was the primary cause of 25.4 # of deaths, per 100,000 people # of deaths among adults age 75+, per 100,000 people deaths for every100,000 Vermonters, and the contributing cause for 123.2 deaths per 100,000 Vermonters. 123.2 629.1 The difference between primary and contributing 99.9 Diabetes-related deaths cause likely reflects the fact that diabetes is the cause of other fatal diseases. For example, diabetes 421.8 is the most common cause of kidney disease, which can progress to death from kidney failure.

Diabetes as primary cause of death • Alzheimer’s Disease 28.1 25.4 Alzheimer’s is a disease of the brain that is not yet fully understood. The disease primarily affects adults age 75+. In Vermont, the number of deaths | 2007 | 2009 | 2011 | 2013 | 2015 | 2005 | 2007 | 2009 | 2011 | 2013 | 2015 due to Alzheimer’s disease has steadily increased since the 1990s. Among Vermonters age 75+, the mortality rate has nearly doubled in the past Drug Overdose Deaths in New England States decade. The average age at death is 87. Vermont Vital Statistics / National Center for Health Statistics • 2010–2015 # of deaths by drug poisoning, per 100,000 population • Drug Overdose NH Compared to other chronic diseases, is not a leading cause of death. Still, 30 RI an increasing number of people have been dying MA from opioid drug overdoses. In Vermont in 2016, 96 people died from accidental or undetermined CT drug poisoning from opioids. 20 ME VT Heroin and fentanyl-related deaths have risen sharply since 2013, and fentanyl is now the main 10 contributor to opioid-involved fatalities.

The New England states have higher rates of drug United States overdose deaths compared to the U.S. Of the New England states, Vermont has the lowest death rate, 2010 2011 2012 2013 2014 2015 which is similar to the U.S. rate overall.

Vermont Department of Health • 43