UH Review 2010
Together, We Reach.
Utah’s Health: An Annual Review
UH Review 2010
Utah’s Health: An Annual Review
5 Original Research Articles
7 Collection and Utilization of Family Health History Information in the Health
Care Setting: A Case for Asthma and Diabetes
Celeste Beck, MPH; Brenda Ralls, PhD; Rebecca Giles, MPH, CHES; Richard
Bullough, PhD; Shelly Wagstaff, BS; William F.Stinner, PhD
14
Dietary Patterns of Overweight and Obese Tongan-Americans: A Preliminary
Investigation
Timothy K. Behrens, PhD, CHES; Soo J. Schmidt, MS
21
Psychotherapeutic Medication Report on Utah’s Foster Care Clients
Chris Chytraus RN, BSN, CPM; Navina Forsythe, PhD, MPA
27
Development of a Fertility Preservation Program at the University of Utah and
Current State of Affairs
Colleen Milroy, MD; Kirtly Parker Jones, MD; Janet Bloch, ANP; Mark Gibson
MD; Ahmad O. Hammoud, MD, MPH; Douglas T. Carrell, PhD; C. Matthew
Peterson, MD
37
Does Utah’s Largest School District Meet the Alliance for a Healthier Generation’s Food and Beverage Guidelines?
Karen Schliep, MSPH; Marilyn S. Nanney, PhD, MPH, RD; Keely Cofrin, PhD;
Derek Anderson
44
Geographic Patterns in Lung Cancer Incidence and Mortality in Utah: 19972006
Antoinette M. Stroup, PhD; Eric B. Durbin, MS; C. Janna Harrell, MS; Kim
Herget; John Williams, MS; Rosemary Dibble, CTR
53 Perspectives Articles
55 Patient Centered Medical Home: Its Role in Health Care Reform
Julie Day, MD; Debra L. Scammon, PhD; Michael K. Magill, MD
58
“Do’s and Don’ts” for Eating Disorder and Obesity Prevention in Community
Settings
62
How Would Utah’s Small Businesses be Affected by Health Care Reform? 62
Andrada Tomoaia-Cotisel, MHA & MPH (est 2011); Samuel Allen, MST (est
2010)
Justine J. Reel, PhD, LPC, CC-AASP; Joseph Halowich, MS, CHES
77 Health Policy
2010 Utah Legislative Review
Michael J. Rasmussen
91 2010 Utah Health Data Review 91
183 Health Services Directory 183
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu/UHReview
Utah’s Health: An Annual Review
Executive Editors
Faculty Advisor
Editor-in-Chief
Governor Scott M. Matheson Presidential Endowed Chair in
Health Policy Management
JB Flinders, MPH, MBA
Jose Morales
Managing Editor
Shannon Talbott, MS
Richard Sperry, MD, PhD
Advisory Board Members
Marlene Egger, PhD
Articles Editor
Professor, Family & Preventive Medicine, University of Utah
Chris Stockmann
Leslie Francis, PhD
Data Editor
Sarah Watts, MPA/MHA
Production Editor
Allison Stuart, MS
Associate Articles Editor
Michael Rasmussen
Legislative Editor
Editorial Board Members
Charlene Hill
Gregg Jones
Anthony Tran
Michelle Everill-Flinders
Priti Shah
Cici Zhou
Trevor Wright
Blake Wilde
Kyley Joell Cox
Acknowledgement
We would like to thank Dr. Richard Sperry for his continued support and guidance, the
University of Utah Publications Council, ASUU, and the Governor Scott M. Matheson
Center for Healthcare Studies for their financial support.
Dean, College of Humanities, Alfred C. Emery Professor of
Law
Robert Paul Huefner, PhD
Professor Emeritus, Political Science, University of Utah
Pamela S. Perlich, PhD
Senior Research Economist, Bureau of Economic and Business
Research, University of Utah
Daniel M. Rozanas, MEd
Professor, Alta High School
Randall Rupper, MD, MPH
Assistant Professor, Division of Geriatrics, University of Utah
Debra Scammon, PhD
Emma Eccles Jones Professor of Marketing, David Eccles
School of Business, University of Utah
Tawna Skousen, PhD
Vice-President of Finance, Sawyer Technologies; Instructor,
University of Utah
Julia Summerhays, PhD
Assistant Professor, Health Promotion and Education,
University of Utah
Norman J. Waitzman, PhD
Professor, Department of Economics, University of Utah
2010 Utah’s Health: An Annual Review
Introduction and Editor’s Note
It is with great pleasure that I, on behalf of the 2009-10 Editorial Board, present the fifteenth volume of Utah’s Health: An Annual
Review. As a scientific journal, Utah’s Health is dedicated to publishing original and timely health-related research relating to the
State of Utah, and providing an analysis of important health-related data. It is a vehicle for health policy dialogue at both state and
national levels and is designed to aid students, researchers, legislators, and health-related professionals in the continual pursuit
of health-related knowledge and practice. Utah’s Health also serves as a health education resource to the general public, and is
available online at www.matheson.utah.edu.
As in previous years, Utah’s Health is comprised of four main sections: Original Research Articles, Perspectives, a Legislative
Review, and a Data Review. The Original Research Articles submitted this year are of the utmost quality and demonstrate a
high caliber of peer-reviewed scientific research that relates to the health of Utahns. I am most grateful for all of the wonderful
submissions that were received.
As the Editor-in-Chief, I was unaware of the amount of time and effort such a journal would involve. The process has been a
fascinating learning experience, and one which I am proud to have shared with so many exceptional individuals. I would first like
to thank the diligent group of authors, contributors, and volunteers that have sacrificed their time and effort to make this journal
possible. Their commitment to the research and analysis of, and dedication to, the health-related issues in Utah is the impetus
behind the quality of this edition. I am extraordinarily fortunate and extremely thankful for the fantastic group of advisory board
members that have provided expert reviews and assisted with the editing of the numerous articles and data pages. I would also
like to thank Dr. Richard Sperry for his unwavering patience, support, and direction as our faculty advisor this past year.
Above all, I would like to acknowledge the contributions of a remarkable group of fellow students and editorial board members
who exceeded all expectations in the creation of this work. As the editor-in-chief, I extend to each one of them a sincere and
heartfelt thank you for their hard work and commitment to the success of this publication. My extra special thanks to Shannon
Talbott, Allison Stuart, and my wonderful wife, Michelle Everill-Flinders, for going the extra mile with their last minute help
and support, and Ms. Sarah Watts for her diligence, guidance, and steady hand throughout the revision and publication process.
Lastly, this volume is dedicated to the friends, colleagues, relatives, and loved ones we have lost over the past year. May we
continue to use our gifts of knowledge, research, and practice for the health, safety, and ever-improving quality of life in our
communities, our families, and within ourselves.
JB Flinders, MPH, MBA
Editor-in-Chief
Utah’s Health: An Annual Review—Volume XV, 2010
©2010 The University of Utah. All Rights Reserved.
1
Table of Contents
Original Research Articles.............................................................................................5
Collection and Utilization of Family Health History Information in the Health Care Setting:
A Case for Asthma and Diabetes..........................................................................................................................................7
Celeste Beck, MPH; Brenda Ralls, PhD; Rebecca Giles, MPH, CHES; Richard Bullough, PhD;
Shelly Wagstaff, BS; William F.Stinner, PhD
Dietary Patterns of Overweight and Obese Tongan-Americans: A Preliminary Investigation................................... 14
Timothy K. Behrens, PhD, CHES; Soo J. Schmidt, MS
Psychotherapeutic Medication Report on Utah’s Foster Care Clients............................................................................ 21
Chris Chytraus RN, BSN, CPM; Navina Forsythe, PhD, MPA
Development of a Fertility Preservation Program at the University of Utah and Current State of Affairs...............26
Colleen Milroy, MD; Kirtly Parker Jones, MD; Janet Bloch, ANP; Mark Gibson MD;
Ahmad O. Hammoud, MD, MPH; Douglas T. Carrell, PhD; C. Matthew Peterson, MD
Does Utah’s Largest School District Meet the Alliance for a Healthier Generation’s Food
and Beverage Guidelines?................................................................................................................................................... 37
Karen Schliep, MSPH; Marilyn S. Nanney, PhD, MPH, RD; Keely Cofrin, PhD; Derek Anderson
Geographic Patterns in Lung Cancer Incidence and Mortality in Utah: 1997-2006....................................................44
Antoinette M. Stroup, PhD; Eric B. Durbin, MS; C. Janna Harrell, MS; Kim Herget;
John Williams, MS; Rosemary Dibble, CTR
Perspectives Articles..................................................................................................... 53
Patient Centered Medical Home: Its Role in Health Care Reform.................................................................................55
Julie Day, MD; Debra L. Scammon, PhD; Michael K. Magill, MD
“Do’s and Don’ts” for Eating Disorder and Obesity Prevention in Community Settings............................................58
Justine J. Reel, PhD, LPC, CC-AASP; Joseph Halowich, MS, CHES
How Would Utah’s Small Businesses be Affected by Health Care Reform?.................................................................. 62
Andrada Tomoaia-Cotisel, MHA & MPH (est 2011); Samuel Allen, MST (est 2010)
Health Policy.................................................................................................................77
2010 Utah Legislative Review
Michael J. Rasmussen
2010 Utah Health Data Review.................................................................................91
Health Services Directory......................................................................................... 183
UH Review 2010
Utah’s Health: An Annual Review
Original Research Articles
Pages 7─50
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu
2010 Utah’s Health: An Annual Review
Collection and Utilization of Family
Health History Information in the
Health Care Setting: A Case for
Asthma and Diabetes
Authors:
Celeste Beck, MPH
Brenda Ralls, PhD
Rebecca Giles, MPH, CHES
Richard Bullough, PhD
Shelly Wagstaff, BS
William F.Stinner, PhD
Abstract
Key Words
asthma, diabetes, family health
history, chronic disease prevention
Correspondence
Primary Author Contact
Information:
Celeste Beck
Phone: 801-538-6894
Address: PO Box 142106,
Salt Lake City, Utah 84114
email: celestebeck@utah.gov
Colleague Contact Information
for Peer-Review:
Randy Tanner
email: rtanner@utah.gov
Phone: 801-538-9193
Fax: 801-538-9495
Mary Catherine Jones
email: mcjones@utah.gov
Phone: 801-538-6536
Fax: 801-538-9495
©2010 The University of Utah. All Rights Reserved.
Chronic diseases, particularly asthma and diabetes, tend to run in families. Results from
a statewide survey of Utah adults were analyzed to assess the risk for these two diseases
based on having an immediate family member with the disease, and also to examine the
collection and utilization of family health history information in the health care setting.
Adults with an immediate family member with asthma or diabetes had more than triple
the adjusted odds of being diagnosed with the disease compared to adults without a
family history (3.6 and 3.1, respectively). However, less than one-third of adults with a
family history of any chronic disease, including asthma and diabetes, reported having
ever actively collected family health history information, and less than half reported having ever discussed their risk for disease or received recommendations from a health care
professional based on their family history. Collection and discussion of family health
history appears to be underutilized in the health care setting.
Introduction
Chronic diseases tend to run in families. Individuals who are aware of their potential for
an inherited risk for a condition may be especially diligent about taking steps to avoid
developing it. Family history information can be important for assessing risk and act as
a prompt calling for screening and early detection and treatment (Hariri, Yoon, Qureshi,
Valdez, et al., 2006). Genetic testing is one way to identify an inherited risk, but this type
of testing is slow, expensive, and difficult. Knowing and collecting one’s family health
history is a practical alternative.
Collecting family health history means actively pursuing and recording diseases known
within one’s family, along with familial relationships, and where possible, the age at
diagnosis and death (See CDC, 2010). Family health history is useful for predicting a
person’s risk for developing a host of chronic conditions, including birth defects, asthma,
cardiovascular disease, cancer, diabetes, depression, Alzheimer’s disease, and osteoporosis. Two diseases with a particularly strong genetic link are asthma and diabetes (both
type 1 and type 2). Studies indicate the risk for developing diabetes can at least double
A Case for Asthma and Diabetes
7
2010 Utah’s Health: An Annual Review
when an individual has a family history of the disease (NIDDK, 2002; Li, Isomaa,Taskinen, Groop, et al., 2000, Rotter,
Anderson, Rubin, Congelton et al., 1983). Family history has
an especially strong impact on asthma. The risk for developing
asthma may increase almost fivefold if a family member has
asthma (Liu, Valdez, Yoon, Crocker et al., 2009).
Most people are aware of the link between family history and
increased risk of certain chronic conditions. In fact, among
Utah adults, 86.0% believe that family history increases the
risk for developing a chronic disease (BRFSS 2005). Nationally, 96% of adults say it is important to know one’s family
health history (CDC, 2004). Nevertheless, despite its perceived
value, simplicity and low cost, family health history is widely
underused as a public health tool. Less than 30 percent (29.8%)
of U.S. adults actively collect their family health history (CDC,
2004). This lack of awareness regarding the potential for increased risk precludes the opportunity for open discussion
with a health care provider about steps that can be taken to help
prevent the development of a chronic condition. Widespread
lack of awareness of family history can translate into an unfortunate lost opportunity for prevention.
Awareness and subsequent discussion of one’s family health
history with health care providers can improve communication about reducing the risk for developing a disease. However,
given doctors’ busy schedules, the responsibility for discussion
may fall upon the patient. One study indicated that only about
half of primary care providers discussed family histories with
patients during their initial visits, and it was discussed at only
22 percent of follow-up visits. When providers did discuss
family history, the majority of the clinical time tended to focus
more on the psychosocial aspects of the family rather than
medical aspects (Acheson, Wiesner, Zyzanski, Goodwin, et al,
2000).
Interventions that incorporate family health history are becoming more prominent in the public health arena. Still, little
is known about awareness of family health history among Utah
adults and the extent to which they formally pursue collecting
this information. Even less is known about the patient/provider
interactions and discussions regarding family health history.
Therefore, the objectives of this study, based on a statewide
survey of Utah adults are: (1) to examine, for asthma and
diabetes, separately, the link between the respondent’s having
ever been diagnosed with either disease and evidence from the
family history findings that the disease was also experienced
by any immediate family members; (2) to assess the degree
to which respondents have actively collected a family health
history; and (3) to gauge the degree to which providers have
discussed family history findings with the respondent and
proffered recommendations on the basis of such evidence.
8
A Case for Asthma and Diabetes
Methods
The Behavioral Risk Factor Surveillance System (BRFSS) is a
state-based survey established by the Centers for Disease Control and Prevention (CDC), which is used to gather information
on health behaviors, chronic disease and injury among adults.
In years 2006 through 2008, a subsample of respondents in
Utah was selected to be asked additional questions about family health history. Questions were added to the Utah BRFSS
to assess the percentage of Utah adults who were actively collecting health information from their relatives for the purpose
of developing a family health history. Respondents were also
asked whether or not they had discussed their family health
history with their health care provider and if their providers
had made recommendations. Not all questions were asked for
all years, as noted in the results section, below.
Only valid responses were included in the analyses. Responses
with “Don’t know” and “Refused” were set as missing values.
Variables included in the study are defined below.
Asthma diagnosis: A dichotomous variable based on the
question, “Have you ever been told by a doctor, nurse, or
other health professional that you had asthma?” (Yes=1; No
=0).
Diabetes diagnosis: A dichotomous variable based on the
question “Have you ever been told by a doctor that you have
diabetes?” (Yes=1; No =0).
Age: A continuous variable based on self-reported age at last
birthday.
Gender: A dichotomous variable (Male=1; Female=2).
Smoking history: A dichotomous variable based on the question, “Have you smoked at least 100 cigarettes in your
lifetime?” (Yes=1; No =0).
Family history of asthma: A dichotomous variable based on
the question, “Have any of your immediate family members
ever been told by a doctor, nurse, or other health professional
that they had asthma?” (Yes=1; No =0).
Family history of diabetes: A dichotomous variable based
on the question “Have any of your immediate family members ever been told by a doctor, nurse, or other health professional that they had diabetes? Do not include female relative
who only had diabetes during pregnancy.” (Yes=1; No =0).
Family history of at least one chronic disease: A dichotomous variable based on the question “Now thinking about
your immediate family including your grandparents, parents,
brothers, sisters, and children, both living and deceased, to
the best of your knowledge, does one or more chronic disease, such as heart disease, stroke, diabetes, or cancer tend
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
to run in your family?” (Yes=1; No =0).
Collection of family health history: A dichotomous variable based on the question “Have you ever actively collected
health information from your relatives for the purpose of
developing a family health history?” (Yes=1; No =0).
Provider discussion of risk: A dichotomous variable based
on the question “Has a doctor or other health professional
ever discussed with you your risk for certain diseases or
other health problems based on your family medical history?” (Yes=1; No =0).
Provider recommendations: A dichotomous variable based
on the question “Has a doctor or other health care professional ever made any recommendations to you based on your
family medical history?” (Yes=1; No =0).
Bivariate analyses were used to examine associations between
family history and prevalence of disease. Chi-square values
were used to determine statistical significance. A two-tailed p
value of less than .05 was considered statistically significant.
Logistic regression was used to calculate odds ratios for the
risk of being diagnosed with either asthma or diabetes if a family history were present. Several confounding factors for the
prevalence of asthma or diabetes were discovered in the initial
analysis, namely, age and smoking history. Odds were adjusted
for these confounding factors and both unadjusted and adjusted odds are shown in the results. Finally, bivariate analyses
were conducted to determine if adults with a family history
of at least one chronic disease of any nature were discussing
ways and receiving recommendations for prevention with their
health care providers. The same analysis was conducted for
respondents with a family history of asthma. Information on
patient/provider interaction was not available for respondents
with a family history of diabetes. Because females may have
greater reason to learn about and discuss family health history,
particularly because of childbearing concerns, gender is also
included in the analyses.
Analyses were conducted using SAS 9.1.3. and SUDAAN Version 10.
Results
An overview of the sample is provided in Table 1. Nearly threefourths, 69.5%, of Utah adults reported they had a family history of at least one chronic disease. Approximately one-third
(33.1%) of adults reported a family history of asthma, and nearly half (46.5%) reported having a family history of diabetes.
Females were significantly more likely to report a family history of chronic disease than males for each condition. Among
Table 1. Percentages of Utah Adults with a History of At Least One Chronic Disease, Asthma, or Diabetes,
Overall and by Gender
Utah BRFSS
Characteristic
Percentage with a
Family History of at
Least One Chronic
Disease1
Percentage with a Family History
of Asthma2
Percentage with a Family History
of Diabetes3
Percentage (CI)
69.5 (67.9-71.0)
Percentage (CI)
33.1 (30.4-35.8)
Percentage (CI)
46.5 (44.5-48.5)
62.7 (60.1-65.1)
76.2 (74.3-77.9)
28.9 (24.9-33.0)
37.3 (33.6-41.0)
41.9 (38.8-45.0)
51.1 (48.5-53.7)
78.6 (74.9-81.9)
59.0 (51.2-66.7)
55.4 (49.5-61.2)
67.9 (66.2-69.6)
28.2 (25.4-31.0)
45.2 (43.0-47.3)
83.0 (78.5-86.7)
31.9 (23.6-40.2)
68.9 (62.9-74.3)
68.6 (67.0-70.2)
33.2 (30.3-36.1)
45.1 (43.1-47.2)
Total
Gender
Males
Females
Asthma Status
Diagnosed with
Asthma
Not Diagnosed with
Asthma
Diabetes Status
Diagnosed with
diabetes
Not diagnosed with
diabetes
1
2006-2008
2
2006
3
2007-2008
CI=95% Confidence Interval
©2010 The University of Utah. All Rights Reserved.
A Case for Asthma and Diabetes
9
2010 Utah’s Health: An Annual Review
adults who were diagnosed with asthma, 59.0% reported they
had a family history of asthma, compared to 28.2% of those
without asthma. Differences were similar for diabetes. Over
two-thirds, 68.9%, of adults with diabetes reported a family
history of diabetes, compared to 45.1% of those not diagnosed
with diabetes. Differences in prevalence between adults with
and without asthma or diabetes were statistically significant for
each condition.
Risk for Utah adults of asthma or diabetes based on
family history
Results showing associations between family history and the
prevalence of asthma and diabetes are illustrated in Figures 1
and 2. As may be seen, nearly three times as many adults with
a family history of asthma reported having been diagnosed
with asthma (26.9%) compared to adults without a family history of asthma (9.1%). The pattern was similar for adults with
and without diabetes. Among adults with a family history of
diabetes, 9.0% reported having been diagnosed with diabetes,
compared to only 3.5% of adults without a family history of
diabetes. The statistical significance persisted when differences were examined by gender.
Another way to look at the impact of family history on the
prevalence of a chronic disease is through odds ratios. For
asthma, the unadjusted odds of being diagnosed with asthma
were 3.7 (CI 2.6-5.2) times greater for adults with a family history of asthma compared to adults not reporting a family history of asthma. Adjusting for potentially confounding factors
(age and smoking history) decreased the odds only slightly, to
3.6 times (CI 2.6-5.1). The unadjusted odds of having diabetes
were 2.7 (2.0- 3.6) times that of adults without a family history
of diabetes. After adjustment for age and smoking history, the
odds increased to 3.1 (2.3 -4.2).
Figure 1. Percentage of Utah Adults Who Have Been Diagnosed with Asthma,
by Family History of Asthma, Utah
40
35
30.1
26.9
22.6
Percentage
30
25
Family History of Asthma
20
15
9.3
9.0
9.1
10
No Family History of
Asthma
5
0
Total
Males
Females
Figure 2. Percentage of Utah Adults Who Have Been Diagnosed with Diabetes,
by Family History of Diabetes, Utah
10.9
14.0
12.0
9.0
Percentage
10.0
7.4
8.0
6.0
Family History of
Diabetes
3.5
3.7
3.4
4.0
2.0
0.0
Total
10
Males
Females
A Case for Asthma and Diabetes
No Family History
of Diabetes
Collection of family health history
information
Turning now to the subsample of
respondents who reported having a
family history of at least one chronic
disease, more detailed analysis reveals how they used this information.
These respondents were asked if they
had ever actively collected health information from their relatives for the
purpose of developing a family health
history. Only 30.7% reported having
ever actively collected family health
history information from relatives.
Results were similar for adults reporting they specifically had a family
history of asthma or diabetes, 25.8%
and 32.2%, respectively.
Females appear more likely to have
ever collected family history information compared to males. Among
adults with a family history of any
chronic condition, asthma, or diabetes, significantly higher percentages
of females reported having ever actively collected health information
from relatives for the purpose of
developing a family health history.
Differences are illustrated in Figure
4 (also see Table 2).
Discussions of risk with health
professional:
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
respondents with a family history of
diabetes).
Figure 3: Unadjusted and Adjusted Odds for Asthma and Diabetes Based on Family
History, BRFSS 2006 (Asthma), 2007-2008 (Diabetes)
6
3.7
3.6
5
3.1
4
Odds
Of adults who reported having a
family history of at least one chronic
illness, less than half (41.1%) reported
having ever discussed their risk for
certain diseases based on family history with a health care professional.
Results were similar for adults with
a family history of asthma, with
only 40.1% reporting they had ever
discussed their risk for disease with
a health care professional based on
their family history. Data suggest that
females were more likely than males
to have discussed their risk for disease
with a health care professional, but the
difference was not statistically significant (see Table 2).
2.7
3
2
1
0
Unadjusted
Adjusted
Unadjusted
Asthma
Adjusted
Diabetes
Note: Adjustment includes age and smoking
Recommendations by provider
based on family history:
Figure 4. Percentage of Utah Adults Who Have Actively Collected Family Health History
Information, by Family History and Gender, Utah BRFSS
45
40
Percentage
35
30
25
20
37.9
34.2
36.6
25.2
23.5
15.1
15
Males
Females
10
5
Among adults with a family history
of any chronic disease only 35.0%
reported having ever received recommendations from a health care
professional regarding their risk for
developing certain diseases based on
their family history. A slightly higher
percentage of females reported that a
health care professional had discussed
their risk for disease with them compared to males (37.1% vs. 32.5%),
though differences were not statistically significant.
Findings for adults with a family history of asthma specifically were simiFamily History of at
Family History of
Family History of
Least One Chronic
Asthma (2)
Diabetes (3)
lar, with only 34.4% reporting that
Disease (1)
a health care professional had ever
discussed their risk for disease with
them based on their family history.
Collection of family history is important, but it is equally important that people act on what they know and that they discuss There were no differences between males and females. Results
their family history with their health care provider. Because for adults with a family history of diabetes were not available.
diabetes and asthma risks are so strongly linked to family hisA summary is included in Table 2.
tory, this discussion is especially important for those with a
family history of either disease.
0
Comparisons were made to see if respondents with a family
history of asthma, in particular, were more likely to discuss
their disease risk than respondents, overall, with a history of
any chronic disease (This information was not available for
©2010 The University of Utah. All Rights Reserved.
Discussion
Having a family history of a chronic disease increases the risk
for developing it, yet the majority of adults are not taking advantage of the opportunity to mitigate their risk by collecting
family health history information and discussing prevention
A Case for Asthma and Diabetes
11
2010 Utah’s Health: An Annual Review
Table 2. Collection, Discussion of Risks for Disease and Provider Recommendations Made Based on
Family History
Utah, BRFSS Subsample 2006-2008
Collected Family
Health History 1,2,3
Ever Discussed
Risk of Disease
with Health
Professional Based
on Family History
Ever Received Recommendations
from Health Professional Based on
Family History 2
Percentage (CI)
Percentage (CI)
41.1 (37.9-44.5)
36.4 (31.5-41.6)
45.0 (40.7-49.4)
35.0 (32.0-38.2)
32.5 (27.7-37.6)
37.1 (33.2-41.1)
40.1 (35.4-45.1)
37.2 (29.6-45.5)
42.4 (36.5-48.6)
34.4 (29.9-39.1)
35.3 (27.8-43.7)
33.6 (28.5-39.2)
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
2
Percentage (CI)
Adults with Family History of at Least One Chronic Disease
All Adults
30.7 (28.9-32.6)1
Males
23.5 (21.0-26.2)1
Females
36.6 (34.2-39.0)1
Adults with a Family History of Asthma
All Adults
25.8 (22.0-30.1)2
Males
15.1 (10.9-20.6)2
Females
34.2 (28.6-40.3)2
Adults with a Family History of Diabetes
All Adults
32.2 (29.6-34.9)3
Males
25.2 (21.6-29.3)3
Females
37.9 (34.5-41.4)3
1
2006-2008
2
2006
3
2007-2008
CI=95% Confidence Interval
with their health care provider. Findings from this study indicate that few adults, even those with a known family history of chronic illness, discuss their risk for disease based on
family history in the health care setting. Results also suggest
that health care professionals may need to take a more active
role in promoting discussion of family health history with their
patients.
More than two thirds of Utah adults report they have a family
history of at least one chronic disease, and most recognize that
family history is a risk factor for a number of chronic diseases.
Data from this study support the notion of increased risk. In
particular, there was a dramatically increased risk for having
an asthma diagnosis if a family member had asthma. This
increased risk persisted even after adjustment for potentially
confounding factors. Results were similar for those with a
family history of diabetes. Nevertheless, less than one third
of adults with a family history of a chronic disease, including
asthma and diabetes, are actively pursuing information about
their family health history. Less than half of adults in Utah
with a family history of at least one chronic disease, asthma, or
diabetes reported they had discussed their risk based on family
history with their health care provider; and even fewer, just
over one-third, reported they had received recommendations
from their health care provider for preventing the disease based
on their family health history.
Knowing and discussing family health history is an important
12
A Case for Asthma and Diabetes
part of preventive health care. As Americans today are living
longer than ever before, their chances for developing a chronic
condition continue to rise. Nevertheless, much can still be done
to mitigate the risk. One of the most effective methods would
be to help individuals better understand the role family health
history plays on their personal risk for a disease. Most people
are aware of the link between family health history and risk of
disease, yet the collection and discussion of family health history information for disease prevention is widely underused.
Public health interventions aimed at reducing the prevalence
of chronic diseases must encourage individuals to collect their
family health histories and speak to their health care providers
about prevention.
A number of family health history collection tools are available. One tool recommended by the authors is the family health
history toolkit developed by the Utah Department of Health.
This toolkit is available online at Family Health History Toolkit, http://health.utah.gov/genomics/familyhistory/toolkit.html.
Limitations
Information is self-reported and is subject to the biases inherent in any self-reported survey. Not all questions were asked in
all years, limiting the availability of data. Information regarding timing of primary care visits versus timing of family health
history awareness was not available. Finally, the information
contained in the survey presented only the respondents’ view-
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
point; health care providers may have a different perspective
of having discussions and giving recommendations to patients.
References
Acheson, LS, Wiesner, GL, Zyzanski, S J, Goodwin, MA, & Stange, KC
(2000). Family history-taking in community family practice: Implications for
genetic screening. Genetic Med (3) 2, 180-185. Abstract available from http://
www.ncbi.nlm.nih.gov/pubmed/11256663?itool=EntrezSystem2.PEntrez.
Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=12
Annis AM, Caulder MS, Cook ML, & Duquette D. (2005). Family history,
diabetes, and other demographic and risk factors among participants of the
National Health and Nutrition Examination Survey 1999–2002 Preventing
Chronic Disease. Available from: http://www. cdc. gov/pcd/issues/2005/
apr/04_0131.htm
Centers for Disease Control and Prevention (2004). Awareness of family
health history as a risk factor for disease --- United States, 2004 (Morbidity
and Mortality Weekly Report 54(44): 1044-1047. Available from http://www.
cdc.gov/mmwr/preview/mmwrhtml/mm5344a5.htm
Centers for Disease Control and Prevention (2010). Family Health History.
Available from http://www.cdc.gov/genomics/famhistory/index.htm
Hariri S, Yoon, PW, Qureshi N, Valdez R, Scheuner MT & Khoury MJ
(2006). Family history of type 2 diabetes: A population-based screening tool
for prevention? Genet Med.(2):102-8. Abstract available from http://www.
ncbi.nlm.nih.gov/pubmed/16481893
Li H, Isomaa B, Taskinen MR, Groop L & Tuomi T (2000). Consequences of a
family history of type 1 and type 2 diabetes on the phenotype of patients with
type 2 diabetes. Diabetes Care 23:589-594
Liu T, Valdez, R, Yoon, PW, Crocker D, Moonesinghe R, & Khoury MJ
(2009). The association between family history of asthma and the prevalence
of asthma among US adults: National Health and Nutrition Examination Survey, 1999-2004. Genetics in Medicine 11(5): 323-328. Abstract available online from http://journals.lww.com/geneticsinmedicine/Abstract/2009/05000/
The_association_between_family_history_of_asthma.3.aspx
National Diabetes Information Clearinghouse (2002. May). NIH Publication
No. 02-3265. Available online from http://diabetes.niddk.nih.gov/dm/pubs/
hispanicamerican/index.htm
Rotter JI, Anderson CE, Rubin R, Congelton, JE, Terasaki PI & Rimoin
DL(1983). HLA genotypic study of insulin-dependent diabetes the excess of
DR3/DR4 heterozygotes allows rejection of the recessive hypothesis. Diabetes 32(2): 169-174. Abstract available online from http://diabetes.diabetesjournals.org/content/32/2/169.short
©2010 The University of Utah. All Rights Reserved.
A Case for Asthma and Diabetes
13
2010 Utah’s Health: An Annual Review
Dietary Patterns of Overweight
and Obese Tongan-Americans: A
Preliminary Investigation
Authors:
Timothy K. Behrens, PhD, CHES
Soo J. Schmidt, MS
Abstract
Objective: The aim of this study was to provide preliminary data on the dietary intake
of Tongans living in the U.S.
Correspondence
Timothy K. Behrens, Ph.D.,
CHES, Department of Health
Sciences, University of Colorado
at Colorado Springs, CO; Email:
tbehrens@uccs.edu; TEL:
719.255.4664
Author info
Timothy K. Behrens, PhD, CHES
Department of Health Sciences
University of Colorado at Colorado
Springs
Colorado Springs, Colorado
Dr. Tim Behrens, formerly an
Assistant Professor of Health
Promotion & Education at the
University of Utah, is an Assistant
Professor in the Department of
Health Sciences at the University
of Colorado at Colorado Springs.
His research interests focus around
physical activity and public health.
Soo J. Schmidt, MS
Division of Nutrition
University of Utah
Salt Lake City, Utah
Soo Schmidt, MS, is a graduate
of the nutrition program at the
University of Utah.
14
Design: A sample of 32 overweight or obese adult men and women were recruited to
participate in this cross-sectional descriptive study from a Tongan community in Utah.
A 24-hour recall was collected for each participant through a telephone interview. The
ESHA Food Processor nutrient database program was used for nutrient analysis.
Results: The average energy intake was 2,139 calories, the average carbohydrate intake
was 264g or 55% of total calories, the average protein intake was 88g, the average total
fat intake was 71g or 30% of total calories, the average saturated fat intake was 27g or
11% of total calories, and the average cholesterol intake was 335mg. Foods that were the
highest sources of energy, carbohydrate, total fat, and protein included pizza, fast food,
beef, chicken, and white bread.
Conclusion: These data illustrate the need for more effective nutrition interventions in
the Tongan community.
Introduction
Analysis of the most recent National Health and Nutrition Examination Survey
(NHANES) indicates that 30.5% of the U.S. population is obese (BMI > 30) and 64.5%
is overweight ( BMI > 25; Flegal, Carroll, Ogden, & Johnson, 2002; National Center for
Health Statistics). These data also provide evidence estimating the prevalence of overweight and obesity in different racial/ethnic groups. These groups included non-Hispanic
whites, non-Hispanic blacks, and Mexican Americans. All other ethnicities, including
Asians and Pacific Islanders, were placed in the “All” category when comparing data
among the groups. However, these data do not accurately represent the overweight and
obesity prevalence in Pacific Islanders.
The Polynesian nation of Tonga is one such population that falls into the Pacific Islander
category. Obesity has been a major health concern for Pacific Island populations for the
past 30 years (Ulijaszek, 2005). BMI measurements of several native Pacific and Indian
Ocean populations between 1978 and 1987 showed that along with Micronesians, Polynesians had the highest prevalence of obesity of all the groups surveyed (Collins, Dowse,
Dietary Patterns of Tongan-Americans
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
& Zimmet, 1990). In the aforementioned study obesity was
defined as having a BMI ≥ 27 kg/m2 for males and a BMI ≥ 25
kg/m2 for females. On average, more than 60% of Polynesians
were found to be obese.
This frequency of overweight and obesity is often attributed to
the economic development and modernization of the traditional lifestyle, which have led to changes in energy expenditure
as well as in the type and amount of energy intake (Ulijaszek,
2005). In recent decades, the Kingdom of Tonga has experienced a similar expansion in global trade and economic development that have led to increased consumption of imported
foods (Evans, Sinclair, Fusimalohi, & Liava’a, 2001, 2002).
These imports were primarily meats with a high-fat content,
such as corned beef, mutton flaps, and chicken parts, and also
simple carbohydrates such as refined sugar and white flour.
In contrast, the more traditional native Tongan diet consisted
of complex carbohydrates such as corn, breadfruit, plantain,
and banana; root vegetables such as sweet potato, taro, yam,
and cassava; and indigenous chicken, fish, and seafood as
the primary sources of protein (Evans et al., 2001; Ulijaszek,
2005). This economic effect has had an undeniable effect in
subsequent obesity rates among Tongans.
Further complicating the comorbidities associated with obesity among Tongans, the increase in obesity has resulted in
the emergence of noncommunicable diseases as a major health
threat in Tonga. A study conducted between 1998 and 2000
on over 1000 randomly selected participants showed that the
prevalence of type 2 diabetes has doubled from 7.5% in 1973 to
15.1% in 2000 (Colagiuri et al., 2002). Furthermore, it was estimated that another 20% of the population had lesser degrees
of glucose intolerance. In addition, there is evidence to suggest
that Tongans are genetically prone to obesity. Studies have
found that Tongans have a high prevalence of polymorphisms
of genes associated with metabolism (Duarte, Colagiuri, Palu,
Wang, & Wilcken, 2003a, 2003b, 2003c). While these statistics primarily highlight indigenous Tongans, behavioral and
genetic components may affect their U.S.-living counterparts
as well.
There have been few published studies on the dietary intake
of Tongans. One study assessed the adequacy of energy and
nutrient intake of Tongan children living in New Zealand (Bell
& Parnell, 1996). The information collected included specific
nutrients such as protein, total fat, saturated fat, carbohydrates,
and fiber. Currently no such data on the dietary intake of Tongans residing in the U.S. are available.
According to the 2000 U.S. census data, there were 36,846
Tongans, of which 8,655 were living in Utah (Native Hawaiian Research Center). A large subpopulation resides in the
Salt Lake Valley, and this population provided a unique opportunity to ascertain preliminary data on the dietary intake
©2010 The University of Utah. All Rights Reserved.
of Tongan Americans. Previous research on the Tongan diet
has focused more on the social and economic factors that affect food choices of native Tongans, and less on actual nutrient composition. The high prevalence of type 2 diabetes and
the potential genetic links to obesity place this group at high
risk for developing more obesity-related diseases. These facts
highlight the importance of obtaining dietary information on
Tongans living in the U.S. Thus, the aim of this study was to
describe the dietary intakes of a small subset of the Tongan
population in Utah. Specifically, the goal was to obtain data
on energy, total fat, saturated fat, protein, carbohydrates, and
cholesterol and compare to the key recommendations for intake put forth in the Dietary Guidelines for Americans 2005.
An additional goal of this study was to identify foods that are
frequently consumed and that may have future health implications for the Tongan community.
Methods
Research design
This study utilized a cross-sectional descriptive design. Data
from this study represents the dietary component of a larger
study investigating health outcomes in Tongans. Data collection took place from October of 2006 to March of 2007.
Participants
Study participants were of Tongan descent and currently residing in the Salt Lake Valley of Utah. Following approval from
the university’s Institutional Review Board, researchers and
community leaders recruited eligible participants through local
churches, community centers, flyer postings, and through the
National Tongan American Society of Utah (NTAS). Eligible
participants were male or female, between the ages of 18–64,
and were required to be overweight or obese with a body mass
index (BMI) > 25 kg/m2.
Instruments
A telephone administered survey was used to measure dietary
intake. The 24-hour recall method was used to survey the
sample population. This method has been widely used to assess
nutrient intake and has acceptable psychometric properties
(Stang et al., 2005; Wright et al., 2007).
Procedures
Potential participants were asked to call for pre-screening to
determine eligibility. Once eligibility was determined, participants were instructed a time and date for initial assessment.
Following the initial screening process and during the first
visit, the research staff informed the participant that he/she
would be contacted by telephone to obtain information about
their diet. After the initial visit, the names and telephone numbers of the eligible participants were obtained from the study
principal investigator.
Dietary Patterns of Tongan-Americans
15
2010 Utah’s Health: An Annual Review
Table 1. Standardized script for the 24-hour recall interview
1. Introduction
-Inform participants of the purpose of the call (to obtain dietary information
for the study).
-Inform participants it will take ~ 10 minutes and involves getting a list of
foods and beverages they consumed the previous day.
2. List of foods
and beverages
-Ask participant to list all foods and beverages (other than water), and the
amounts consumed during the previous day, starting with the first thing
he/she had in the morning.
-Refrain from questions or comments during this step. The purpose is to
obtain an initial list of foods and beverages that participant can recall
unaided.
3. Detailed
descriptions
-Collect detailed descriptions of each food and beverage, starting with the
first item consumed (i.e. breakfast) to the last item (dinner or snack).
-Ask about preparation methods, any additions such as sugar, butter,
cream in their coffee/tea, etc., brand names, and amounts.
-For amounts, use common measures (e.g., teaspoons, tablespoons,
cups, and ounces). To further clarify portion sizes, use comparisons to
household objects to get a more accurate description (e.g., if the
participant had pancakes for breakfast, the size of each pancake can be
compared to the size of a CD. Items such as steak can be compared to
the size of the palm).
4. Forgotten foods
-Probe for foods and beverages that may have been forgotten in the first
list. Ask specific questions such as, “Did you have a snack in the
afternoon between lunch and dinner?” or “Did you have anything to drink
with lunch other than water?”
-Forgotten items may include side dishes, desserts, or beverages other
than water, and also snacks
between
breakfast
lunch, between lunch
DIETARY
PATTERNS
OFand
TONGAN-AMERICANS
and dinner, or before bedtime.
Table 2. Comparison of nutrient intake versus recommended intakes in the Dietary
Guidelines for Americans, 2005.
Nutrient
Energy (kcal)
Recommended Intake
2000*
Tongan Americans
2139 ± 940
45 – 65**
55 ± 20
20 – 35
30 ± 11
Saturated Fat (% kcal)
< 10
11 ± 5
Cholesterol (mg)
≤ 300
335 ± 340
Carbohydrates (% kcal)
Total Fat (% kcal)
*estimated caloric needs for a sedentary adult, from A Healthier You, Based on Dietary Guidelines for Americans
**represents the Acceptable Macronutrient Distribution Range (AMDR) for carbohydrates
16
Dietary Patterns of Tongan-Americans
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
In the weeks following the initial visit, each participant was Data analysis
contacted by telephone at a random date and time to obtain di- Sixty-nine adults were recruited to participate in the larger
etary information using the 24-hour recall method. Both week- study. From this sample, 32 dietary surveys were successfully
days and weekend days were sampled. A single 24-hour food completed for analysis. Items and amounts from each parrecall was collected for each participant. During the telephone ticipant’s 24-hour food recall were then entered into the ESHA
interview, the participants were asked to provide by memory a Food Processor nutrient database program (Bazzano et al.,
list of foods and beverages and the amounts consumed during 2002a; Bazzano et al., 2002b). A separate food list containing
the previous day. A standardized script was followed for each all of the items from the food recall was created for each particinterview (Table 1). The responses were recorded by hand onto ipant. Once the data were entered, the program generated the
a data collection form, which included designated spaces for total amounts of all macro- and micronutrients present in the
food list. The nutrients of interest were the total energy (kcals),
the description and amount for each food or beverage item.
DIETARY PATTERNS OF TONGAN-AMERICANS
Table 3. Frequency of foods reported by participants, by category
Meat
Chicken leg
Steak
Turkey lunchmeat
Corned beef
Other
Frequency*
11
5
5
3
9
Seafood
2
Eggs/egg dishes
5
Grain/grain products
Breakfast cereal
White rice
White bread
Wheat bread
Oatmeal
Pasta
Other
10
8
7
2
3
3
2
Starchy vegetables
Potatoes
Corn
Sweet potatoes/yam
13
3
2
Other vegetables
Lettuce
Tomato
Carrots
Other
7
6
3
6
Fruit
Banana
Other
7
5
Traditional Tongan Foods
Taro
Manioke
Breadfruit
Coconut milk
3
2
1
1
Beverages
Milk
Regular soda
100% fruit juice
Sports drink
Fruit drink
Hot cocoa
Other
Frequency
18
8
8
6
6
3
6
Pizza/Fast food
Pizza
Fast food
6
7
Mixed dishes
Burrito
Chicken w/mushroom sauce
Other
7
3
6
Snack foods
Ice cream
Chips/crackers
Candy
Other
5
4
4
5
Sauces/Condiments
Butter
Mayonnaise
Sugar
Gravy
Salad dressing
Other
7
5
4
4
3
4
* represents number of participants reporting item
©2010 The University of Utah. All Rights Reserved.
Dietary Patterns of Tongan-Americans
17
2010 Utah’s Health: An Annual Review
carbohydrates (g), protein (g), total fat (g), saturated fat (g),
and cholesterol (mg). Prepared dishes that were not found in
the database were broken down into their component parts and
entered separately. For example, for “chicken and potato soup”
the participant was asked during the interview to describe the
ingredients - dark meat or white meat chicken, whether it was
cream-based or water-based, and the approximate amounts
consumed (one chicken thigh and 1 small – sized potato). Food
items matching the ingredients were then entered into the Food
Processor. All of the food items considered native to the Tongan culture such as taro, breadfruit, and cassava were listed
in the database. Descriptive statistics were calculated for total
calories (kcals) carbohydrates, protein, total fat, saturated fat,
and cholesterol.
Results
Table 2 indicates the estimated energy and nutrient intakes of
the sample and comparisons between the actual nutrient intake
and those recommended in the Dietary Guidelines for Americans, 2005. The average intakes for carbohydrates and total fat
were within the recommended ranges. The average percent of
calories from saturated fat (11%) was slightly higher than the
recommended intake of less than 10% of total calories. The
average cholesterol intake of 335mg was also slightly higher
than the recommendation of no more than 300mg.
For the total sample, pizza was one of the most frequently
consumed foods and represents a top source of energy, carbohydrates, and fat. White bread was also a top source of carbohydrate. In addition to pizza, beef and chicken contributed
as top sources of fat. Chicken was also a frequently consumed
food and was by far the highest source of protein. Items placed
in the chicken category included both white and dark meat
chicken that was fried, roasted, or stewed in a sauce. Beef items
included corned beef and steak and did not include hamburgers
or beef in mixed dishes such as burritos, tacos, or spaghetti
with meat sauce. Table 5 provides the frequencies of foods and
beverages consumed by this sample by category.
Discussion
Previous research on the Tongan diet has provided insight
into the causes of rising obesity rates in this population. It has
been demonstrated that increased globalization and economic
change have had a significant impact on the consumption patterns of native Tongans (Evans et al., 2001, 2002; Ulijaszek,
2005). However, there are no studies that have determined
the specific energy and nutrient content of an adult Tongan
population. This study has provided a preliminary profile of
the nutrient intake for Tongans living in the U.S. Our results
indicated that the average intake of carbohydrates and total
fat were within the recommended intake ranges. In addition,
saturated fat and cholesterol intakes were only slightly higher
than the recommended limits.
18
Dietary Patterns of Tongan-Americans
Given that all of the participants were overweight or obese,
it may be reasonable to expect intakes of carbohydrates and
total fat that exceed recommended amounts. The average energy intake of 2139 calories, however, is not much higher than
the estimated need of 2000 calories for a sedentary adult (U.S.
Department of Health and Human Services). It must be noted,
however, that the high standard deviation indicates that some
participants had a much higher caloric intake. The lower than
expected average suggests two things. First is that there was
gross underreporting of foods during the 24-hour recalls, resulting in much lower averages of energy and nutrient intakes
than would otherwise be measured. The second possibility for
the lower than expected energy intake is that genetics plays a
larger role in this population than previously thought. There
have been several studies that investigated a possible association between obesity rates and the high frequency of genetic
polymorphisms (Duarte et al., 2003a, 2003b, 2003c). These
genes are specifically related to metabolism, and the fact that
Tongans have an unusually high prevalence of polymorphisms
may somehow make Tongans more prone to obesity.
Pizza and fast food were among the highest sources of energy,
carbohydrates, protein, and fat. Meats, especially chicken and
beef, were also quite prevalent in the Tongan American diet.
Chicken was usually dark meat – leg or thigh – instead of white
meat, and was typically fried or stewed in a cream-based sauce.
These food choices may have contributed to chicken being a
top source of fat in the diet. Beef, particularly in the form of
corned beef or steak, was frequently consumed. It is interesting to note that corned beef is also a popular imported food
item in Tonga (Evans et al., 2001) and was found to be a high
source of protein among American Samoans (Galanis, McGarvey, Quested, Sio, & Afele-Fa’amuli, 1999). This suggests that
the effects of modernization on food choices in native Tonga
may have carried over to the U.S. However, this theory cannot
completely explain the popularity of pizza and fast food among
Tongans living in the U.S. Because these and other foods such
as chicken, steak, and hot dogs are common in the “typical”
American diet, it is difficult to determine exactly the factors
that drive food choices of a particular group in the U.S. Cost,
availability, and taste preference are just a few factors that can
readily influence an individual’s diet.
A traditional Tongan food – manioke, a tapioca made from the
cassava root – was the highest source of energy for 2 of the 32
participants. Other Tongan foods reported include taro leaves,
breadfruit, coconut milk used in recipes, sweet potatoes, and
yams. Nine of the 32 participants (28%) reported one of these
items in their 24-hour recall. There was also a noticeable lack
of fresh fruits and vegetables, whole grains, and fish in the
recall data. There were 12 fresh fruits reported in all of the
recalls and 7 out of the 12 fruits were bananas. Wheat bread
appeared only twice in all of the recalls. Two participants
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
reported either fish or shrimp. Potatoes were by far the most
frequently consumed vegetable.
A study describing the dietary intake of American and Western Samoans served as a precedent for the current study on
Tongan dietary intakes in Utah. In the 1999 study, Galanis and
colleagues (1999) measured intakes of energy and nutrients
using the 24-hour recall method. Tongans are ethnically and
geographically similar to Samoans. The Polynesian island nation of Samoa is divided into the independent country of Western Samoa and the US territory of American Samoa. Although
the American Samoans in this study did not reside in the U.S.,
they have experienced similar changes in lifestyle and dietary
patterns as a result of modernization. These changes provided
an opportunity not only to examine the dietary impact of modernization on American Samoans, but also to quantify nutrient
intake in the context of health and disease risk.
This study had a much larger sample size of 946 adults, of
which 455 were American Samoans and 491 were Western
Samoans. The 24-hour recall data from the two populations
were collected and analyzed for the following: total energy,
carbohydrate, protein, fat, saturated, monounsaturated, and
polyunsaturated fats, cholesterol, fiber, sodium, potassium, and
calcium. The results showed that Western Samoans consumed
more total energy, with more of that energy as fat and saturated
fat. However, intakes of carbohydrate, protein, cholesterol, and
sodium were higher among American Samoans. This result
could be due to the increased consumption of animal products
and processed foods associated with modernizing populations.
The authors concluded that these nutrients, along with other
lifestyle factors associated with modernization such as physical inactivity, stress, smoking, and hypertension, could have a
greater impact on cardiovascular disease risk than total energy
and fat intake alone.
The nutrient profile alone of this group of Tongans does not
signify a great risk for obesity in terms of excess energy and
total fat intakes. The estimated intakes fall within dietary
guidelines (Table 2). However, since all of the participants
were either overweight or obese, this would indicate that they
are maintaining their weight status and thus continue to be
at a higher risk for obesity-related diseases. Similar to what
was concluded in the Samoan study with cardiovascular disease risk (Galanis et al., 1999), specific nutrients may not be
the primary factor in the risk of obesity-related diseases, but
rather lifestyle factors such as physical inactivity. However,
the overall dietary pattern that emerged from the data was a
diet consisting primarily of energy dense foods high in total fat
and saturated fat such as pizza, fast food, burritos, and steak.
Regardless of physical activity level, this pattern of intake
stresses the need for nutrition intervention in this population.
Indeed, community-based intervention programs that include
both nutrition education and an emphasis on physical activ©2010 The University of Utah. All Rights Reserved.
ity may be effective for this group. Educational components
of an intervention should address the various factors that may
influence food choices. For example, in addition to teaching
nutritional value, offering information on how to eat healthier
on a budget would address the socioeconomic factor that may
be limiting food choices for many Tongans.
This study is not without its limitations. This limited sample
may not representative of the overweight and obese Tongan
population in the United States. However, these findings are
novel in that they do provide preliminary evidence for an underrepresented population in the scientific literature. Additionally, over- or underestimation of intake is a potential drawback
to using the recall method. Another study limitation that is
inherent to the 24-hour recall method is that a single day of intake is unlikely to be representative of usual intake. For many
individuals, intake can vary highly from day to day and from a
weekday to a weekend day. Obtaining additional days of recall
for each participant may have provided more accurate nutrient
estimates of the group. Despite these limitations, the 24-hour
recall was an effective method for this study and our findings
offer important information for researchers and practitioners.
The aim of this study was to provide preliminary data on the
dietary intake of a sample of overweight and obese Tongans
living in the U.S. It was estimated that average intakes of
energy, and percent of calories from carbohydrates and total
fat were within dietary guidelines. The percent of calories
from saturated fat and the average amount of cholesterol were
slightly higher than the recommended limits. The types of
foods consumed by this group of Tongans were also described.
This type of information has not previously been documented
for this group. The findings from this study emphasize the need
for more research on the diets of Tongans in the U.S., which
will aid in developing and implementing culturally-tailored
nutrition-based intervention programs for the Tongan community.
Acknowledgements
The authors thank Dr. E. Wayne Askew, Julie Metos, Dr.
Kristine Jordan, and the National Tongan-American Society of
Utah for their assistance. This study was funded by the College
of Health Research and Creative Grant Award at the University
of Utah.
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Duarte, N. L., Colagiuri, S., Palu, T., Wang, X. L., & Wilcken, D. E. (2003a).
A 45-bp insertion/deletion polymorphism of uncoupling protein 2 in relation
to obesity in Tongans. Obesity Research, 11(4), 512-517.
Duarte, N. L., Colagiuri, S., Palu, T., Wang, X. L., & Wilcken, D. E. (2003b).
Obesity, Type II diabetes and Ala54Thr polymorphism of fatty acid binding protein 2 in the Tongan population Molecular Genetics and Metabolism,
79(3), 183-188.
Duarte, N. L., Colagiuri, S., Palu, T., Wang, X. L., & Wilcken, D. E. (2003c).
Obesity, Type II diabetes and the beta 2 andrenoceptor gene Gln27Glu polymorphism in the Tongan population Clinical Science, 104(3), 211-215.
Evans, M., Sinclair, R. C., Fusimalohi, C., & Liava’a, V. (2001). Globalization, diet, and health: an example from Tonga. Bulletin of the World Health
Organization, 79(9), 856-862.
Evans, M., Sinclair, R. C., Fusimalohi, C., & Liava’a, V. (2002). Diet, health
and the nutrition transition: some impacts of economic and socio-economic
factors on food consumption patterns in the Kingdom of Tonga. Pacific
Health Dialog, 9(2), 309-315.
Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among US adults, 1999-2000. Journal of the
American Medical Association, 288(14), 1723-1727.
Galanis, D. J., McGarvey, S. T., Quested, C., Sio, B., & Afele-Fa’amuli, S.
(1999). Dietary intake of modernizing Samoans: implications for risk of
cardiovascular disease. Journal of the American Dietetic Association, 99(2),
184-190.
National Center for Health Statistics. Prevalence of overweight and obesity
among adults: United States, 1999-2002. Available from: http://www.cdc.gov/
nchs/products/pubs/hestats/obese99.htm [Accessed 30 November 2006].
Native Hawaiian Research Center. A portrait of Tongans in America. Available from: http://thepaf.org/Research/Summary%20of%20Comparisons%20
USvTongan.pdf [Accessed 5 November 2006].
Stang, J., Zephier, E. M., Story, M., Himes, J. H., Yeh, J. L., Welty, T., et al.
(2005). Dietary intakes of nutrients thought to modify cardiovascular risk
from three groups of American Indians: The Strong Heart Dietary Study,
Phase II. Journal of the American Dietetic Association, 205(12), 1895-1903.
U.S. Department of Health and Human Services. A healthier you, based on
the Dietary Guidelines for Americans. Available from: http://www.health.
gov/dietaryguidelines/dga2005/healthieryou/html/chapter4.html [Accessed
20 July 2007].
Ulijaszek, S. (2005). Modernisation, migration, and nutritional health of
Pacific Island populations. Environmental Science and Technology, 12(3),
167-176.
Wright, J., Borrud, L., McDowell, M., Wang, C., Radimer, K., & Johnson,
C. (2007). Nutrition assessment in the National Health and Nutrition Examination Survey 1999-2002. Journal of the American Dietetic Association,
105(12), 822-829.
20
Dietary Patterns of Tongan-Americans
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Psychotherapeutic Medication Report
on Utah’s Foster Care Clients
Aurthors
Chris Chytraus RN, BSN, CPM
Navina Forsythe, PhD, MPA
Abstract
The purpose of this report is to provide information on the use of psychotropic medication by children in Utah’s foster care system, the Division of Child and Family Services
(DCFS). A few studies have shown that children in foster care are prescribed psychotropic medication at a higher rate than children in the general population12. However,
prior research has also demonstrated that children in foster care also have a higher rate
of psychological disorders resulting from the conditions necessitating their placement in
foster care1,2,3,4.
The objective of this study was to augment the sparse literature on psychotropic medication use by children in foster care.
The methods utilized were extraction of data from the DCFS management information
system and the Medicaid system to provide information on children in foster care, as well
as to provide a comparison group.
It was found that 31 percent of children in foster care were prescribed psychotropic medications. Older children were more likely to be prescribed psychotropic medications. Of
those prescribed psychotropic medication, 42% were prescribed more than two medications.
The findings of this study suggest that due to the higher prevalence of psychotropic medication use by children in foster care, child welfare agencies need to institute mechanisms
for careful tracking of medications prescribed to children. A system that incorporates
partnerships with health professionals is advised.
Purpose
Key Words
psychotropic medication, foster
care, psychotherapeutic medication, mental health, division of
child and family services
©2010 The University of Utah. All Rights Reserved.
According to the American Academy of Child and Adolescent Psychiatry, “being removed from their home and placed in foster care is a difficult and stressful experience for
any child. Many of these children have suffered some form of serious abuse or neglect.
About 30% of children in foster care have severe emotional, behavioral or developmental
problems. Physical health problems are also common.” Other studies have indicated that
psychological disorders, such as conduct, attention, mood, anxiety, and posttraumatic
stress disorder, occur in 50% to 96% of children in custody, with 35% in the severe
range.2,3,4 The few research studies available on medication treatment show rates of psychotropic medication use ranging from 13-50% among children in foster care5,6,7,8,9,10,11
compared with approximately 4% of youth in the general population.
This study was conducted to compare the rate of Utah’s foster children’s psychotropic
medication use with research done in other areas of the nation, to augment the literature
Psychotropic Medication in Foster Care
21
2010 Utah’s Health: An Annual Review
by providing another study on psychotropic medication use by
children in foster care systems, and to expand the research in
this area by reporting on the age of foster children being prescribed psychotropic medications, and number of medications
they are prescribed in Utah.
formation was requested from the Utah Medicaid management
information system on children aged zero years to 19 years as
a comparison. Children receiving Medicaid because of their
foster care status were flagged.
Medications were selected based on their category listing in
It is important to note that studies may have varied in method- the 2008 Physician’s Desk Reference Book. The list of medicaology and definitions of terms, which may account for varia- tions used to pull data was the same for both agencies. The list
tions in reported rates of psychological disorders and use of included the following:
psychotropic medications. Additionally, as we will discuss, there
2008 PDR Psychotherapeutic Agents
are many variables to consider
Anti-Anxiety Agents
when evaluating this data.
Cymbalta*
Effexor*
Librium
Limbitrol*
Niravam
Methods
Paxil*
Tranxene Valium
Zoloft*
Anti-Depressants
Celexa Cymbalta*
Effexor*
Emam
Lexapro
Limbitrol*
Marplan
Parnate
Paxil*
Prozac*
Symbyax*
Welbutrin Zoloft*
Anti-panic Agents
Klonopin
Niravam*
Paxil*
Prozac*
Zoloft*
Anti-Psychotic Agents
Abilify*
Clozaril
Geodon*
Invega
Moban
Risperdal
Seroquel
Thioridazine Thiothixene
Zyprexa*
Bipolar Agents
Abilify*
Depakote
Geodon*
Lamictal
Symbyax*
Zyprexa*
Obsessive Compulsive Agents
Paxil*
Prozac*
Zoloft*
Central Nervous System Stimulants
Adderall
Concerta Daytrana Desoxyn Dexedrine
Focalin Metadate Provigil Ritalin Strattera
Vyvanse
* appears in more than one category; however were only counted once
The Fostering Healthy Children
Program (FHCP) is contracted
by DCFS to provide medical care
coordination for all clients that
enter foster care. Nurses are colocated with DCFS caseworkers
in the local offices and oversee
the health, dental and mental
health/developmental needs of
these children. The R.Ns work in
collaboration with the caseworkers to provide medical information to all persons involved in the
case in understandable terms and
coordinate the care of multiple
providers. This coordination may
include staffing difficult medical
cases with the Medical Director of the Children with Special
Health Care needs (CSHCN) Bureau or other medical experts in their field of expertise. In addition, the R.N. participates in child and family team meetings
and works with both the biological parents and foster parents
to address health care concerns. If concerns are raised about
medication usage the nurse will follow-up with the medical
provider, caseworker, or an expert in the field.
The FHCP staff input information from the children’s health
visits into the DCFS management information system, SAFE.
Data is entered into the SAFE system by the nurses as they receive records from the medical providers. The SAFE database
is utilized to track the medical history, diagnoses, medications,
allergies, family history and immunizations for all children in
foster care. For this study, data was extracted from the SAFE
system on medications prescribed to foster children in custody
as of July 9, 2008.
In addition to reviewing the data from the SAFE database, in-
22
Psychotropic Medication in Foster Care
Of the 46 psychotropic medications listed, only 30 of them are
currently being prescribed for children in foster care. The data
shows that there are over 140 licensed medical providers that
are prescribing these medications.
Results
There were 2,651 children in foster care custody on July 9,
2008. Of these children, 833 were receiving one or more of the
psychotropic medications. This is 31% of the total foster care
population.
For fiscal year 2008, 166,750 recipients received Utah Medicaid that were less than or equal to 19 years of age. Of these, 3%
(5,543) had been in foster care at some point during the fiscal
year, and 1,695 of those (31%) had a psychotropic medication
prescription filled. Ninety-seven percent of the recipients
(161,207) had not been in foster care. Of those, 9,263 (6%) had
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
medications, 16% were taking three medications; 4% were taking four medications, 1% were taking five medications or more.
The rate of psychotropic medication use for children in foster The table below shows the percentage of children from the
care was consistent between the DCFS and Medicaid data at Medicaid data that were prescribed medication during 2008.
31%. Data was extracted from both systems and compared as a It is important to note that they may not have been taking all
way to check the accuracy of the data.
of the medications at the same time, they were just prescribed
them during the year. Because the Medicaid data is for an enAges of foster children taking psychotropic medications
tire year, the percentages of children being prescribed multiple
Of the 833 children in foster care being prescribed psychotro- medications is higher than that of the point in time number
pic medications, only 2% are less than five years, 23% are 6 above. Of all foster children served during the entire year 40%
to 12 years, and 75% are 13 and older. When comparing to were prescribed one medication, 30% were prescribed two
the total foster care population, children five and younger are medications, 19% were prescribed three medications, 8% were
rarely prescribed these medications, whereas almost half of prescribed four medications, 11% were prescribed five medicathe children in foster care ages 13 and above are prescribed tions or more. For those in the general Medicaid population
psychotropic medications. The age breakdown for children being prescribed psychotropic medications during 2008, 58%
in foster care on July 9, 2008 being prescribed psychotropic were prescribed one medication; 23% were prescribed two
medications or central nervous system stimulants is as follows: medications; 11% were prescribed three medications; 5% were
prescribed four medications; and
3% were prescribed five medicaPercent of Foster
tions or more. Children in the fosNumber of Foster
Children in Age
Total Number of
ter care population are more often
Children Prescribed
Age Grouping
Group Prescribed
Foster Children
prescribed multiple medications.
Psychotropic Meds
a psychotropic medication prescription filled.
Psychotropic Meds
0-2 years
423
0
0%
3-5 years
313
14
4%
6-12 years
631
195
13-15 years
557
274
16+ years
727
350
Discussion
The above data is undoubtedly
a helpful tool in monitoring the
49%
psychotropic medication use of
48%
children in custody. Due to the
number of variables that may impact medication decisions in these cases, great caution should
be used when drawing conclusions about the discrepancies in
psychotropic medication use by foster children in comparison
to the general population. This information is therefore provided to inform and to raise issues for discussion.
31%
Number of medications taken by foster children
Of those children in foster care being prescribed psychotropic
medications that were in custody July 9, 2008, SAFE data
shows 46% were taking one medication, 33% were taking two
Comparison percent of children being prescribed psychotropic medications in foster care
and general Medicaid population for the year 2008:
Other
Medicaid
Age
3-5
Foster
Medicaid
Age
6-12
Other
Medicaid
Age
6-12
Foster
Medicaid
Age
13-15
Other
Medicaid
Age
13-15
Foster
Medicaid
Age
16-19
Other
Medicaid
Age
16-19
1%
4%
6%
26%
10%
11%
22%
16%
<1%
<1%
4%
10%
8%
5%
17%
7%
<1%
<1%
3%
4%
5%
3%
10%
4%
0%
<1%
1%
2%
2%
1%
5%
2%
0%
<1%
<1%
<1%
<1%
1%
<1%
2%
<1%
0%
0%
0%
0%
<1%
<1%
<1%
<1%
<1%
<1%
0%
0%
0%
0%
0%
<1%
<1%
<1%
<1%
<1%
8
0%
0%
0%
0%
<1%
<1%
0%
0%
0%
<1%
9
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
10
0%
0%
0%
0%
0%
<1%
0%
0%
0%
0%
Number
of Meds
Foster
Medicaid
Age
0-2
Other
Medicaid
Age
0-2
1
<1%
<1%
2
0%
<1%
3
0%
0%
4
0%
0%
5
0%
6
7
Foster
Medicaid
Age
3-5
©2010 The University of Utah. All Rights Reserved.
Psychotropic Medication in Foster Care
23
2010 Utah’s Health: An Annual Review
Psychotropic medications are prescribed by licensed medical
providers for specific reasons to treat disorders that children
have been diagnosed with and where symptoms have raised
concerns. Although the rate of children in foster care prescribed psychotropic medication is higher than that of children
in the general Medicaid population, as research has shown,
foster children have a high rate of psychological concerns that
result from trauma or neglect they may have experienced1,2,3,4.
Because their rate of psychological disorders is more prevalent,
their use of medications to treat these disorders will be higher
as well.
Additionally, children in foster care are required to have mental health assessments that the general Medicaid population are
not. It is possible that mental health conditions are identified
due to these exams that would otherwise go undiagnosed and
untreated in the general Medicaid population.
A psychotropic/Central Nervous System stimulant medication
may be used for a reason other than a psychiatric condition.
The provider may have different reasons for treating a patient
with these particular medications or a combination of these
medications. Examples of non-psychiatric medical conditions
that may result in use of these medications include: narcolepsy, sleep apnea, smoking cessation, seizures and/or weight
control. Additionally, different medications may be used to
treat similar conditions due to client’s reactions to different
medications. Physicians who prescribe these medications
may try a combination of medications to address a patient’s
needs. Therefore, it cannot be concluded that children who are
prescribed psychotropic medication are utilizing it for psychiatric purposes. A future study that correlates the children’s
psychotropic medication use with psychiatric diagnoses would
provide further information regarding the reasons for psychotropic medication use.
The appropriateness of a particular prescription can be determined only after considering all the facts relevant to the treatment decision. While, this study did not do a complete chart
review of patient history and therefore cannot determine the
appropriateness of medications prescribed, it may be useful to
do this as a future study.
Increased use of psychotropic medication by children in foster care, may not necessarily be attributed to the foster care
system. As mentioned earlier children in foster care have a
high rate of psychological diagnosis. Children may have been
taking psychotropic medications prior to their entry into foster
care. The SAFE system only records medications prescribed
as the result of the initial health and mental health assessment
the child receives when entering care, consequently we were
unable to assess the number of children who came into custody
or who were receiving Medicaid benefits that were already on
psychotropic medications. Without knowing this information,
24
Psychotropic Medication in Foster Care
we are unable to conclude that all children in foster care were
given medications only after they entered custody.
There are children who are receiving more than one psychotropic medication. Studies are being conducted regarding the use
of psychotropic medications and the mixing of multiple medications. Data from two national surveys representing civilian
populations 18 years or younger showed co-prescriptions
of psychotropic medications (i.e., prescribing more than one
psychotropic medication at once to treat an ailment) increased
from 3% in 1987 to 23% in 1996 representing an eight fold
increase. The use of two rather than one medication increased
25 times in the 10 year interval.14 For the past two years, the
numbers of children on multiple medications in Utah’s foster
care system has remained constant.
The data in this study highlights the need for child welfare
systems to have the capacity to track health and medication
data related to children in foster care. Utah is in the forefront
of providing medical oversight for children in foster care. FHC
and DCFS have the capabilities to provide updated information to the medical home or primary care provider whenever
changes are made. An example of the success of this collaboration is when the Federal Drug Administration issues a caution
for any medication whether psychotropic or not, FHC notifies
the prescribing physician if a child is on the medication and
they are asked to review the case. For instance, when concerns
were raised about the use of Paxil and Effexor with children
and adolescents under the age of 18, a list of all children in care
receiving the medication was extracted and the provider was
sent a letter requesting a response back that they reviewed the
case. In most cases, the child had already been placed on a new
medication. Most states would be unable to do this for children
in their foster care system.
Utah’s child welfare system’s partnership with the Department
of Health and the FHC program is considered progressive in
ensuring foster children’s health care needs are met and that
coordination between different medical providers occurs.
Several other states have reviewed Utah’s system with plans to
duplicate it. Most recently, the United States Government Accountability Office did a site visit to evaluate Utah’s program
in response to a request to evaluate what child welfare agencies
were doing to care for the health needs of children in foster
care. Utah’s system was one of the examples they used in their
report of successful ways to address the health care needs of
these children15. The information was released in October 2009
as a follow-up to the new Fostering Healthy Success legislation passed by the federal government. DCFS will continue
to coordinate with FHC so that this system of oversight and
coordination remains in place. Additionally regular review of
the use of psychotropic medications will continue so that if
the trend changes or the rates become inconsistent with rates
found in the literature, further analysis can occur.
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Assurances
Research done using data or clients of the Department of Human Services (DHS) falls under the jurisdiction of the DHS
Institutional Review Board (DHS IRB). This project originated as a response to legislative inquiries regarding the use of
psychotropic medication by children in foster care. As such, it
did not meet the definition of research under 45 CFR 46.102(d).
It was a program evaluation done by persons internal to the
agency for non-research purposes and thus considered exempt
from DHS IRB review. One of the authors of the project is the
current chair of the DHS IRB and is strict about following the
federal laws regarding the protection of human subjects.
References
1. American Academy of Child & Adolescent Psychiatry. “AACAP Quick
Links: Facts for Families, Foster Care” No. 64, Updated May 2005.
2. Dore, M.M. (1999). Emotionally and behaviorally disturbed children in
the child welfare system: Points of preventive intervention. Children and
Youth Services Review, 21(1), 7-29.
3. Leslie, L. K., Hurlburt, M. S., Landsverk, J., Rolls, J. A., Wood, P. A., &
Kelleher, K. J. (2003). Comprehensive assessments for children entering
foster care: A national perspective. Pediatrics, 112(1), 134-142
4. Schor, E.L. (1982). The foster care system and health status of foster children. Pediatrics, 69(5), 521-528.
5. Ferguson DG, Glesener DC, Raschick M. Psychotropic drug use with European American and American Indian Children in foster care. J Child
Adolesc Psychopharmacol. 2006;16(4):474-481.
6. Zima BT, Bussing R, Crecelius GM, Kaufman A, Belin TR. Psychotropic
medication treatment patterns among school aged children in foster care. J
Child Adolesc Psychopharmacol. 1999;9(3):135-147.
7. McMillen JC, Scott LD, Zima BT, Ollie MT, Munson MR, Spitznagel E.
Use of mental health services among older yuths in foster care. Psychiatr
Ser. 2004;55(7):811-817.
8. Breland-Noble AM, Elbogen EB, Farmer EM, Dubs MS, Wagner HR,
Burns BJ. Use of psychotropic medications by youths in therapeutic foster
care and group homes. Psychiatr Serv. 2004;55(6):706-708.
9. Zito JM, Safer DJ, Sai D et al. Psychotropic medication patterns among
youth in foster care. Pediatrics 2008;121(1):e157-e163.
10. Raghavan R, Zima BT, Andersen RM, Leibowitz AA, Schuster MA,
Landsverk J. Psychotropic medication use in a national probability sample
of children in the child welfare system. J Child Adolesc Psychopharmacol.
2005;15(1):97-106.
11. Zima BT, Bussing R, Crecelius GM, Kaufman A, Belin TR, Psychotropic
medication use among children in foster care: relationship to severe psychiatric disorders. Am J Public Health.1999;89(11):1732-5.
12. Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the
use of Psychotropic Medications by Children. J Am Academy Child Adolescent Psychiatry.2002;41(5):514-21.
13. Once the PDR list of medications was obtained, the list was reviewed.
It was noted that the PDR did not list Ritalin any longer under Central
Nervous System Stimulants or Psychotherapeutic agents. This medication
was added to the list.
14. Psychiatry. “Pediatric Psychotropic Polypharmacy,” Mark R. Zonfrillo,
M.D.; Joseph V. Penn, M.D. and Henrietta L. Leonard M.D.
15. United States Government Accountability Office (2009), FOSTER CARE:
State Practices for Assessing Health Needs, Facilitating Service Delivery,
and Monitoring Children’s Care. Washington, D.C. : author.
©2010 The University of Utah. All Rights Reserved.
Psychotropic Medication in Foster Care
25
2010 Utah’s Health: An Annual Review
Development of a Fertility
Preservation Program at the
University of Utah and Current State
of Affairs
Authors:
Colleen Milroy, MD1
Kirtly Parker Jones, MD1
Janet Bloch, ANP2
Mark Gibson MD1
Ahmad O. Hammoud, MD, MPH1
Douglas T. Carrell, PhD1,3,4
C. Matthew Peterson, MD1
1. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynecology, University of Utah Health Sciences Center, Suite 2B200, 30 North 1900
East, Salt Lake City, UT, 84132, USA.
2. Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City Utah 84112, USA.
3. Andrology and IVF Laboratories, Division of Urology, Department of Surgery, University of Utah Health Sciences Center, Suite 205, 675 Arapeen Drive, Salt Lake City,
Utah 84108, USA.
Keywords
4. Department of Physiology, School of Medicine, 420 Chipeta Way, Suite 1700, University of Utah, Salt Lake City, Utah 84108, USA.
fertility preservation, cancer,
fertility, oncofertility, pregnancy
Correspondence
Kirtly Parker Jones, MD, Division
of Reproductive Endocrinology
and Infertility, Department of
Obstetrics and Gynecology,
University of Utah Health Sciences
Center
Suite 2B200, 30 North 1900 East,
Salt Lake City, UT, 84132, USA
e-mail: kirtly.jones@hsc.utah.edu,
Tel: 801-581-3834
Fax: 801-585-2231
Funding Source
Division of Reproductive
Endocrinology and Infertility
26
Abstract
To provide a resource for patients facing cancer treatment, the University of Utah’s Division of Reproductive Endocrinology and Infertility and the Utah Center for Reproductive
Medicine partnered with the Huntsman Cancer Hospital and Institute to develop and
implement a Fertility Preservation Program. This program provides educational materials and training to oncology staff, prompt dissemination of information to patients, expedited referrals, and state of the art technology to cancer patients facing loss of fertility
in the Intermountain West. This article describes the development, implementation and
resources of the Fertility Preservation Program.
Introduction
Improved cancer detection and treatment modalities have substantially increased current
survival rates for many cancers prompting much greater attention to quality of life issues.
The 2005 Breast Cancer Progress Review Group of the National Cancer Institute and
the President’s Cancer Panel have designated quality of life issues for cancer survivors
Developing a Fertility Preservation Program
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
as a top research priority ((NCI), 2005; NIH, 2003). Gonadal
toxicity and its resultant sterility/subfertility is one of the most
significant sequelae of cancer treatment (Oktay & Sonmezer,
2007). Despite gonadal failure, many cancer patients report the
desire for future offspring. In one study of cancer survivors,
76% of childless individuals reported the desire to have a child
in the future, whereas 31% of those with children reported the
desire to have future offspring (Schover, Rybicki, Martin, &
Bringelsen, 1999).
Despite this substantial patient desire for future children,
existing literature suggests that less than half of men and
women will receive information from their providers about
their reproductive potential and options after cancer treatment.
Ninety-one percent of surveyed oncologists agreed that sperm
banking should be offered to all men at risk of infertility due
to cancer treatment, however, over 48% of the same physicians
failed to mention the topic to their cancer patients (Schover,
Brey, Lichtin, Lipshultz, & Jeha, 2002). Furthermore, only
15% of women undergoing colorectal surgery for malignancy
received any counseling on their reproductive healthcare options (Strong, Peche, & Scaife, 2007).
Current American Society of Clinical Oncology guidelines
state that pretreatment education and informed consent should
address the possibility of sterility/infertility with patients
treated during their reproductive years. Furthermore, fertility
preservation options and/or referral to reproductive specialists
should be provided when desired. Clinician judgment should
be employed in the timing of this discussion, but it should occur at the earliest possible opportunity (Lee, et al., 2006).
In order to address the need for a fertility preservation resource
in our region, the University of Utah’s Division of Reproductive Endocrinology and Infertility partnered with Huntsman
Cancer Hospital and Institute to develop and implement a
Fertility Preservation Program. This program’s mission is to
provide educational materials and training to oncology staff,
promptly disseminate information to patients, families and
caregivers, expedite referrals, and offer state of the art technology to cancer patients facing the loss of fertility. This article
describes the development, implementation and resources of
the Fertility Preservation Program.
Current State of Fertility Preservation
The following summarizes the current facts about cancer and
infertility and outlines current strategies for fertility preservation in men and women.
Patient Population Profile
Annually in the US, more than 130,000 patients are diagnosed
with cancer during their reproductive years (up to age 45)
(ACS). The probability of cancer in 2008 in individuals aged
©2010 The University of Utah. All Rights Reserved.
1-39 years is 1 in 49 (2.03%) and 1 in 70 (1.42%) for men and
women, respectively (Jemal, et al., 2009). As a consequence
of rapidly improving cancer survival rates, 77% of patients
under 45 years old and 80% of children diagnosed with cancer
will survive at least 5 years (Jemal, et al., 2008; SEER). These
demographics create a large cohort in need of information and
treatment options for fertility preservation.
In Utah, the most common types of cancer diagnosed in 2006
include breast and thyroid cancer for reproductive aged women,
with prostate cancer and melanoma found in reproductive aged
men, (Tables 1 and 2). Many cancer diagnoses would benefit
from rapid referrals and effective fertility preservation techniques. The Fertility Preservation Program at the Utah Center
for Reproductive Medicine (UCRM) is designed to address
these needs.
Risk of Infertility with Cancer Treatment
The risk of infertility with cancer treatment depends on
multiple factors including age, gender, type of chemotherapy
or radiotherapy, dose and duration of treatment and other
pre-existing medical conditions. Rates of premature ovarian
failure range from greater than 90% with bone marrow transplant treatments (Mertens, Ramsay, Kouris, & Neglia, 1998)
to a very low, if any, risk with radioactive iodine treatments
for thyroid cancer (Sawka, et al., 2008). Similarly, the rates of
testicular dysfunction, resulting in oligospermia or azospermia from chemotherapeutic agents, range from greater than
90% azospermia for typical Hodgkins’ leukemia treatments
to minimal effects on sperm counts with various lymphoma
treatment protocols (Howell & Shalet, 2001, 2005). The risk
greatly depends on the type of gonadotoxic chemotherapeutic
agent utilized. Many clinical and animal studies confirm that
alkylating agents such as cyclophosphamide and busulfan have
the highest risk of gonadal failure and its related infertility in
both men and women. Other drugs associated with substantial
risks of azospermia include antimetabolites (cytarabine), vinca
alkaloids (vinblastine, vincrisitne) and cisplatin. Cisplatin and
adriamycin also pose an intermediate risk for premature ovarian failure, whereas, non-alkylating agents such as vincristine
and methotrexate pose a lower risk (Lee, et al., 2006; Sonmezer & Oktay, 2004). Because menstrual status may not be a
reliable indicator of fertility after chemotherapy, other markers of ovarian reserve such as FSH, estradiol, anti-Mullerian
hormone and ultrasound-derived antral follicle counts may
produce far superior assessments of ovarian reserve after chemotherapy (Oktay, Oktem, Reh, & Vahdat, 2006; Scheffer, et
al., 2003).
The degree of uterine damage after pelvic irradiation, potentially affecting fertility, depends on the age of the patient, the
total dose of radiation delivered, and the extension of the radiation field (Critchley, Bath, & Wallace, 2002; Revelli, Rovei,
Developing a Fertility Preservation Program
27
2010 Utah’s Health: An Annual Review
Racca, Gianetti, & Massobrio, 2007). Radiation therapy may
affect the volume of the uterus, its blood flow and endometrial
proliferation with reported clinical consequences of recurrent
pregnancy loss, premature labor, abnormal placentation, and
small for gestational age offspring (Green, 2001; Green, Hall,
& Zevon, 1989; Pridjian, Rich, & Montag, 1990; Sanders, et
al., 1996). Gestational surrogacy (another female patient carries and delivers the baby) should be considered in all patients
receiving pelvic radiation. Current information does not provide precise guidance as to the relationship between estimated
uterine radiation dose and reproductive performance.
The difficulty in counseling patients regarding their specific
risk of infertility/subfertility has been made easier with the
Risk Calculator provided on the Fertile Hope Website (www.
fertilehope.org). The Risk Calculator on this site allows a
cancer specific assessment of the risk of infertility based on
the unique treatment regimen. Complementary information
and nuanced advice may be obtained by a thorough literature
search, referral to a reproductive medicine specialist and other
online resources (Table 3).
Fertility Preservation Options for Women
The menu of options for women pursing fertility preservation
depends on the patient’s age, type of treatment, diagnosis,
partner status, time available, potential for ovarian metastasis
and costs (Table 4).
Currently, the most common and successful option for women
who would like to preserve their own germline for future child
bearing is in vitro fertilization (IVF). This process requires
hormone stimulation of the ovary to create multiple follicles
bearing eggs. The eggs are then retrieved and fertilized with
sperm from a partner or donor. Resulting embryos are then
matured in a culture system and subsequently frozen until the
woman has completed cancer treatment and is ready to attempt
pregnancy. Nationally, frozen embryo transfers yield a 20-34%
per cycle pregnancy rate (CDC, 2007) and some patients may
have sufficient numbers of frozen embryos for several cycles
of attempt.
Fertility preservation in patients with hormonally responsive
cancers requires careful consideration (Jeruss & Woodruff,
2009). Despite a lack of evidence for increased recurrence rates
in breast cancer patients who become pregnant after treatment,
continued concerns surrounding recurrence rates and tumor
growth potential with hormonal stimulations can be circumvented by newer protocols using alternative regimens (Blakely,
et al., 2004; Ives, Saunders, Bulsara, & Semmens, 2007). Successful IVF and embryo cryopreservation has been reported
in breast cancer patients utilizing lower estrogen producing
protocols employing aromatase inhibitors and the selective
estrogen receptor modulator tamoxifen (Azim, Costantini-
28
Developing a Fertility Preservation Program
Ferrando, & Oktay, 2008; Oktay, Buyuk, Libertella, Akar, &
Rosenwaks, 2005). Peak estrogen levels in aromatase protocols
for IVF range from 58 pg/ml to 1166 pg/ml, much lower than
standard hormonal stimulation protocols which can yield short
term estrogen levels of 2,000 pg/ml to 5,000 pg/ml (Azim, et
al., 2008; Oktay, et al., 2005). As of submission of this manuscript, there has been no short-term increase in recurrence or
decreased survival rates in breast cancer patients participating
in IVF for fertility preservation, however, longer follow-up is
needed to confirm these findings (Azim, et al., 2008).
Overall, IVF and embryo cryopreservation has proven to be a
clinically successful technique, however, its use is limited by
the need for a sperm source (partner or sperm donor) and the
creation of embryos. These limitations can restrict the use of
IVF for example, in single women who do not have an available
sperm donor and in women who chose not to create embryos
for cryopreservation.
For the woman who chooses not to undergo IVF (donor sperm
and the creation of embryos), oocyte cryopreservation is an
available, albeit experimental option. The technique of oocyte cryopreservation, thawing, subsequent fertilization and
transfer of a resulting embryo with a successful pregnancy
and delivery was first reported in the mid 1980’s (Chen, 2006).
Since that time over 900 live births have been documented utilizing this technique (Noyes, Porcu, & Borini, 2009). The egg
retrieval process for oocyte cryopreservation utilizes the same
methodology as in-vitro fertilization (IVF). This includes several weeks of hormonal manipulations to suppress endogenous
ovulatory processes (GnRH agonist therapy) followed by
hormone injections (exogenous gonadotropins, FSH and LH)
or aromatase inhibitors to develop multiple follicles. When
the follicles have reached appropriate dimensions ultrasound
guided needle aspiration of the ovarian follicles occurs under
sedation. Retrieved eggs are then vitrified using a rapid freeze
technique. The egg is the largest cell in the human body and is
comprised of a large percentage of water. Previous slow freezing techniques have resulted in non-viable eggs due to large
ice crystal formations. During vitrification, a high concentration of cryoprotectant is used to surround the egg and then the
egg undergoes a flash-freezing technique, resulting in a solid
glass-like frozen egg, free of ice crystals. Previous theoretical
concerns with vitrification resulting in increased rates of aneuploidy and/or developmental disorders in offspring have not
been born out in early experience with this technique (Noyes,
et al., 2009).
The success rates for oocyte cryopreservation continue to
improve. There have been over 900 reported live births from
oocyte cyropreserved gametes (Noyes, et al., 2009). The American Society of Reproductive Medicine (ASRM) issued a Practice Committee Opinion stating the overall clinical pregnancy
rate per thawed oocyte was 4% (“Ovarian tissue and oocyte
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
cryopreservation,” 2006). A recent meta-analysis calculated a
clinical pregnancy rate per cryopreserved embryo transfer of
45% (61/134 women that had an embryo transfer derived from
a cyropreserved oocyte had a positive pregnancy test), with a
live birth rate per embryo transfer of 39% (49/134 women that
had an embryo transfer derived from a cyropreserved oocyte
delivered a live birth) (Oktay, Cil, & Bang, 2006). The number
of oocytes retrieved and available for freezing (ten to fifteen for
women under thirty and decreasing with increasing maternal
age) is an important determinant of the potential for pregnancy
for women pursing this therapy. Given that most published
reports have described outcomes for women younger than 35
years, it is likely that quoted rates may be significantly lower
for older women (“Essential elements of informed consent for
elective oocyte cryopreservation: a Practice Committee opinion,” 2007).
Other experimental options include GnRH agonist therapy as
a gonadal protectant during chemotherapy, and ovarian tissue freezing as a means for banking oocytes for future use.
Controversy exists regarding the use of GnRH agonist therapy
for fertility preservation and no clear medical consensus yet
exists. GnRH agonist treatment mimics a prepubertal state,
theoretically making the ovary less sensitive to cytotoxic
agents. The exact mechanism for ovarian protection however,
is unknown (Grady, 2006). GnRH agonist proponents argue,
based on small prospective studies using retrospective control
data, that GnRH agonist therapy decreases the risk of amenorrhea in cancer patients receiving routine (not BMT) doses
of chemotherapy and subsequently increases the chance of
pregnancy after cancer treatment (Blumenfeld, 2007). Others
argue that there is no biologic plausibility for the mechanism
of GnRH agonist action as primordial follicles lack FSH receptors and cite the unknown risks of GnRH agonist therapy on
the effectiveness of cancer outcomes (Oktay, et al., 2007). Until
an appropriately designed randomized prospective study is
conducted, the efficacy of GnRH agonist therapy as a gonadal
protectant remains uncertain.
The banking of ovarian tissue could be an ideal fertility preservation technique for prepubertal children and adult patients
who do not have the time to undergo ovarian stimulation for
embryo or oocyte freezing. However, this technique remains
in its infancy with feasibility mainly exhibited in animal models (Shamonki & Oktay, 2005). There remain only a limited
number of human cases in which autologously transplanted
cyropreserved ovarian tissue produced subsequent follicular
growth and pregnancies (Oktay, Oktem, et al., 2006; Oktay &
Tilly, 2004). The Oncofertility Consortium is currently recruiting patients to participate in an IRB approved, NIH funded
program of Ovarian Tissue Banking.
Other complexities of fertility preservation, unique to women,
include cancers of the reproductive organs (ovary, uterus, and
©2010 The University of Utah. All Rights Reserved.
cervix). Tables 5, 6 and 7 summarize pregnancy rates after
fertility sparing options that may include alternate medical
and surgical therapies for cancers of the female reproductive
tract such as progestin treatments, and radical trachelectomies
for cervical cancers and progesterone treatments for selected
grades of endometrial cancer (Leitao & Chi, 2005). As recognition of the genetic contributions to the development of
gynecologic malignancies continues to evolve, recent findings also suggest a differential response to therapy based on
hormone receptor status. Women with progesterone receptor
positive endometrial cancer treated with progesterone had
a 60-72% response rate compared to a 12-19% response rate
for progesterone receptor negative endometrial cancer (Yu, et
al., 2009). Women facing gynecologic malignancies require
individual consultation and consideration with a gynecologic
oncologist and reproductive endocrinologist to determine their
best options. If fertility-sparing options are not feasible, donor
egg IVF and surrogacy remain as options.
Fertility Preservation Options for Men
The fertility preservation menu for men offers a number of
techniques depending on the patient’s age, type of treatment,
diagnosis, partner status, time available, and cost (Table 8).
The standard of care for post-pubertal men is sperm banking.
This procedure includes semen collection, analysis and frozen
storage of sperm for indefinite amounts periods and can be
performed from ejaculates banked every 24 to 48 hours in an
outpatient setting (Table 9) (Bunge, Keettel, & Sherman, 1954).
Patients may be able to bank several samples between the
cancer diagnosis and treatment initiation without significant
delays. Sperm banked during chemotherapy or radiotherapy
is suboptimal as it may already be damaged and success with
such samples is uncertain.
Rarely, men presenting for sperm preservation may exhibit
azsoospermia. Testicular sperm extraction (TESE) can be
performed in some azoospermic men and includes an outpatient surgical procedure where testicular tissue is removed,
fragmented and sperm are extracted and stored. Such sperm
are not suitable for insemination, and intracytoplasmic sperm
injection during IVF is required. This procedure can be done
before or after cancer treatment. Post chemotherapy TESE is
not always successful in azoospermic men, however, in those
who do retrieve sperm a modest success rate (22% live birth
rate from TESE retrieved sperm after chemotherapy) has been
achieved. (Chan, Palermo, Veeck, Rosenwaks, & Schlegel,
2001).
Lastly, testicular tissue freezing is an experimental option
for pre-pubertal boys wherein testicular tissue is surgically
removed and frozen. This technique is only offered at certain
centers around the United States with only one reported resultant pregnancy (Gianaroli, Magli, Munne, Fortini, & FerDeveloping a Fertility Preservation Program
29
2010 Utah’s Health: An Annual Review
raretti, 1999).
Barriers to Treatment
Current barriers for cancer patients desiring fertility preservation include cost, timely access to care, and the stress of facing
a new cancer diagnosis. While many insurance policies cover
initial gynecologic consultations, most do not cover fertility
preservation treatments. The University of Utah’s Division of
Reproductive Medicine through the Oncofertility Consortium
now provides cancer patients assisted reproductive technology care at reduced cost that is jointly funded by industry,
the Lance Armstrong Foundation and the physicians at the
University of Utah’s Utah Center for Reproductive Medicine.
Unfortunately, until insurance begins to cover these treatments
and procedures, much of the financial burden continues to lie
with the patient and extended family.
The second barrier to fertility preservation is the need for expedited referrals and timely care. It is important for male and
female cancer patients to be referred as soon as possible in the
process. It is difficult, if not impossible, to begin fertility preservation treatments after the onset of chemotherapy or radiotherapy. Most treatment plans take two to six weeks for women
and only days for men. Fertility preservation treatments should
not delay the initiation of cancer therapy and in most situations
can be completed between the diagnosis phase and treatment
phase of most cancer programs. The sooner that patients can be
referred to reproductive medicine specialists, the broader their
range of fertility preservation options.
The third barrier is the immense stress facing newly diagnosed
cancer patients who have concerns about their condition, treatment and prognosis. Not all patients will be ready or capable to
engage in fertility preservation discussions, especially early in
the post diagnosis period. Oncologists need to weigh the best
time to address fertility preservation and provide expedited
reproductive medicine referrals to interested candidates.
Development of a Fertility Preservation Program
Education of Personnel
To initiate the Fertility Preservation Program, two physicians and one oncology nurse practitioner teamed to create
the fertility preservation education program with the help of
the non-profit organization Fertile Hope. Educational seminars were conducted from 2007-2009 to adult and pediatric
oncology staff physicians, trainees, and support staff (nurse
practitioners, nurses, social workers and other oncology team
members), obstetrics and gynecology staff, and community
physicians, including urologists and surgeons. Attendees came
from both the University of Utah and other community institutions and organizations. The one-hour seminars covered the
topics of male and female fertility risks, fertility preservation
30
Developing a Fertility Preservation Program
options, pregnancy after cancer, and barriers to accessing fertility preservation information and treatment. As new information appeared in this rapidly evolving field, presentations were
modified to incorporate these changes.
Secondly, reproductive endocrinology and infertility clinicians
and andrology/embryology laboratory teams held multiple sessions of group literature review and attended several national
meetings to familiarize themselves with the latest fertility
preservation techniques and research.
Over a two-year period, the global education efforts have allowed the clinician and laboratory staff to knowledgeably
counsel cancer patients on fertility risks and preservation techniques. This education initiative is ongoing and it is anticipated
that the desire for outreach educational seminars will continue
to grow as the discussion of fertility preservation options become the standard of care.
Dissemination of Information to Cancer Patients
To establish the program’s availability in the community in
a similar fashion to other established fertility preservation
programs around the United States, systems were designed to
distribute fertility preservation information, by pamphlet, to
applicable cancer patients. Educational materials created by
Fertile Hope and by the Fertility Preservation Program were
displayed in lobbies, hallways and the patient library of the
Huntsman Cancer Hospital and Institute.
Furthermore, a hospital wide program was instituted that enabled all new cancer patients to receive fertility preservation
information in their new patient packets prior to the first visit.
Fertile Hope and the Fertility Preservation Program provided
pamphlets and educational materials for this packet.
Finally, web-based links for patient education were created.
Through the Huntsman Hospital Patient Learning Center website, a link for the Fertility Preservation Program was designed.
This link includes information about current techniques offered at our center, as well as outside resources for additional
patient information.
Newly diagnosed and returning cancer patients now have
multiple avenues and formats to obtain fertility preservation
information. As a quality measure, an upcoming goal will be
to ensure that during the informed consent process all oncologists systematically address the possibility of infertility with
patients and refer interested patients to appropriate reproductive specialists.
Referral Lines to Reproductive Specialists
A dedicated nurse practitioner, located in and well known
within the Huntsman Cancer Hospital and Institute system,
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
was trained to function as a fertility preservation triage and
referral source. This practitioner provides immediate patient
contact, screens the patients for appropriate referrals and acts
as an information source for patients and clinicians. Once a
referral has been made to the reproductive specialist by either
the nurse practitioner, an outside clinician or by a patient themselves, the REI physician contacts the patient by telephone
within 24-48 hours for a preliminary telephone interview and
sees interested patients within 72 hours of the initial referral.
This ensures rapid patient access to information and options.
All decisions about patient care are made in coordination with
the REI physician team and the patients’ primary oncologist
or surgeon.
State of the Art Technology
To promote fertility preservation, several new programs have
been instituted over the past two years at the University of Utah
Division of Reproductive Endocrinology and Infertility and
the Utah Center for Reproductive Medicine. These experimental technologies include oocyte (egg) freezing (vitrification),
ovarian tissue freezing, and GnRH agonist treatment. These
techniques complement the already existing standard list of
options offered at the Utah Center for Reproductive Medicine
(UCRM) including IVF with embryo freezing, sperm banking, testicular biopsy and cryopreservation, and donor egg and
donor embryo IVF programs.
Additionally, the UCRM has partnered with twenty other leading academic centers in the U.S in the NIH-funded Oncofertility Consortium. Through participation in this consortium,
the UCRM will continue to provide state-of-the-art fertility
preservation research and techniques to cancer patients facing
the loss of fertility. The UCRM also provides cancer patients
assisted reproductive technology care at a reduced cost that is
jointly funded by industry, the Lance Armstrong Foundation
and UCRM physicians.
Through IRB approved protocols, patients requesting information and pursing fertility preservation treatments are tracked.
Data including patient referral sources, patient demographics
and treatment outcomes are collected for each year. : 67 patients requested and received Fertility Preservation consults by
the Utah Center for Reproductive Medicine in 2009 (52 males,
16 females) in comparison to 58 patients in 2008 (54 males, 4
females). In 2009, the average age was 29.5 years old (15-54)
for males and 28.6 years old (19-40) for females. All 52 men
participated in sperm banking, 1-6 (mean 1.8) times prior to
chemotherapy. Three patients had azoospermia. 44% of male
patients banking sperm had results indicating significant
sperm quality deficits that would require IVF with ICSI in the
future. The most common male cancers were: Testicular (22),
Leukemia/Lymphoma (9), Gastrointestinal (5) and Prostate (5).
Of 16 women accessing the FP program, 11 were childless. Six
©2010 The University of Utah. All Rights Reserved.
of the 16 women initiated a form of fertility preservation: 2 Oocyte Freezing, 4 GnRH Agonist Therapy. Of the 10/16 women
that failed to begin a Fertility Preservation program, 6 cited
prohibitive costs, 3 cited time constraints of their cancer treatment and one was ineligible due to ovarian metastases. The
most common cancer diagnoses in women seeking consultation were breast (4), cervical (4), and leukemia/lymphoma (3).
Conclusion
Through the collaborative efforts of the University of Utah’s
Division of Reproductive Endocrinology and Infertility, the
Utah Center for Reproductive Medicine and the Huntsman
Cancer Institute and Hospital, the Fertility Preservation Program provides cancer patients with fertility aspirations a number of viable options in the rapidly evolving field of fertility
preservation.
Clinicians can continue helping to address fertility preservation concerns in their cancer patients by implementing the
American Society of Clinical Oncology’s Fertility Preservation Guidelines (Lee, et al., 2006). This includes informing
patients of planned gonadotoxic treatments, distributing
educational resources, referring appropriate patients and continuing to build multidisciplinary relationships with infertility
colleagues. Patients can be referred to the University of Utah’s
Division of Reproductive Endocrinology and Infertility, the
Utah Center for Reproductive Medicine or Fertile Hope at any
time for supplemental education and treatment menus (http://
healthcare.utah.edu/ucrm).
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 1. Utah Incident Cancer Cases, 2006, Male, Ages 15-54 years old
Prostate
Melanoma of the Skin
Colon/Rectum
Testicular
Non-Hodgkin …
Thyroid
Kidney and Renal Pelvis
Brain
Oral Cavity and Pharynx
Lung/Bronchus
Incident Cancer Cases
0
100
200
IBIS-PH Data Query, Utah Cancer Registry 2006
Table 2. Utah Incident Cancer Cases, 2006, Female, Ages 15-54 years old
Breast
Thyroid
Melanoma of the Skin
Uterus
Colon/Rectum
Cervix
Ovary
Non-Hodgkin Lymphoma
Brain
Lung/Bronchus
Incident Cancer Cases
0
200
400
600
IBIS-PH Data Query, Utah Cancer Registry 2006
©2010 The University of Utah. All Rights Reserved.
Developing a Fertility Preservation Program
33
2010 Utah’s Health: An Annual Review
Table 3. Online Resources for Clinicians and Patients
O RGANIZATION
O NLINE RESOURCE
University of Utah Division of Reproductive Medicine
www.utahfertiltycenter.com
Fertile Hope
www.fertilehope.org
Oncofertility Consortium
www.myoncofertility.org
Huntsman Cancer Hospital Wellness Center Fertility Preservation
Link
www.huntsmancancer.org/group/programservices~/well
nessCenter/fertility.jsp
Livestrong Lance Armstrong Foundation
www.livestrong.org
American Society of Reproductive Medicine
www.asrm.org
Table 4. Fertility Preservation Options: Women
Technique
Description
Status of Technique
Approximate Costs in the
US*
Embryo Freezing
Harvesting of eggs, fertilization of eggs and
freezing of embryos (IVF)
Standard of Care
$10,000-12,000 (not
discounted through fertile
hope)
Egg Freezing
Harvesting and freezing of unfertilized eggs
Experimental
$10,000-12,000 (not
discounted through fertile
hope)
Ovarian Tissue
Freezing
Freezing of ovarian tissue and reimplantation after
cancer treatment
Experimental
$6,000-12,000 for
procedure
Ovarian
Suppression
Gonadotropin Releasing Hormone Agonist
(GnRH-a) used to suppress ovaries
Experimental
$500/month
Donor
Egg/Embryo
Donated eggs or embryos
Standard of Care
$5,000-15,000 (in addition
to IVF costs)
Standard of Care
$2,500-35,000
Adoption
* Approximate costs for procedures according to fertilehope.com
34
Developing a Fertility Preservation Program
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 5. Pregnancy Rates After Conservative Treatment of Early Stage
Endometiral Cancer
Study
Number Attempting to
Conceive
Pregnancy Rate
Kim (1997)
7
0
Kim (1997)
14
2 (14%)
Randall (1997)
12
3 (25%)
Kaku (2001)
12
2 (16%)
Wang (2002)
9
4 (44%)
Gotlieb (2003)
13
3 (23%)
Nivrwa (2005)
10
7 (70%)
Mazzon (2009)
6
4 (66%)
Signoreli (2009)
21
9 (43%)
Table 6. Pregnancy Rates After Conservative Treatment of Early Stage
Epithelial Ovarian Cancer
Number Attempting to
Conceive
Pregnancy Rate
Columbo (1994)
25
25 (100%)
Zanetta (1997)
36
2 (14%)
Duska (1999)
6
2 (33%)
Morice (2001)
18
4 (22%)
Schilder (2002)
24
17 (17%)
Morice (200)
23
9 (39%)
Anchezar (2009)
7
6 (86%)
Study
Table 7. Pregnancy Rates After Trachelectomy for Early Stage Cervical
Cancer
Study
Number Attempting to
Conceive
Pregnancy Rate
Shepherd (2001)
13
8 (62%)
Mathevet (2003)
42
33 (79%)
Burnett (2003)
4
3 (75%)
Steed (2003)
39
18 (46%)
Schlaerth (2003)
4
4 (100%)
Shepherd (2006)
63
26 (41%)
Nishio (2009)
29
4 (14%)
©2010 The University of Utah. All Rights Reserved.
Developing a Fertility Preservation Program
35
2010 Utah’s Health: An Annual Review
Table 8. Fertility Preservation Options: Men
Technique
Description
Status of Technique
Approximate Costs in
the US*
Sperm Banking
Sperm are donated, analyzed,
frozen and stored
Standard of Care
Average Storage fees of
$200-500/year
Testicular Sperm
Extraction
Testicular tissue is removed and
examined for sperm
Standard of Care
$4,000-16,000 (In addition
to IVF fees)
Testicular Tissue
Freezing
Testicular tissue is removed,
frozen and stored
Experimental
$500-2500 for procedure,
$300-1000 for freezing
Donor Sperm
Donor sperm procured through
sperm bank
Standard of Care
$200-500 per vial (Plus
insemination costs)
Standard of Care
$2,500-35,000
Adoption
* Approximate costs for procedures according to fertilehope.com
Table 9. Myths About Sperm Banking
36
Myth
It will delay treatment
Truth
Sperm can be banked every 24-48 hours
Myth
Sperm count and quality are too low
Truth
As few as 1 sperm may be enough
Myth
Patient can’t ejaculate, can’t bank
Truth
Electroejaculation is available
Myth
Patient is azoospermic
Truth
Testicular sperm extraction may be an option
Developing a Fertility Preservation Program
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Correspondence
Karen Schliep, MSPH (Corresponding Author)
University of Utah
Department of Family and Preventive Medicine
Division of Public Health
375 Chipeta Way, Suite A
Salt Lake City, Utah 84108
email: karen.schliep@utah.edu
Phone: 801-587-3316
Ms. Schliep is a doctoral student at
the University of Utah and served
as the research and manuscript
coordinator for the work presented.
Marilyn S. Nanney, PhD, MPH, RD
University of Minnesota
Department of Family Medicine and
Community Health
Program in Health Disparities
Research
717 Delaware Street S.E.
Suite 166
Minneapolis, MN 55414
email: msnanney@umn.edu
Phone: (612) 626-6794
Dr. Nanney is an Assistant Professor at University of Minnesota
formally with University of Utah at
the time of data collection.
Keely Cofrin, PhD
Office of Health Care Statistics
Utah Department of Health
P.O. Box 144004
Salt Lake City, Utah 84114-4004
email: kcofrin@utah.gov
Phone: (801) 538-6551
Fax: (801) 538-9916
Dr. Cofrin is a statistician at the
Utah Department of Health and
provided the data analysis.
Derek Anderson
email: derek.anderson@intermountainmail.org
Phone: 801-440-4833
Mr. Anderson was a research
assistant at University of Utah at the
time of data collection and participated in the data collection.
©2010 The University of Utah. All Rights Reserved.
Does Utah’s Largest School District
Meet the Alliance for a Healthier
Generation’s Food and Beverage
Guidelines?
Authors:
Karen Schliep, MSPH
Marilyn S. Nanney, PhD, MPH, RD
Keely Cofrin, PhD
Derek Anderson
Abstract
Purpose: Many school nutrition and food industry professionals are calling for uniform and mandatory nutrition guidelines for competitive foods sold at school. Industry
professionals, followed by school nutrition and national organizations have put forth
recommendations. This study informs the current legislative discussion by describing
the application of the Alliance for a Healthier Generation’s (Alliance) guidelines in one
school district.
Methods: Data on the availability and nutritional content of items offered via a la carte
and vending machines were collected from middle and high schools (n=29) of the largest
district in Utah and compared to the Alliance’s nutritional standards.
Results: Standards for snack foods, calories, percent calories from fat and saturated fat
were the most difficult to meet across categories while serving size and percent sugar
by weight were the easiest to meet. Six percent of middle school and 2% of high school
snack foods met all the guidelines and 27% of middle school and 21% of high school
beverages met all the guidelines. Vending snacks and beverages met fewer criteria than
a la carte.
Application to Child Nutrition Professionals: This evaluation approach identifies
potential implementation challenges by food and beverage patterns, distribution venues
and secondary schools for one school district. Future discussions should include educating legislators on the pros and cons of adopting various criteria during this decisive
reauthorization period.
Introduction
There is a national call for uniform and mandatory school nutritional standards for
food and beverages sold outside of the federal school meal program by school nutrition
(School Nutrition Association, 2008; Institute of Medicine, 2008; National Alliance for
Competitive Foods and Beverages in Schools
37
2010 Utah’s Health: An Annual Review
Nutrition and Activity, 2008) and food industry professionals
(The National Coalition for Responsible Nutrition Information, 2008). The current lack of nationwide standards is of
particular concern because studies have shown that the sale of
competitive foods is widespread (M. K. Fox, Gordon, Nogales,
& Wilson, 2009), negatively impact student dietary behaviors
(Cullen, 2000) and contributes to youth obesity (Kubik, Lytle,
& Story, 2005). Competitive foods are defined by the U.S. Department of Agriculture and pertain to schools that participate
in the federal school meal programs (i.e. the National School
Lunch Program and School Breakfast Program). Any food
that is sold to students during the school day that is not part of
the federal meals programs is considered a competitive food.
Vending machines, school stores and a la carte cafeteria items
are where students access competitive foods (Governmental
Accountability Office, 2005).
A nationally representative survey conducted by the Centers
for Disease Control and Prevention in 2006 found that 33% of
elementary schools, 71% of middle schools and 89% of high
schools had a vending machine or a school store, canteen, or
snack bar where students could purchase food or beverages
(O’Toole, Anderson, Miller, & Guthrie, 2007). The most common beverages sold were sports drinks, soda pop, and fruit
drinks (not 100% juice), and the most common foods sold
were high-fat salty snacks. Another national survey found that
students who obtained competitive foods at school consumed
more than 150 calories from foods that were energy dense and
low in nutrients (Gordon & Fox, 2007). This is problematic because several studies and reports have presented evidence linking increased snacking of high-density foods and decreased
consumption of fruits and vegetables with growing risks of
obesity for youth (Jahns, Siega-Riz, & Popkin, 2001; Kubik,
et al., 2005; Moreno & Rodriguez, 2007; Nicklas, Baranowski,
Cullen, & Berenson, 2001; Rodriguez & Moreno, 2006; Sturm,
2005). School food practices that promote frequent snacking of
foods and beverages high in calories and low in nutrients are
adversely associated with student body mass index (Kubik, et
al., 2005). Additionally, greater consumption of sugar sweetened beverages is associated with weight gain and obesity
(Ludwig, Peterson, & Gortmaker, 2001; Malik, Schulze, & Hu,
2006). Even though schools provide healthier options via the
school meal programs, research has shown that given a choice,
students often choose the high-fat, high-sugar items (Cullen,
2000; IOM, 2005). Barriers to changing the competitive food
environment by schools include a lack of national consensus
on nutritional standards for competitive foods (Governmental
Accountability Office, 2005).
First to respond to these disconcerting reports was the Alliance
for a Healthier Generation (Alliance), a partnership between
the William J. Clinton Foundation and the American Heart
Association with the goal to stop the nationwide increase
38
Competitive Foods and Beverages in Schools
in childhood obesity by 2010 and to empower kids to make
healthy lifestyle choices (Alliance for a Healthier Generation,
About the Alliance, 2006). Beginning in 2006, the Alliance
convinced leading food and beverage manufacturer’s to establish a coalition that produced voluntary nutrition standards for
competitive foods and beverages sold at school (Alliance for
a Healthier Generation, Alliance School Beverage Guidelines;
School Snack Food Guidelines, 2009).
While descriptive studies that examine the competitive food
environment of schools have been done (French SA, 2003;
GAO, 2005; Harnack, et al., 2000; Kann, Grunbaum, McKenna, Wechsler, & Galuska, 2005), they have not been evaluated within the context of nationally proposed guidelines. The
goals of this study were to apply a set of nationally proposed
guidelines in an existing school setting and identify potentially
challenging implementation criteria. The Alliance for Healthier Generation guidelines for competitive foods was selected
because they were the only available nationally proposed standards at initiation of the study.
Methods
A descriptive study of the competitive food environment of the
largest Utah school district, Jordan School District, was conducted in the winter of 2006. After obtaining school district
approval, data were gathered through a food and beverage audit. The audit was conducted within the middle schools (n=17),
high schools (n=10), and technical centers (enrolling high
school juniors and seniors; n=2) of the district. This district
provided a food environment to 35,398 students in the 20052006 academic year. Schools were predominantly suburban in
location with enrollments ranging from approximately 500 to
2800 students. By district grade, on average, 11% of the middle
and high school students were non-white with Hispanics making up 7% of the non-white population. Twenty-one percent
of the middle and high school students were eligible for free
or reduced-price lunch (state average = 32%, national average=59%). All 29 schools were participating in the USDA’s
National School Lunch Program during data collection and
had their meals serviced by the district.
Data Collection Procedures:
Over a four-week period, 13 trained dietetics masters students
conducted an assessment of the competitive food environment
in middle and high schools within the school district. Data collection of the food environment occurred in the lunch rooms of
the schools (a la carte snack lines and vending machines) and at
all other vending machines located both inside the school and
outside on the school grounds, including teacher lounges. Interviewers recorded every product displayed in all the vending
machines and at the a la carte lines documenting product brand
name, flavor/type, and product size (ounces for beverages and
grams for foods). Data collected were entered into a master
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
database.
Data Management and Analysis
A nutrient content analysis was performed on each of the
food and beverage items reported and compared to the Alliance guidelines for compliance. Nutritional information for all
unique food and beverage items (n = 506) was obtained from
the products’ manufacturers, the Food and Nutrient Database
for Dietary Studies 1.0 (FNDDS) (United States Department
of Agriculture, 2004), NutritionData (ND) and consultations
with school food service managers for information on a la
carte items. Using the Alliance’s nutritional criteria for foods,
percent fat, percent saturated fat, percent sugar by weight,
trans fat (grams), sodium (milligrams), calories and size were
calculated per item. Additionally, based on the Alliance’s
“minimum number of required nutrients” fiber (grams), protein (grams), Vitamin A (µg), Vitamin C (mg), calcium and
iron were calculated per item. Size (ounces) and calories per
beverage item were calculated in accordance with Alliance
guidelines. The unique food and beverage items were then
grouped into 14 food categories and 4 beverage categories following the Alliance guidelines. Alliance category guidelines
are listed in Tables 1 (for foods) and 2 (for beverages).
Using SPSS (version 14.0; Chicago, IL), means for the Alliance
food and beverage nutritional criteria were generated. Mean
percentage of items meeting all Alliance criteria within each
of the 14 food and 4 beverage criteria were also generated. Ttests were used to compare differences in the competitive food
and beverage environment between middle and high schools
and between a la carte and vending machines. We compared
whether there was a statistical difference between the overall percentage of foods and beverages that met the Alliance
criteria between middle and high schools and additionally
significant differences in the mean calories, fat, saturated fat,
sugar by weight, trans fat, sodium and size between middle and
high schools.
Results
Alliance Guidelines Application
A total of 4444 food items (55.1%) and 3623 beverage items
(44.9%) made up the competitive offerings in all 29 schools.
The number of vending machines at a school ranged from 7
to 31, with a median of 13. For food items, the mean number
of kilocalories was 298 (SE ± 176) and mean serving size was
74.5 (SE ± 50.1) grams. For beverage items, the mean number
of kilocalories was 188 (SE ± 121) and mean serving size was
19.0 (SE ± 3.4) ounces. The majority (88.7%) of the selections
were offered via vending machines (7,159 versus 908 in a la
carte).
Tables 1 and 2 present the number and type of food and beverage items, respectively, found in both the vending machines
©2010 The University of Utah. All Rights Reserved.
and a la carte lines of all study schools. The vast majority
of food items fell in the baked goods, bars, candy, chips and
crackers category (88.5%) while sodas, non-100% juice and
sports drinks made up the largest proportion of beverage items
(78.0%).
Table 1 reports the mean values of applicable macronutrients
along with the Alliance criteria for the 9 observed food categories. There were no items in the dried fruit, fruit in syrup,
100% frozen fruit bar, egg or soup categories in the audited
district. All of the items in the fresh fruit/vegetable category
and fruit-in-own-juice category met the Alliance guidelines.
None of the vegetables with sauce, fried vegetables, cheese
and nuts/seeds met the Alliance criteria. In the yogurt, yogurt
smoothie and cottage cheese category, 45.5% met the Alliance
guidelines while in the frozen yogurt/ice cream category, 7.8%
met the Alliance guidelines. In the baked goods, bars, candy,
chips and crackers category, only 1.2% met the Alliance guidelines. Based upon Alliance nutrient standards for snack foods,
calories, percent calories from fat and saturated fat were the
most difficult to meet across categories, and serving size and
percent sugar by weight were the easiest to meet.
Table 2 reports the mean serving size and number of calories
along with the Alliance criteria for the four different beverage
categories. All bottled water met Alliance criteria. No 100%
fruit or vegetable juice met Alliance criteria since all products
were greater than 12 ounces and the Alliance stipulates that
the portion size should be no greater than 10 ounces for middle
school and no greater than 12 ounces for high school. According to the Alliance guidelines, no sodas, non-100% juice or
sports drinks are allowed in middle school. Thus none of the
1344 middle school beverage items that fell into this category
met the Alliance criteria. For the district’s high schools, 12.1%
of the sodas, non-100% juice and sports drinks were “low- or
no-calorie” (up to ten calories per eight ounces). Although the
district did have sodas, non-100% juice and sports drinks that
fell into the Alliance’s “other drinks with no more than 66
calories per eight ounces” category, none of these 238 items
(16.0%) met the Alliance size limit of twelve ounces. For milks/
flavored milks, 41.7% met the Alliance criteria in the middle
schools while only 8.2% met the criteria in the high schools.
Finally, Alliance standards specify that high schools need to
have 50% of their non-milk beverage offerings to be water or
“low- or no-calorie drinks.” Two of the twelve high schools
met this standard; overall, the average high school water or
“low- or no-calorie drink” offerings was 35%.
Middle School versus High School Alliance Guidelines
Application
Table 3 compares differences in compliance with the guidelines for middle schools and high schools. About 6% of middle
school and 2% of high school foods (P < 0.001) met the Alliance guidelines while 26.6% of middle school and 20.9% of
Competitive Foods and Beverages in Schools
39
2010 Utah’s Health: An Annual Review
high school beverages (P < 0.001) met the Alliance guidelines
(using the high school beverage criteria). Regarding nutrient
differences among foods, middle schools have significantly
greater number of calories (307.8 kcal versus 288.5 kcal; P
< 0.001) and serving sizes (78.2 g versus 70.3 g; P < 0.001)
compared to high schools. Among beverages, high schools
have significantly greater number of calories (198.6 kcal versus
177.4 kcal; P < 0.001) compared to middle schools.
A la Carte versus Vending Machine Alliance Guidelines
Application
When comparing vending machines and à la carte lines, 1.0%
of vending and 17.9% of à la carte foods (P < 0.001) met the
Alliance guidelines, while 22.3% of vending and 55.4% of à la
carte beverages (P < .001) met the Alliance guidelines (table
4). Other findings include à la carte food items having greater
percent calories from fat, percent calories from saturated fat,
sodium, calories, and size (P < 0.001) while also having less
percent sugar by weight and trans fat than vending items (Table
4).
Limitations
Evaluating school food environments is challenging and such
a task has limitations to recognize. First, this cross-sectional
study is limited to evaluating the food and beverage offerings
at one point in time. Second, it was not the intention of the
study district to implement the Alliance guidelines. Although,
shortly after this evaluation, the Jordan School District enacted
a wellness policy that included “nutritional value standards
regarding competitive foods” (Jordan School District, 2006).
The extent to which the nutrition standards adopted reflect the
Alliance guidelines is unknown. Third, the evaluation is limited to one school district although we chose the largest in the
state. The district has been characterized by the State Office of
Education as a leader and role model for other districts. Fourth,
the authors selected the Alliance guidelines because they were
the first nationally proposed and available. Since the conduct of
this study, the Institutes of Medicine (IOM, 2008) and School
Nutrition Association (SNA, 2008) have proposed their own
guidelines. Further evaluation using the IOM or SNA criteria
may yield different results. Fifth, adhering to the Alliance
categories limited our ability to discern distribution of certain
foods. For example, 88.5% of the District’s foods fell into the
“baked goods, bars, candy, chips and crackers” category, of
which only 1.2% met Alliance guidelines. Breaking this large
category up into smaller categories would help clarify which,
and for what reason (e.g. saturated fat), foods in this category
are not meeting the Alliance guidelines. Finally, this research
does not address the barriers schools face to providing healthy
options in a la carte and vending venues nor does this study
evaluate the actual food choices students made.
40
Competitive Foods and Beverages in Schools
Conclusion
This study contributes to the current discussion of uniform and
mandatory national nutrition standards for competitive foods
sold in school in two distinct ways. First, it is the first study to
apply a set of nationally proposed guidelines in a school setting
and, second, to identify potentially challenging criteria to meet
across food and beverage nutrients and patterns, distribution
venues (i.e., a la carte, vending) and secondary schools (i.e.,
middle, high schools) if those guidelines were to be adopted.
Based upon the Alliance guidelines criteria assessment, there
were several potentially challenging food categories which
contribute to a difficulty in meeting standards for snack foods,
calories, percent calories from fat and saturated fat. However,
this assessment was conducted before the full adoption and
implementation of a local wellness policy, which included
language addressing nutrition standards for competitive foods.
Findings from this study illustrate the importance of evaluations across food and beverage distribution venues and between middle and high schools.
Without national consensus and policy adoption, states have
been left on their own to respond to the demands to regulate
competitive foods. As a result, 25 states have set their own
nutritional standards for competitive foods available in schools
(F as in Fat Report, 2008). For example, 12 states limit portion
sizes for beverages, 14 limit portion sizes for snacks, 16 limit
the saturated-fat content of school snacks, 11 address trans
fat, 5 set limits on sodium and 26 limit added sugars in school
snack foods. A 2007 report from the Center for Science in the
Public Interest describes these state level efforts as a nation of
“patchwork policies” (Center for Science in the Public Interest,
2007). So many different state standards present unique challenges for the food industry to package and formulate product.
A uniform national policy to establish nutrition standards
could address these concerns.
Application to Child Nutrition Professionals
These research findings are important and timely for child
nutrition professionals in several ways: establishing the feasibility of evaluating the school competitive food environment
within the context of guidelines; adding to the science base,
albeit with limitations, regarding the potentially challenging
criteria areas, and; facilitating discussion around national standards legislation.
Industry, school nutrition and national organizations have
put forth recommendations for competitive foods and beverages sold in schools. Child nutrition professionals are expertly
positioned to be a part of the discussion and endorsement of
all, parts or none of the proposed guidelines. A science-based
discussion, grounded in reality, about the pros and cons between the multiple sets of proposed national standards is an
important and timely child nutrition professional role. Now
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
is the time to build upon the foundation laid by the Alliance
and subsequent steps taken by IOM and SNA and continue to
improve the school food environments of children. It is critical
that legislators hear the voices of child nutrition professionals
working in the field, both school and industry, and conducting
research to make informed policy decisions.
Acknowledgements
This work was funded by the National Cancer Institute (K07
CA114314). The authors thank the data collectors from the
Department of Nutrition at University of Utah. Thanks go to
Marilyn Clayton, Director of Child Nutrition Services at the
Jordan School District for her active support of this project.
Thank you to Dr. Jayna Dave for providing thoughtful feedback to a manuscript draft.
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2009 from http://www.fns.usda.gov/ora/MENU/published/CNP/FILES/
SNDAIII-SummaryofFindings.pdf
Fox, M. K., Gordon, A., Nogales, R., & Wilson, A. (2009). Availability and
consumption of competitive foods in US public schools. Journal of the American Dietetic Association, 109(2 Suppl), S57-66.
United States Department of Agriculture (USDA). (2004). USDA Food and
Nutrient Database for Dietary Studies, 1.0. Beltsville, MD: Agricultural
Research Service, Food Surveys Research Group.
French SA, S. M., Fulkerson JA & Gerlach AF (2003). Food environment in
secondary schools: a la carte, vending machines and food policies and practices. American Journal of Public Health, 93(7), 1161-1167
Governmental Accountability Office (GAO) (2005). School meals programs:
competitive foods are widely available and generate substantial revenues
for schools. Retrieved April 22, 2009 from http://www.gao.gov/new.items/
d05563.pdf
Harnack, L., Snyder, P., Story, M., Holliday, R., Lytle, L., & Neumark-Sztainer, D. (2000). Availability of a la carte food items in junior and senior high
schools: a needs assessment. Journal of the American Dietetic Association,
100(6), 701-703.
Institute of Medicine. (2008). Nutrition Standards and Meal Requirements for
©2010 The University of Utah. All Rights Reserved.
Competitive Foods and Beverages in Schools
41
2010 Utah’s Health: An Annual Review
Does Utah’s largest school district meet the Alliance for a Healthier Generation’s food and beverage guidelines?
Table 1: District’s competitive foods compared to Alliance criteria (Alliance nutritional criteria follows the District’s mean nutritional value)
Items
(n)
% of
Total
Mean
Fat
(%)
Alliance
Fat (%)
Limit
Mean
Sat
Fat
(%)
Alliance
Sat Fat
(%)
Limit
Mean
Sugar
by
Weight
(%)
Alliance
Sugar
by
Weight
(%)
Limit
Mean
Trans
Fat
(g)
Alliance
Trans
Fat (g)
Limit
Mean
Sodium
(mg)
Alliance
Sodium
(mg)
Limit
Mean
Calories
Alliance
Calorie
Limit
Mean
Size
(g)
Alliance
Size (g)
Limit
Meets
AFHG
Guidelines
(%)
Fresh fruits and
vegetables
93
2.1
1.3
n/a
0.3
n/a
10.5
n/a
0.0
n/a
12.2
n/a
91.0
no
limit
165.3
n/a
100.0
Dried fruits
0
0.0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
200†
n/a
n/a
n/a
Fruits in own juice
2
0.0
0.0
n/a
0.0
n/a
14.0
n/a
0.0
n/a
1.1
n/a
68.0
200†
113.4
n/a
100.0
Fruits in syrup
0
0.0
n/a
35.0
n/a
10.0
n/a
35.0
n/a
0.0
n/a
230.0
n/a
200†
n/a
n/a
n/a
Vegetables with sauce
8
0.2
59.5
35.0
10.1
10.0
10.7
35.0
0.0
0.0
566.9
480.0
280.0
100.0‡
169.2
n/a
0.0
Fried vegetables
30
0.7
45.8
35.0
10.4
10.0
0.8
35.0
0.2
0.0
586.6
230.0
495.0
200†
175.0
n/a
0.0
100% frozen fruit bar
0
0.0
n/a
35.0
n/a
10.0
n/a
35.0
n/a
0.0
n/a
230.0
n/a
200†
n/a
n/a
n/a
Yogurt, yogurt
smoothie, cottage
cheese
13
0.3
11.1
35.0
7.5
10.0
15.4
35.0
0.0
0.0
164.2
480.0
202.0
200†
104.0
n/a
45.5
Cheese
6
0.1
59.7
n/a
37.8
n/a
0.6
n/a
0.0
n/a
264.0
n/a
151.0
n/a
50.0
42.52
0.0
307
6.9
40.9
35.0
23.4
10.0
18.5
35.0
0.1
0.0
115.9
480.0
267.0
200†
77.6
n/a
7.8
0
0.0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1 egg
n/a
3934
88.5
31.2
35.0
11.5
10.0
40.7
35.0
0.3
0.0
226.3
230.0
306.0
200†
71.4
n/a
1.2
Nuts and Seeds
51
1.1
38.0
n/a
9.3
10.0
12.7
35.0
0.0
0.0
223.1
230.0
218.0
200†
46.5
n/a
0.0
Soups
0
0.0
n/a
35.0
n/a
10.0
n/a
35.0
n/a
0.0
n/a
750*
n/a
100.0‡
n/a
n/a
n/a
Food Category
Frozen yogurt, ice
cream
Egg
Baked goods, bars,
candy, chips, crackers
4444
Total Items
† 180 calorie limit in Middle Schools
‡ 150 calorie limit if fulfills 2 of the "minimum number of required nutrients"
Does Utah’s largest school district meet the Alliance for a Healthier Generation’s food and beverage guidelines?
Table 2: District’s competitive beverages compared to Alliance criteria
19
Items (n)
% of Total
Mean Serving
Size (ounces)
Middle School
Alliance Size
Limit
High School
Alliance Size
Limit
Mean
Calories
High School
and Middle
School
Alliance
Calorie Limit
Bottled water
500
13.80
20 ounces
no limit
no limit
0
n/a
100%
100% fruit or
vegetable juice
90
2.48
16.7 ounces
up to 10
ounces
up to 12
ounces
232.2
up to 120
calories/ 8
ounces
0%
212.0
up to 66
calories/ 8
ounces
0% middle
school
12.1% high
school*
304.0
up to 150
calories/ 8
ounces
41.7% middle
school/ 8.2%
high school
Beverage
Category
Sodas, juice,
sports drinks
2827
78.03
19.2 ounces
none allowed
any size if less
than 10
cals/8oz; up to
12 ounces if
less than 66
cals/8oz
Milk/flavored
milk
206
5.69
14 ounces
up to 10
ounces
up to 12
ounces
Total
3623
Meets AFHG
Guidelines
(%)
*Of the 2827 sodas, juice and sports drinks, 47.5% of them were found in the middle schools. None met the criteria since the Alliance guidelines do
not allow any beverages of this type in middle schools. In the high school, 12.1% were beverages with up to 10 calories/ 8 ounces. Although the
district did have sodas, juice and sports drinks that fell into the Alliance’s “other drinks with no more than 66 calories per eight ounces” category,
none of these 238 items (16.0%) met the Alliance size limit of twelve ounces.
42
Competitive Foods and Beverages in Schools
©2010 The University of Utah. All Rights Reserved.
20
2010 Utah’s Health: An Annual Review
Does Utah’s largest school district meet the Alliance for a Healthier Generation’s food and beverage guidelines?
Table 3: District’s middle versus high school competitive foods and beverages
Middle Schools
High Schools
Mean (standard error)
Mean (standard error)
5.7 (0.5)
2.0 (0.3)‡
307.8 (199.4)
288.5 (145.0)‡
Fat (%)
32.0 (20.2)
31.0 (21.0)
Sat Fat (%)
12.1 ( 10.0)
11.9 (9.9)
Sugar by Weight (%)
35.8 (26.7)
39.9 (59.0)†
Trans fat (g)
0.29 (1.1)
0.25 (0.95)
Sodium (mg)
224.0 (262.4)
209 (226.7)*
78.2 (1.2)
70.3 (0.9)‡
Characteristic
FOODS
Meets all Alliance Guidelines (%)
Calories (kcals)
Size (g)
BEVERAGES
Meets all Alliance Guidelines (%) §
26.6 (1.1)
20.9 (0.9)‡
Calories (kcals)
177.4 (2.9)
198.6 (2.8)‡
Serving size (oz)
18.9 (0.1)
19.1 (0.1)
* P < 0.05
† P < 0.01
‡ Plargest
< 0.001school district meet the Alliance for a Healthier Generation’s food and beverage guidelines?
Does Utah’s
§ per high school beverage criteria
Table 4: District’s vending machine versus a la carte competitive foods and beverages.
21
Vending Machine
A la carte
Mean (SE)
Mean (SE)
Meets all Alliance Guidelines (%)
1.0 (0.2)
17.9 (1.4)†
Percent kcals from fat
16.3 (0.3)
30.1 (0.7)†
Percent kcals from sat fat
6.5 (0.1)
13.2 (0.4)†
Percent sugar by weight
25.1 (0.5)
19.8 (0.8)†
Trans fat (g)
0.32 (0.02)
0.05 (0.01)†
Sodium (mg)
156.2 (1.9)
278.8 (12.5)†
Calories (kcals)
239.7 (1.6)
320.8 (10.0)†
Size (g)
43.1 (0.4)
99.1 (2.9)†
Meets all Alliance Guidelines (%)‡
22.3 (0.7)
55.4 (4.1)†
Calories (kcals)
190.0 (2.0)
147.4 (13.4)†
Serving size (ounces)
19.2 (.05)
13.9 (.75)†
Characteristic
FOODS
BEVERAGES
* P < 0.01
† P < 0.001
‡ per high school beverage criteria
22
©2010 The University of Utah. All Rights Reserved.
Competitive Foods and Beverages in Schools
43
2010 Utah’s Health: An Annual Review
Geographic Patterns in Lung Cancer
Incidence and Mortality in Utah:
1997-2006
Authors:
Antoinette M. Stroup, PhD1
Eric B. Durbin, MS2
C. Janna Harrell, MS1
Kim Herget1
John Williams, MS2
Rosemary Dibble, CTR1
Abstract
Introduction: We examined geographic incidence and mortality trends for lung cancer
in Utah from 1997-2006.
Methods: Utah incidence and mortality maps were generated using data from the Surveillance, Epidemiology, and End Results (SEER) Program and the Utah Department of
Health (UDOH), Office of Vital Records, respectively; and, geographically displayed
using cancer-rates.info © .
Results: Male lung cancer incidence and mortality rates were significantly higher in
Grand, Beaver, Uintah, and Carbon counties as compared to the statewide rates. Male
lung cancer incidence and mortality were also higher in Duschesne and Tooele counties.
Utah and Cache counties had consistently lower lung cancer incidence and mortality
rates as compared to the state average.
Key Words
lung cancer incidence, lung cancer
mortality, cancer mapping, Utah,
SEER, cancer- rates.info
Correspondence
Utah Cancer Registry, University
of Utah, Salt Lake City, Utah
84108
1
Kentucky Cancer Registry,
University of Kentucky,
Lexington, KY 40504
2
44
Conclusion: The higher rates in these counties may be attributed to their higher smoking
rates in addition to environmental/occupational carcinogenic exposures associated with
the mining and utilities industries. The lower rates in Utah and Cache counties are likely
due to the low smoking rates in those counties.
Introduction
The Utah Cancer Registry (UCR), in collaboration with the Kentucky Cancer Registry
(KCR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results
(SEER) Program, recently published cancer incidence and mortality data on cancerrates.info © (1). Cancer-rates.info © is a web-hosting service provided by the KCR at the
University of Kentucky, enabling public access to interactive, geographic representations
of cancer incidence and mortality data. As a result of this collaboration, Utah patterns in
cancer incidence and mortality may be evaluated geographically. This article provides an
Geographic Patterns in Lung Cancer
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
introduction to the Utah data available through cancer-rates.
info © by producing and describing Utah age-adjusted lung
cancer incidence and mortality rates from 1997-2006.
Lung Cancer Incidence and Mortality
Although overall cancer incidence and mortality is declining,
trends in lung cancer are varied (2). According to the latest Annual Report to the Nation on the Status of Cancer, lung cancer
incidence among men has been declining steadily at an annual
percent (APC) of approximately 1.8% per year (2). Lung cancer
incidence among women, however, has been steady since 1991,
but only after significant increases from 1975-1982 (5.6 APC)
and from 1983-1990 (3.4 APC) (2). Lung cancer mortality
trends among men and women were similar to the incidence
trends.
Lung cancer incidence and mortality in Utah are substantially
lower than national averages. In fact, lung cancer incidence
and mortality rates from 2002-2006 in Utah were 51% to
nearly 57% lower, respectively (Table 1). Utah’s lower lung
cancer incidence and mortality rates due to lung cancer are
largely attributed its lower prevalence of smoking. According
to Jemal, Thun, Ries, et al. (6), in 2006, Utah men and women
had the lowest prevalence of current smokers in the nation at
10.4% and 9.3%, respectively. The national average was double
that of Utah (21.9% among men, 17.6% among women) (6).
In addition to lower incidence and mortality, from 1997-2006
Utah rates continue to follow similar declining trends as the
rest of the nation (Table 2).
Table 1. Age-Adjusted Lung Cancer Incidence and
Mortality Rates by Sex 2002-2006
Incidencea
Sex
Total
Male
Female
Mortalitya
Utah(3)
SEER(4)
Utah(5)
US(4)
29.6
63.1
24.4
53.4
37.8
77.7
32.8
70.5
23
52.5
17.6
40.9
Rates are per 100,000 and age-adjusted to the 2000 US Std Population (19
age groups - Census P25-1130) standard.
a
Table 2. Age-Adjusted Lung Cancer Incidence and
Mortality Trends by Sex 1997-2006
Incidencea
Sex
Total
Male
Female
APCb
Utah(3)
APCb
SEER(4)
Mortalitya
APCb
Utah(5)
APCb
US(4)
-1.2
-1.5*
0,7
-1.1*
-2.8 *
-2.3*
-1.7*
-2.0*
0.7
-0.6*
0.3
-0.1
Rates are per 100,000 and age-adjusted to the 2000 US Std Population (19
age groups - Census P25-1130) standard.
a
b
APC = Annual Percent Change
This article aims to further characterize Utah-specific trends
with special focus on geographic patterns of lung cancer incidence and mortality. Geographic patterns are described using
data and maps publicly available through cancer-rates.info ©.
Methods
Incident cases include all Utah residents diagnosed with primary lung and bronchus cancer from January 1, 1997 through
December 31, 2006. All cases were reported to the Utah
Cancer Registry as part of routine cancer surveillance for the
Utah Department of Health (UDOH) and the SEER Program.
Lung and bronchus cancers were identified following the conventions of the SEER program, which uses primary site and
histology codes defined in the International Classification of
Diseases for Oncology (ICD-O), Third Edition (7). Mortality
data were provided by the Utah Health Department, Office of
Vital Records. Age-adjusted incidence rates were calculated in
cancer-rates.info © using SEER population data. All incidence
and mortality data were processed by the Kentucky Cancer
Registry and incorporated into the cancer-rates.info © website.
Confidence intervals were calculated by the Kentucky Cancer
Registry and are based on the Gamma distribution method (8).
Cancer incidence and mortality data on cancer-rates.info ©
may be viewed geographically, by cancer type, year(s), sex,
and race. Interactive maps display age-adjusted rates linked
to several graphical tools that can be used to navigate, explore
and interpret the underlying data (9). To protect patient confidentiality and ensure the high-reliability of statistical measures
(incidence and mortality rates), Utah data were aggregated,
configured to follow data suppression rules (less than 5 cases
and/or population at risk less than 1,000), and verified by the
Utah Cancer Registry prior to publication.
Generating State-Specific Rates
We accessed Utah-specific data by clicking on the state of Utah
on the map displayed on the cancer-rates.info © home page
(http://www.cancer-rates.info/), Figure 1 shows the main page
for Utah, which is divided into 3 panels: (a) cancer map and
legend, (b) selection criteria or query specifications, and (c) the
rate table. Details about specific functions in each panel can
be found by clicking the help icon on each panel or via the
Kentucky Annual Report (10).
By default, the main page automatically displayed overall cancer rates from 2002-2006 by county. We modified the query
specifications in Panel B (Figure 1) to expand the years of diagnosis to 1997-2006 and generate incidence and mortality rates
for invasive lung and bronchus cancers, by sex and county or
local health district. All rates were generated using the 2000 U.S.
Standard Population with confidence intervals (see Figure 2).
* The APC is significantly different from zero (p<0.05)
©2010 The University of Utah. All Rights Reserved.
Geographic Patterns in Lung Cancer
45
2010 Utah’s Health: An Annual Review
Figure 1. Main Page of http://cancer-rates.info
Figure 2. Lung Cancer Incidence by County
46
Geographic Patterns in Lung Cancer
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Results
Invasive Cancer Incidence Rates 1997-2006:
Lung and Bronchus Cancers by County
The statewide age-adjusted incidence of lung and
bronchus cancer from 1997-2006 was 30.45 per
100,000 (95% CI 29.61-31.30) (Figure 3). Although
county-specific rates are displayed in the table panel, the corresponding map only displays the quartile
distribution of cancer rates for each county. The
corresponding map also provides a visual representation of areas (counties) with rates that are based on
sparse data (less than 15 cases). These counts are too
small to generate stable age-adjusted rates. Readers
are encouraged to consider information about these
areas with caution. As described earlier, the map
also identifies and suppresses rates for areas with
a risk population of less than 1,000 to protect confidentiality. Given these considerations, we found
that 7 counties (Grand, Beaver, Uintah, Carbon,
Tooele, Weber, and Salt Lake) had significantly
higher lung cancer incidence rates as compared to
the state average, and 3 counties (Box Elder, Utah,
and Cache) had significantly lower lung cancer
incidence rates. Sex-specific analyses showed that
much of the rates were driven by high lung cancer
incidence among males in those counties (Figure
4). Many of the counties had fewer than 15 female
cases and, therefore, many of the county-specific
rates among females are statistically unstable. Utah
and Cache counties, however, still have significantly
lower female lung cancer incidence rates than the
state average (Figure 5).
Cancer Mortality Rates 1997-2006: Lung and
Bronchus Cancers by County
The statewide age-adjusted mortality from lung
and bronchus cancer from 1997-2006 was 24.54
per 100,000 (95% CI 23.79-25.31) (Figure 6). Results show that 5 counties (Grand, Beaver, Uintah,
Carbon, and Tooele) have significantly higher lung
cancer mortality rates as compared to the state average, and 2 counties (Utah and Cache) have significantly lower cancer mortality rates. Like incidence
patterns, sex-specific mortality among males seem
to be driving much of the county rates (Figure 7).
Much of the female mortality rates were suppressed
or considered unstable due to sparse data (Figure 8).
An interesting result, however, is that lung cancer
mortality among women in Uintah and Tooele counties are significantly higher than the state average.
©2010 The University of Utah. All Rights Reserved.
Figure 3. Lung Cancer Incidence by County
Figure 4. Male Lung Cancer Incidence by County
Figure 5. Female Lung Cancer Incidence by County
Geographic Patterns in Lung Cancer
47
2010 Utah’s Health: An Annual Review
Conclusion
Most lung cancer cases are attributed to tobacco
use (cigarette smoking). According to the American Lung Association, smoking accounts for 80%
to 90% of lung cancer deaths in men and women,
respectively (11). A few environmental and/or occupational exposures that increase the risk for lung
cancer include asbestos, nickel, polyaromatic hydrocarbons, arsenic, chromium, and radon (12-13). The
risks for lung cancer increases when exposure to
these environmental/occupational contaminants occurs in conjunction with cigarette smoking (11,14).
The significantly lower rates of lung cancer in Utah
are largely attributed to low rates of smoking, which
is about 10% (15). This is half the national average
rate, which is approximately 20% (15). In this article,
however, we have shown that geographic patterns
within the state vary by county and gender. Notably,
male lung cancer incidence and mortality rates were
significantly higher in Grand, Beaver, Uintah, and
Carbon counties. Male lung cancer incidence and
mortality were also higher in Duschesne and Tooele
counties, respectively. Given what is known about
cigarette smoking and lung cancer, it is not surprising to find that these areas have significantly higher
smoking rates than the state average. In fact, smoking prevalence in these areas approach or exceed
the national average (15). When these patterns were
evaluated using cancer-rates.info ©, we found that 4
of the 6 counties are adjacent counties located along
the north-eastern quadrant of the state. This area is
known for its mining and utilities industries (16-17)
and has been investigated previously for high cancer
rates (18). In addition occupations in these industries
have been associated with exposure to carcinogenic
substances and excess lung cancer risk (19-21).
Figure 6. Lung Cancer Mortality
Figure 7. Male Lung Cancer Mortality
Figure 8. Female Lung Cancer Mortality
Beaver County is another county that had significantly higher lung cancer incidence and mortality
rates as compared to the state average. The higher
incidence and mortality, however, may be due to an
elevated risk of radon exposure in addition to smoking prevalence. According to the UDOH, smoking
rates for the region were approximately 21.5% from
2001-2005 (22). Radon exposure, however, has
been identified as an environmental concern by the
UDOH in Beaver County (23). According to a study
conducted by the UDOH, Beaver County had the
highest average radon levels among sampled homes
tested throughout the state, averaging 25.1 pCi/L.
This amount is nearly twenty times the maximum
recommended level of 2.0 pCi/L (24).
48
Geographic Patterns in Lung Cancer
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Utah and Cache counties had consistently lower lung cancer
incidence and mortality rates as compared to the state average.
This finding is not surprising given the low smoking prevalence
in those areas at approximately 5% (15). In fact, populations
in Utah and Cache counties have some of the lowest smoking
prevalence in the entire state.
There are several caveats to our findings, however. While
county-level data were available, the analyses only considered
counties with adequate case and population counts to generate
stable incidence and mortality rates. Thus, there were some
areas that showed higher or lower rates as compared to the
state average, but the difference failed to reach significance
at the p<0.05 level due to sparse data. Another caveat is the
ecologic nature of our evaluation, which hinders our ability
to affirmatively assess causality between both smoking and
environmental/occupational exposures and lung cancer rates
in specific counties. Indeed, the 1997 IARC report on coal
dust exposure stated that the exposure-risk associations with
coal mine dust are inconclusive (25). Future investigations
may include geographic analyses of other cancers (i.e., urinary
bladder) that may be linked to the same exposure risk in these
populations. Other factors that affect our ability to establish
causality include difficulty in measuring the amount and duration of exposure, latency period, population migration, other
lifestyle and demographic factors, and family history; which
may influence the relationship between the high/low lung
cancer rates and smoking, environmental, or occupational
exposures.
Acknowledgements
This research was supported by the Utah Cancer Registry,
which is funded by contract N01-PC-35141 from the National
Cancer Institute’s SEER program with additional support
from the Utah State Department of Health and the University
of Utah; the Kentucky Cancer Registry at the University of
Kentucky, which is funded by contract N01-PC-54403 from the
National Cancer Institute’s SEER program. Special thanks to
Sam LeFevre from the Environmental Epidemiology Program
at the Utah Department of Health.
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11. American Lung Association (2010). Lung Cancer Fact Sheet. Available
at
http://www.lungusa.org/lung-disease/lung-cancer/resources/factsfigures/lung-cancer-fact-sheet.html. Accessed February 4, 2010.
12. ACS, American Cancer Society (2009). Tobacco-Related Cancers
Fact Sheet. Available at http://www.cancer.org/docroot/PED/content/
PED_10_2x_Tobacco-Related_Cancers_Fact_Sheet.asp?sitearea=WHO.
Accessed February 4, 2010.
13. CDC, Centers for Disease Control and Prevention (2010). Lung Cancer:
Risk Factors. Available at http://www.cdc.gov/cancer/lung/basic_info/
risk_factors.htm. Accessed January 30, 2010.
14. ACS, American Cancer Society (1992). Facts on Lung Cancer.
15. UDOH, Utah Department of Health, Tobacco Prevention and Control
Program (2009). Tobacco Prevention and Control in Utah: Ninth Annual
Report, August 2009. Available at http://tobaccofreeutah.org/tpcpfy09report.pdf. Accessed in January 2010.
16. GOPB, Governor’s Office of Planning and Budget (2010). Economic
Report to the Governor 2010: January 7, 2010. Available at http://www.
governor.utah.gov/dea. Accessed in January 2010.
17. GOPB, Governor’s Office of Planning and Budget (2008). 2008 County
Profiles. Available at http://www.governor.utah.gov/dea/publications/
html. Accessed in January 2010.
18. UDOH, Utah Department of Health (1998), Environmental Epidemiology
Program. An Investigation of Cancer Incidence Rates in Carbon County,
Utah, 1973-1996.
19. De Matteis S, Consonni D, Bertazzi, PA (2008). Exposure to occupational
carcinogens and lung cancer risk. Evolution of epidemiological estimates
of attributable fraction. Acta Bio Medica, 79; Supp 1: 34-42.
20. Pukkala E, Martinsen JI, Lynge E, (et al) (2009). Occupation and cancerfollow-up of 15 million people in five Nordic countries. Acta Oncologica,
48: 646-790.
21. MacArthur AC, Le ND, Fang R, Band PR (2009). Identification of
Occuptational Cancer Risk in British Columbia: A Population-based
case-control study of 2,998 lung cancers by histopathological subtype.
American Journal of Industrial Medicine, 52:221-232.
22. UDOH, Utah Department of Health (2009). Data and Confidence Limits
Geographic Patterns in Lung Cancer
49
2010 Utah’s Health: An Annual Review
for Percentage of Adults who Reported Current Cigarette Smoking by
Small Area, Utah Adults Aged 18 and Older, 2001-2005 (aggregated
data). Available at http://ibis.health.utah.gov/indicator/view_numbers/
CigSmokAdlt.SA.html. Accessed February 5, 2010.
23. UDOH, Utah Department of Health (2009). Utah Health Status Update:
Measuring Health Insurance coverage in Utah. Available at http://health.
utah.gov/opha/publications/hsu/09May_Insurance.pdf. Accessed February 5, 2010.
24. EPA, Environmental Protection Agency (2009). A Citizen’s Guide to
Radon: The guide to protecting yourself and your family from radon.
United States Environmental Protection Agency’s Indoor Environments
Divison and the Center’s for Disease Control. Available at http:www.epa.
gov/radon. Accessed February 6, 2010.
25. IARC, International Agency for Research on Cancer (1997). Summaries
and Evaluations: Coal Dust, Vol 68:337. Available at http://www.inchem.
org/documents/iarc/vol68/coal.html. Accessed on February 4, 2009.
50
Geographic Patterns in Lung Cancer
©2010 The University of Utah. All Rights Reserved.
UH Review 2010
Utah’s Health: An Annual Review
Perspectives Articles
Pages 55─74
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu
2010 Utah’s Health: An Annual Review
Patient Centered Medical Home: Its
Role in Health Care Reform
Authors: Julie Day, MD
Debra L. Scammon, PhD
Michael K. Magill, MD
Key words
medical home, reform, health
system
Correspondence:
Abstract
Debra L. Scammon, PhD
Marketing Department
David Eccles School of Business
KENDALL D GARFF BLDG
1645 Campus Center Dr. Rm 408
(801) 581-4754
email: debra.scammon@business.
utah.edu
Commentary
Julie Day, MD
Redwood Health Center & Urgent
Care
1525 W 2100 S
(801) 213-9900
email: julie.day@hsc.utah.edu
Michael K. Magill, MD
Professor and Chairman, Department of Family and Preventive
Medicine
Executive Medical Director,
Community Clinics/Community
Physician Group
University of Utah School of
Medicine
375 Chipeta Way, Suite A
Salt Lake City, UT 84108
Voice (801)581-4074
Fax (801)581-2759
email: michael.magill@hsc.utah.
edu (preferred method of communication)
©2010 The University of Utah. All Rights Reserved.
Passage of the Patient Protection and Affordable Care Act in March 2010 signaled the nation’s concern over an ailing healthcare system that is impacting all areas of our economy.
Fixing the system to assure access and quality will require reforms in payment and in
delivery of care. The concept of a Patient Centered Medical Home can help by restoring
primary care as the foundation for a healthy system. Payment reform will be required to
support this vital resource.
Continuing turmoil over political attempts to reform health care has diverted attention
from the fact that health care costs continue to escalate and threaten the core of our economic future (Orszag, 2008; Kaiser Family Foundation & Health Research and Educational Trust, 2008). The economic imperative for reform is compelling. Business owners
looking for relief are passing higher costs on to employees or eliminating health benefits
all together. While understandable from the employer’s perspective, neither strategy
solves the underlying problem of escalating cost of care: both approaches just shift the
problem of cost to the employee. The result is that access to health care deteriorates as
health care becomes more unaffordable for more individuals. Without health care reform,
the average family premium will rise from $12,681 to $21,639 by 2019. Health insurance
is becoming unaffordable: 364,000 Utahans are already uninsured; and 110 more lose
their health insurance every day (Bailey, 2008).
Early in the health care reform discussions the language changed from health care reform
to health insurance reform. Unfortunately, this moved the emphasis away from delivery
system restructuring and payment reform. Mandating insurance coverage does little to
address many underlying drivers of cost, such as lack of access to primary care, fragmentation of care, and resulting overuse of tests, procedures, and hospitalization.
One concept that has been recognized nationally as an essential component of health
system reform is the “Patient Centered Medical Home.” This is a primary care medical
practice that offers personal, accessible, coordinated, comprehensive, and ongoing care
to patients: the characteristics of health care most likely to improve quality, enhance
Patient Centered Medical Home
55
2010 Utah’s Health: An Annual Review
health, and reduce cost.
The Medical Home recognizes the critical role that primary
care plays in improving both access and quality. Barbara
Starfield’s work has revealed the significant cost and quality
benefits of primary care (Starfield, n.d.). According to her studies, adults 25 years and older, with a primary care physician
rather than a specialist as their personal physician had 33%
lower cost of care and were 19% less likely to die (Macinko
2003). Many studies done across countries, both industrialized
and developing, show that areas with better primary care have
better health outcomes, including total mortality rates, heart
disease mortality rates, and infant mortality, and earlier detection for cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma (Shi, 2003). The opposite is
the case for higher specialist supply, which is associated with
worse outcomes (Paulus, 2008).
The Medical Home offers patients an ongoing relationship
with a personal physician who will meet their needs for acute,
chronic, and preventive care. The personal physician works
with a health care team to ensure coordination and continuity of care. When care by a specialist is needed, the primary
care physician and team coordinate and follow up on the care,
making sure that all the necessary linkages are made. Care is
patient-centric and ensures that all recommended care is being
delivered and that unnecessary or harmful care is not. Patients
with specific health conditions are tracked in a registry to ensure timely delivery of needed care. Outreach to these patients
helps ensure they receive recommended care. Health information is managed through an electronic health record. Providers
working within a medical home know how well they are doing
at providing high quality care because ongoing reports provide
continuous feedback to the teams.
The Medical Home receives added payment for the enhanced
services that improve quality while reducing overall cost of
care. The current fee for service payment system incentivizes
piece-work by physicians: doctors and hospitals are paid for
quantity not quality of care. Physicians and medical groups
are incentivized to see more patients, provide more visits, and
order more tests. Much of the care that is required for patients
with chronic diseases could be done more efficiently and cost
effectively by other strategies, such as nurse educators or
peer support groups that are not reimbursed under the current payment system. For example, needed follow-up could be
done with combinations of face-to-face visits, phone calls, or
Internet visits. Telehealth visits using remote devices such as
web cameras in conjunction with in-home monitoring devices
would allow for full evaluation of patients without requiring
them to leave home to see a doctor. The coordination of care
and outreach to patients that are core aspects of delivering
comprehensive and high quality care to entire populations of
patients are simply not paid for in our current system. Because
56
Patient Centered Medical Home
there is no re-imbursement for such care, it is not done well,
quality suffers and cost increases.
Dozens of Medical Home demonstration projects currently
underway across the country include innovative payment to
support comprehensive care delivered in a medical home. Most
demonstration projects across the country pay a flat sum to
cover the extended services while still paying fee for service
for care provided at a visit. They also reward value rather than
just volume of care, by paying more when practices achieve
quality targets.
Many of the Medical Home demonstrations have already
shown improved quality and decreased cost of care. For example, Geisinger Health System’s Medical Home project led
to a 20% reduction in all-cause hospital admissions and a 7%
savings in overall cost of care (Paulus 2008). Community Care
of North Carolina, a Medicaid Medical Home demonstration
project, found that a fiscal year 2004 investment of $10.2
million yielded a $124 million savings compared to 2003
costs and a savings of $225 million compared to Medicaid
Fee For Service. Another report notes statistically and clinically significant decreases in the number of hospitalizations,
days spent in hospital, and emergency room visits (Anderson
2002). Rosenthal (2008) reviewed evidence that PCMH leads
to improved quality, reduced errors, and improved patient
satisfaction. Other positive outcomes have been reported for
patients and staff. Group Health Cooperative’s results included
improvements in patient experience, HEDIS quality metrics,
and staff experience at work (Reid 2010). A recent special issue
of the journal Health Affairs was devoted entirely to discussion
of the need for renovation of primary care, largely through the
PCMH model (Health Affairs 2010).
The Medical Home concept is getting attention not only from
researchers and clinicians but from businesses interested in the
potential for decreasing health benefits costs and improving the
health of their employees. In February 2009, the University of
Utah hosted a symposium on Medical Homes with Paul Grundy, MD, as the keynote speaker. Dr. Grundy is IBM’s Global
Director of Healthcare Transformation and President of the
Patient-Centered Primary Care Collaborative, a national coalition of major employers, insurers, consumer and professional
groups advancing Medical Homes. The Utah symposium drew
over 200 participants, including many local business people
and policy makers. Attendees learned of national efforts to create Medical Homes, and of progress developing them in Utah.
For example, before the current terminology of the Medical
Home was developed, the University’s Community Clinics
began implementing a care delivery model they call “Care by
Design” which provides improved access to care, teams led
by a primary care physician, and advanced electronic medical
record support for chronic care and prevention.
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Employers in Utah should take heart from evidence presented
in a recently released white paper from the Patient Centered
Primary Care Collaborative (PCPCC 2010). The report
makes the business value case for employers suggesting that
value based insurance design works well with the primary care
medical home model. When employers customize employee
benefits to incentivize the use of primary care and preventive
health measures, they win with greater employee productivity and lower overall costs. The PCMH is also a key step
toward higher level integration of care in “Accountable Care
Organizations” (ACO) including other sources of care such as
specialty practices and hospitals (Hester 2010). The recently
passed national health care bill (Patient Protection and Affordable Care Act of 2010) includes mandates that the Center for
Medicare and Medicaid Services initiate pilot projects to pay
for PCMH, ACO, and other innovative service delivery models. In Utah, the Legislative Task Force on Healthcare Reform
has initiated incremental reform with formation of a Payment
Reform Demonstration Project that is considering a pilot effort to help health care providers develop “infrastructure, data
and tools needed to (provide) successful care for the chronic
disease management and preventive care needs of a population
under a global fee or episode payment system,” (Personal communication from Christie North, HealthInsight, May 25, 2010)
such as PCMH or an ACO model.
To truly transform our healthcare system a combination of
delivery and payment reform is needed. Examples abound
across the country and in Utah of benefits that can be achieved
through health care delivery system change. Fostering care
through Medical Homes makes economic sense for the country, for Utah, and for our health.
References
Anderson G, Herbert R, Zeffiro T, Johnson N. Chronic Conditions: Making
the Case for Ongoing Care. In: John Hopkins University Partnership for Solutions; 2002; Baltimore, MD; 2002.
Bailey,Kim, et al. (2008). Premiums versus Paychecks: A Growing Burden
for Utah’s Workers. 2008 Families USA. Retrieved February 1, 2010 from:
http://www.familiesusa.org.
Franks P & Fiscella, K. (1998). Primary care physicians and specialists as
personal physicians. Health care expenditures and mortality experience. The
Journal of Family Practice. 1998; 47(2):105-9.
Health Affairs. 2010; 29(5).
Macinko, James, Barbara Starfield, and Leiyu Shi (2003). The contribution
of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970-1998. Health
Services Research, 38 (3):831-862.
North, Christie (2010). Vice President for Utah, HealthInsights, Salt Lake
City,UT; email, May 25, 2010.
Orszag PR. (2008). Growth in health care costs: statement before the committee on the budget, United States Senate. Washington, DC: Congressional
Budget Office, Jan 31 2008. Retrieved February 1, 2010 from: http://www.
cbo.gov/doc.cfm?index=8948
Paulus,R, Davis, K, Steele, G. (2008). Continuous innovation in health care:
implications of the Geisinger experience. Health Affairs, 27 (5): 1235-1245
Patient Protection and Affordable Care Act of 2010. P.L. 111-148 available at
http://dpc.senate.gov/dpcdoc-sen_health_care_bill.cfm.
Reid, Robert J, Katie Coleman, Eric A Johnson, Paul A Fishman, Clarissa
Hsu, Michael P Soman, Claire E Trescott, Michael Erikson, and Eric B Larson (2010). The Group Health Medical Home at Year Two: Cost Savings,
Higher Patient Satisfaction, And Less Burnout for Providers. Health Affairs;
29(5): 1-9.
Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med 2008;21:427-40.
Patient Centered Primary Care Collaborative (2010). Aligning Incentives and
Systems. Washington, D.C. (March).
Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. (2003). The relationship between primary care, income inequality, and mortality in US States,
1980-1995. Journal of the American Board of Family Practice; 16: 412-22.
Starfield, B. .Primary care contribution to health systems and health. The
Johns Hopkins Primary Care Policy Center for the Underserved.
Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP
(2003). Comorbidity: implications for the importance of primary care in
‘case’ management. Ann Fam Med;1:8-14.
Authors Note
Julie Day, MD, is Quality Medical Director for the University
of Utah Community Clinics, University of Utah Hospitals and
Clinics, and Deputy Director. She practices medicine at the
Redwood Center.
Debra L. Scammon, PhD, is Emma Eccles Jones Professor of
Marketing and Director of the Master of Healthcare Administration program, David Eccles School of Business, University
of Utah.
Michael K. Magill, MD, is Executive Medical Director, University of Utah Community Clinics and Chair, Department of
Family and Preventive Medicine, School of Medicine, University of Utah.
Hester, Jim, Julie Lewis, Aaron McKethan (2010). The Vermont Accountable Care Organization Pilot: A Community Health System to Control Total
Medical Costs and Improve Population Health. The Commonwealth Fund,
May 2010. http://www.commonwealthfund.org/Content/Publications/FundReports/2010/May.
Kaiser Family Foundation & Health Research and Educational Trust. (2008).
Employer health benefits 2008 annual survey. Menlo Park, CA: Kaiser
Family Foundation, 2008. Retrieved February 1, 2010 from: http://ehbs.kff.
org/?page=abstract&id=1
©2010 The University of Utah. All Rights Reserved.
Patient Centered Medical Home
57
2010 Utah’s Health: An Annual Review
“Do’s and Don’ts” for Eating
Disorder and Obesity Prevention in
Community Settings
Authors:
Justine J. Reel, PhD, LPC, CC-AASP
Joseph Halowich, MS, CHES
Abstract
Correspondence
Over 10 million U.S. females have clinically diagnosable eating disorders (i.e., anorexia
nervosa, bulimia nervosa and binge eating disorder) which yield the highest mortality
rate of any psychiatric disorder, cause numerous health consequences and destroy family
systems (Casiero & Frishman, 2006). With an incidence rate of 5% for adolescent females,
eating disorders rank as the third most common chronic illness for this demographic (Society for Adolescent Medicine, 2003). Approximately 24-46% of adolescent girls report
being dissatisfied with their bodies (Presnell, Bearman & Stice, 2004) and in separate
study 61.7% of adolescent females (N=13,953) reported attempting to lose weight by
restricting food, taking diet pills and laxatives, and vomiting (Eaton et al., 2006). Despite
these alarming national statistics, prevention efforts have been focused on obesity prevention without regard for the potentially deleterious effects of over-emphasizing weight,
size and shape (O’Dea & Abraham, 2000). Therefore, the purpose of this paper is to
share intervention strategies for obesity and eating disorder prevention in Utah that do
not incorporate ineffective scare tactics or promote weight discrimination or shame. The
health education methodologies discussed in this paper subsequently promote a broader
health agenda that complements rather than opposes current obesity prevention efforts.
Justine J. Reel, PhD, LPC, CCAASP
Assistant Professor
Department of Health Promotion
and Education
University of Utah
Salt Lake City, UT
“Do’s and Don’ts” for Eating Disorder and Obesity Prevention in Community
Settings
Joseph Halowich, MS, CHES
Health Teacher
Parkside High School
Salisbury, MD
Adolescent girls are inundated with digitally enhanced, ultra-thin, socially constructed
media images while simultaneously being exposed to multi-billion dollar advertising
campaigns for candy, soda and other fattening snacks (Dohnt & Tiggemann, 2006). Approximately 18% of adolescents are overweight in the U.S (Khan et al, 2009; Ogden,
58
On April 27, 2008, Tiffany Cupit, a local Utahn, died at age 34 after a long battle with an
eating disorder (Deseret News, 2008). Her loss was a heartbreaking blow to the Salt Lake
community and raised questions about how to effectively prevent eating disorders while
continuing to fight the well-publicized obesity epidemic.
Eating Disorders and Prevention
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Carroll, Curtin, Lamb & Flegal, 2010). Childhood obesity has
tripled, 33.3% of youth have BMI scores that place them in the
85th percentile which puts them at risk for heart disease, Type
II diabetes, and asthma (DeMattia & Denney, 2008; Ogden et
al., 2006). Over 50% of teens 11-13 years of age see themselves
as overweight, and by age 13, 80% of girls have attempted to
lose weight (Costin, 2007).
Utah boasts a 22.5% obesity rate and it is estimated that as
many as 21.5% of Utah elementary school students and 20.4%
of Utah high school students are at an unhealthy weight for
their height (CDC, 2008). Although state-wide statistics are
not available for clinical eating disorders, studies conducted
by Utah researchers have demonstrated strong body image
concerns among females. Specifically, Dr. Diane Spangler, an
Associate Professor at Brigham Young University, discovered
that women reported increased body image concerns when
viewing images of overweight bodies even if they themselves
were not overweight (Owens, Allen, & Spangler, 2010). Dr.
Sue Smith, an Assistant Professor at Utah Valley University,
conducted a study with college freshmen females in Utah and
discovered that they avoided the “freshmen 15” at all costs
even if it meant adopting unhealthy eating and exercise practices (Smith & Reel, 2009).
Obesity prevention has been the primary focus of health
promotion efforts in Utah (Utah Health Department, 2010).
Because there are obesity prevention programs being implemented with unknown effects on disordered eating symptomatology, there has been a call for integrating prevention efforts
within the fields of obesity and eating disorders (Austin, Field,
Wiecha, Peterson & Gortmaker, 2005; Irving & NeumarkSztainer, 2002). Mixed or modest results have been found
across programs for children and youth focused solely on
obesity prevention, suggesting that current intervention models are inadequate for tackling this problem (Thomas, 2006).
Addressing body image and its link to eating behavior as well
as the psychological implications of binge eating, body weight,
and coping with hunger have been identified as missing pieces
within traditional obesity prevention programs (e.g., Swain,
2009; Wardle et al., 2006; Berg, Buechner & Parham, 2003).
Therefore, the purpose of this paper is to provide eating disorder prevention strategies for health educators and public health
practitioners that subsequently promote a larger health agenda
that complements current obesity prevention efforts. Stice,
Shaw and Marti (2007) reported some optimistic meta-analytic
findings that 51% of eating disorder prevention programs reduced eating disorder risk factors and 29% reduced current or
future pathologies. However, there has been much debate about
the types of prevention efforts that are effective (Fingeret,
Warren, Cedpeda-Benito & Gleaves, 2006). The evidencebased principles presented in this paper are broad enough to
address the spectrum of eating behaviors (i.e., restricting food
©2010 The University of Utah. All Rights Reserved.
intake to binge eating) while attempting to reduce both obesity
and eating disorders in the Utah community.
“Do’s” for Eating Disorder and Obesity Prevention
Intervention programs should focus on building protective
factors against eating disorders/obesity and promoting health
rather than discussing specific types of eating disorder symptoms or weight (O’Dea & Abraham, 2000). Varnado-Sullivan
and Horton (2006) argued that although information- based interventions may not lead to iatrogenic effects, they are unlikely
to produce long-term behavior change. Instead health educators and public health practitioners should focus on enhancing self-respect and self-worth and to increase one’s ability to
discern negative media messages about body image, promote
exercise in moderation along with healthy and balanced nutrition. The most efficacious prevention programs should include
the following characteristics:
• An emphasis on promoting healthy behaviors using a
positive health approach. A “health at every size” perspective that discourages weight discrimination and
promotes health should be adopted by health educators
and public health practitioners rather than primarily
emphasizing weight and body composition changes
(McVey, Gusella, Tweed, & Ferrari, 2009).
• Promoting physical activity during the intervention is
salient because body image has been shown to improve
post-exercise (Hausenblas & Fallon, 2006). Therefore,
eating disorder and obesity interventions should include healthy and safe exercise with motives other than
weight loss.
• Teaching adolescents how to dissect media messages
should be incorporated into eating disorder and obesity
interventions to empower males and females about
negative media messages and the promotion of unhealthy ideals. (Steiner-Adair, 2002)
• •Multiple sessions to reinforce health promotion efforts rather than a single session (e.g., school assembly)
using a universal approach. A single session was found
to be inadequate to provide the depth of content or
opportunity for repeat exposure to lead to necessary
outcomes and attitudinal changes (e.g., Stice & Shaw,
2004).
• Targeted interventions that involve selecting participants who are at risk for developing disordered eating
behaviors are shown to be more effective than trying
to expose an entire community or school population
(Stice et al., 2007).
• Interactive elements and the opportunity to practice
Eating Disorders and Prevention
59
2010 Utah’s Health: An Annual Review
assertiveness, healthy activity and nutrition (e.g.,
cooking classes) should be used rather than a strictly
didactic approach (Utz et al., 2008).
• Parent education and assignments to practice in home
and school environments should be used to reinforce
intervention goals (Berg et al., 2003; Zucker, 2004).
• Teaching participants to move away from feeding
emotional hunger and instead using biological cues of
hunger and fullness to guide food consumption (Tribole & Resch, 2003).
“Don’ts” for eating disorder and obesity prevention
Programs that focus on using scare tactics (e.g., “look at this
woman with anorexia who looks like a skeleton”) rather than
promoting positive health messages should be avoided (Fingeret et al., 2006). O’Dea and Abraham (2000) urged health
educators to resist providing descriptive information about
eating disorders in educational settings. Specifically, using
psychoeducation to “teach” the symptoms of eating disorders
could result in triggering disordered eating behaviors in participants. Other “don’ts” for prevention programs include:
• Avoid using visual images for shock value that could
potentially backfire and have unintended consequences. While the health educator and majority of
participants may see a photo with clear depiction of
protruding bones as horrific, someone with a distorted
sense of body ideals may see the photo as inspirational
for unhealthy behaviors (Vernado-Sullivan & Horton,
2006).
• Likewise, in younger audiences be careful about introducing youth to pro-ana websites. These websites have
been used as a blog to support dysfunctional thoughts
and eating patterns. Unfortunately these unregulated
websites serve as breeding grounds for anorexia and
bulimia nervosa.
• Avoid keeping males and females together for body
image discussions. Males may express different body
image concerns based on changing male ideals (i.e.,
the desire to be larger) than females or may lack the
vocabulary for articulating what they are feeling (Baghurst, Hollander, Nadella, & Haff, 2006). Females, on
the other hand, should be in a setting where they can
discuss sensitive topics at more in-depth levels without
concern for potential teasing behavior (Stice et al.,
2007).
• Be careful about over-emphasizing body weight and
body composition for evaluation procedures. While
Body Mass Index (BMI), waist circumference and body
60
Eating Disorders and Prevention
fat percentage are commonly used to gauge the success
of obesity prevention programs, any measurements
should be considered carefully and taken discretely.
Privacy should be maintained for participants who
should be asked to turn around while having weight
checked. Weights should never be announced or shared
with participants to avoid weight comparison.
Future Directions/Conclusion
Although much lip service has been given about the necessity of preventing obesity and eating disorders, efforts can be
costly, ineffective and harmful. Currently, University of Utah
is conducting an interdisciplinary project across the Colleges
of Health, Medicine and Nursing implementing a communitybased obesity and eating disorder prevention program with
adolescent girls called “Full of Ourselves PLUS.” The project,
funded by a University of Utah interdisciplinary grant, will
provide some preliminary results for the effectiveness of the
above do’s and don’ts and combines the existing curricula
from Full of Ourselves (Steiner-Adair, 2002) and Eat and Live
Well (Utz et al., 2008). This article has outlined guidelines for
health educators and public health practitioners when setting
up community-based programs that integrate prevention efforts for obesity and eating disorders.
References
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Baghurst, T., Hollander, D.B., Nardella, B. & Haff, G.G. (2006). Change in
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Berg, F., Buechner, J. & Parham, E. (2003). Guidelines for childhood obesity
prevention programs: Promoting healthy weight in children. Journal of Nutrition Education and Behavior, 35(1), 1-4.
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Casiero, D., & Frishman, W.H. (2006). Cardiovascular complications of eating disorders. Cardiology In Review, 14, 227-231.
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Prevention of Eating Disorders: The Eating Disorder Sourcebook, 3rd Edition. New York, NY: McGraw-Hill.
DeMattia, L. & Denney, S.L. (2008). Childhood obesity prevention: Successful community-ased efforts. The Annuals of the American Academy of
Political and Social Science, 615(1), 83-99.
Deseret News. (2008). Obituary: Tiffany Cupit. www.deseretnews.com.
Dohnt, H. & Tiggemann, M. (2006). The contribution of peer and media influences to the development of body satisfaction and self-esteem in young girls:
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Eaton, D.K. et al. (2006). Youth Risk Behavior Surveillance System: United
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Fingeret, M.C., Warren, C.S., Cepeda-Benito, A., & Gleaves, D.H. (2006).
Eating disorder prevention research: A meta-analysis. Eating Disorders, 14,
191-213.
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Irving, L.M., & Neumark-Sztainer, D. (2002). Integrating the prevention of
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©2010 The University of Utah. All Rights Reserved.
Eating Disorders and Prevention
61
2010 Utah’s Health: An Annual Review
How Would Utah’s Small Businesses
be Affected by Health Care Reform?
Authors: Andrada Tomoaia-Cotisel, MHA & MPH (est 2011)
Samuel Allen, MST (est 2010)
Abstract
Current legislation before Congress proposes to mandate that businesses offer health
insurance to their employees. Small businesses would be exempt from this mandate, but
the two main bills define small businesses differently. Herein, we present the circumstances surrounding small businesses and health insurance coverage in Utah. First, we
present the effects of a health insurance mandate using the definition in the House bill
for the small business exemption (if annual payroll is less than $500,000). Second, we
repeat this process using the definition in the Senate bill (if under 50 employees). Third,
we summarize the proposed assistance to small businesses qualifying under the mandate. The House bill would require more of the small businesses currently not offering
coverage to offer coverage, while the Senate bill would not affect many Utah businesses,
given that most employers with 50 or more employees already provide health insurance
for their employees.
Correspondence
Andrada Tomoaia-Cotisel, MHA
& MPH (est 2011)
Department of Family &
Preventive Medicine
375 Chipeta Way, Suite A
Salt Lake City, UT 84108
801/581-7020
andradat@gmail.com
Samuel Allen, MST (est 2010)
Department of Family &
Preventive Medicine
375 Chipeta Way, Suite A
Salt Lake City, UT 84108
801/587-9216
samueldee@gmail.com
Key Words
small business, health insurance
mandate
62
Introduction
The high cost of health insurance has been ranked as the most severe problem for small
business owners for over 20 years according to the “Small Business Problems and Priorities” survey conducted by the National Federation of Independent Businesses.1 (Phillips,
2008, Stottlemyer, 2009). On October 29, 2009, President Obama said the following on
the importance of health insurance reform for the small business community:
So what’s at stake isn’t just the success of our businesses or the strength of our
economy or even the health of our people. What’s at stake is that most American
of ideas -- that this is a place where you can make it if you try; where you can be
your own boss; where the only limits to what you can achieve are your smarts, your
savvy, your dreams, your willingness to work hard; where you can pass on to your
children a better life than you inherited. That’s what’s at stake (The White House,
2009).
According to Christopher Chavez, the Regional Communications Director at the US
Small Business Administration 2:
• Small businesses pay up to 18% more than large firms for the same coverage.
More and more are forced to reduce or drop coverage each year.
1 This comprehensive survey is conducted every four years. Researchers ask more than 3,500 small business
owners nation-wide for their views on 75 different issues. For more information on methodology please see
the cited report.
2 This regional office covers Utah, Colorado, Wyoming, Montana, North Dakota and South Dakota.
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
• 13 million uninsured Americans work for businesses
with fewer than 100 employees. We can’t fix the problem of the uninsured without addressing the needs of
affordable health insurance for small business.
• Countless numbers of American workers want to strike
out on their own, but they suffer from “job lock” because they fear losing their health insurance for their
family (Christopher Chavez, personal communication,
December 17, 2009).
Health insurance is important to employees and employers
alike. If the health reform bill that is passed includes an employer mandate – that employers must provide health insurance coverage to their employees – small businesses would be
disproportionately affected. Therefore, both of the currentlyproposed bills suggest that an exemption be made. The exact
design of this exemption is under debate.
How would differences in the design of this exemption affect
small businesses in Utah? This article seeks to assist small
business owners and employees in exploring this question and
in fostering further discussion on the subject of health insurance coverage.
Current Status of Events
The primary actors are small business employers and small
business employees. Their perspectives are explored below.
Other actors involved in the small business health reform debate are lobbying organizations such as the US Chamber of
Commerce and the National Federation of Independent Businesses. Both are in favor of health care reform but both are
also uncomfortable with various aspects of the bills currently
before Congress (Josten, 2009; Businesses, 2009). Another
obvious actor in this debate is the United States government.
The Executive Branch has been very active in disseminating
accurate information about health reform (The White House,
2009). The Legislative Branch has been very active in writing and debating legislation. Also, public agencies3 and notfor-profit organizations are gathering and providing accurate
information to actors all sides.
The Current State of Affairs, From the Employer’s
Perspective:
One reason small businesses give for rating health insurance
as their number one problem is the unpredictable pattern of
constantly-increasing costs. Their premiums can increase up
to 15% in one year if their employee pool becomes sicker or
changes in its demographic makeup (i.e., aging) (Hawley,
2008). The price of premiums also increases for larger firms,
but they do not experience such high levels of increase from
year to year as their policies are usually underwritten without taking individual health status into account. This method
shields these firms from the risk that small businesses face –
that an aging workforce, or one very sick employee, can force
the firm to cancel its health insurance or face bankruptcy.
Another issue is the cost of administering plans. Because small
businesses do not typically have human resource departments,
managers are often required to administer health plans at
the cost of operating their business. According to Blumberg
and McMorrow, 2009: larger employers have the benefit of
“administrative economies of scale… [where the] the costs
of enrollment and other activities by plans and providers are
largely fixed costs.” The number of uninsured small business
employees in Utah is growing every year. Although there has
been yearly growth in the number of small business employees
with health insurance, this growth has been outpaced by the increasing number of people entering this workforce (see Figures
1, 2 and 3 in the appendix).
The Current State of Affairs, From the Employee’s
Perspective:
In Utah, workers are more likely to be uninsured the
smaller the business is that they are working for. The larger
the company: the more likely that it will offer health insurance
coverage, the lower the premium, the less likely that the coverage will require a deductible, if it does have a deductible – then
it will be lower, the less likely that the health insurance will
have an out-of-pocket maximum, and if it does give an out-ofpocket maximum – then it will be lower as well (see Tables 1
and 2 below).
Health reform legislation has been proposed by both Houses The State of Utah’s definition of a small business is one with
of Congress. The Senate bill exemption focuses on employers anywhere from 2 to 50 employees (Hawley, 2008). This definiwith fewer than 50 workers. Those employers not exempt and tion is in line with the Senate bill’s definition. Significant disnot offering coverage will be charged $750 per full-time
worker per year. The House bill exemption focuses on firms
Table 1: Percent of Companies Offering Health Insurance in Utah
with annual payrolls up to $500,000. Those employers not
Company Size
< 50
≥ 50
Employees
Employees
exempt and not offering coverage will be charged an 8%
payroll assessment. That rate is reduced for firms with
Percent
38.1%
92.9%
$500,000 to $750,000 payrolls (Blumberg and McMorrow,
Source: “Utah: Private Sector Coverage” Kaiser Family Foundation. (2008
data) http://www.statehealthfacts.org/profileind.jsp?cat=3&sub=46&rgn=46
2009).
3 Agencies such as: Small Business Administration, Census Bureau, Agency for Healthcare Research &Quality, etc.
©2010 The University of Utah. All Rights Reserved.
Small Business Health Reform
63
2010 Utah’s Health: An Annual Review
Table 2: Relative Insurance Costs for Employees by Firm Size
Comparison
< 25 Employees
< 50 Employees
Insufficient
Information
$4,260 for individual
coverage; $11,100 for
family coverage1
53%**
52%
44.3%
40.4%
$607***
$599***
$386
$336***
Percent with Out of
Pocket Maximum2
71.6%
71%
74.2%
75.4%
Mean Out of Pocket
Maximum2
$2,047***
$2,042****
$1,900
$1,894
Average Health
Insurance Premium
Cost
Percent with
Deductible2
Mean Deductible
Amount2
≥ 50 Employees
>1000 Employees
18% lower than for
smaller firms (<1000
employees)2
Note: Statistical significance denotes difference from all U.S. health plans in each column.
**p < .05 ***p < .01 ****p < .001
Note: the final four rows of this table present data that have been adjusted to take into consideration differences in plan-type
(benefits) offered.
Sources: (1) “Utah: Private Sector Coverage” Kaiser Family Foundation. (2008 data) http://www.statehealthfacts.org/profileind.
jsp?cat=3&sub=46&rgn=46; (2) Gabel, J. et al. “Generosity And Adjusted Premiums In Job-Based Insurance: Hawaii Is Up,
Wyoming Is Down.” Health Affairs 25: 3. (2006). Retrieved from: http://content.healthaffairs.org/cgi/content/full/25/3/832.
Table 3: Utah Industries (SIC) with 10 to 19 Employees Distributed by Geographic Region and Payroll
Industry Sector Industry
(SIC Divisions) description
Share of Utah businesses, by Region2
Utah only
Greater Utah
Estimated Payroll
1
Salt Lake County per employee
Estimated annual
payroll per firm1
11
Agriculture,
Forestry, and Fishing
1%
1%
0%
$ 32,771
$ 475,179
21
Mining
1%
1%
0%
$ 58,171
$ 843,484
48-49
Transportation,
Communications and
Public Utilities
3%
3%
3%
$ 57,897
$ 839,511
23
Construction
11%
13%
10%
$ 38,396
$ 556,746
31-33
Manufacturing
6%
6%
6%
$ 43,223
$ 626,738
42
Wholesale Trade
6%
4%
9%
$ 47,881
$ 694,277
44-45
Retail Trade
31%
31%
32%
$ 32,672
$ 473,750
51, 54, 56, 61,
62, 71, 81
Services
8%
8%
8%
$ 38,707
$ 561,245
52-53
Finance, Insurance,
and Real Estate
31%
31%
32%
$ 32,672
$ 473,750
55
Management of
companies and
enterprises (parts of
all divisions)
0%
0%
1%
$ 73,863
$ 1,071,010
92
Public
Administration3
3%
1%
5%
$ 46,300
$ 671,344
Sources: (1) United States Census Bureau. (2007). Selected Statistics by Economic Sector: 2007. County Business Patterns Survey. Retrieved from: http://factfinder.census.gov; (2) Utah State Department of Workforce Services. (2008) Salt Lake and Utah Firms. Utah State Department of Workforce Services: Information Division. Retrieved from: http://jobs.utah.gov/jsp/firmfind welcome.do#; (3) United States Census Bureau. (2009). 2008 Annual Survey of State and Local
Government Employment and Payroll. US Census Bureau. Retrieved from:http://www2.census.gov/govs/apes/08stlut.txt
Note: Light Gray = exempt from the mandate; Medium Gray = within the sliding assessment rate region; Dark Gray = not exempt; Gray all the way across =
highest share of Utah businesses
64
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 4: Utah Industries (SIC) with 20 to 49 Employees Distributed by Geographic Region and Payroll
Industry Sector
(SIC Divisions)
Industry description
11
Share of Utah businesses, by Region2
Estimated Payroll
1
Salt Lake County per employee
Estimated annual
payroll per firm1
Utah only
Greater Utah
Agriculture, Forestry,
and Fishing
1%
1%
0%
$ 32,771
$ 1,130,597
21
Mining
1%
1%
0%
$ 58,171
$ 2,006,910
48-49
Transportation,
Communications and
Public Utilities
4%
4%
4%
$ 57,897
$ 1,997,458
23
Construction
9%
10%
9%
$ 38,396
$ 1,324,671
31-33
Manufacturing
8%
7%
9%
$ 43,223
$ 1,491,203
42
Wholesale Trade
5%
3%
8%
$ 47,881
$ 1,651,899
44-45
Retail Trade
30%
32%
28%
$ 18,314
$ 631,844
51, 54, 56, 61,
62, 71, 81
Services
33%
32%
33%
$ 32,672
$ 1,127,199
52-53
Finance, Insurance,
and Real Estate
5%
3%
7%
$ 38,707
$ 1,335,376
55
Management of
companies and
enterprises (parts of
all divisions)
1%
1%
2%
$ 73,863
$ 2,548,266
92
Public
Administration3
4%
6%
1%
$ 46,300
$ 1,597,337
Note: sources and footnotes same as Table 3
parities in insurance coverage appear when comparing health
insurance statistics for employers with fewer than 50 employees with those for employers with more than 50 employees (see
Table 2 for details).
Under the House’s Health Insurance Mandate
Under the House’s exemption, firms with less than $500,000 in
annual payroll payments will be exempt from the health insurance mandate. Those employers not exempt and not offering
coverage will be charged an 8% payroll assessment. That rate is
reduced on a sliding scale for firms with $500,000 to $750,000
payrolls4. As shown in Table 1, only 38% of Utah firms with
fewer than 50 employees offer health insurance coverage to
their employees, whereas 93% of the rest of the Utah firms offer it. This legislation would increase the number of Utah firms
offering health insurance coverage in both categories. Table 3
(10 to 19 Employees) and Table 4 (20 to 49 Employees) below
show the distribution of Utah industries (based on the SIC classification system) by geographic region and payroll. They show
how industries would be differentially affected by the House
Bill health insurance mandate.
Sources: (1) United States Census Bureau. (2007). Selected
Statistics by Economic Sector: 2007. County Business Patterns
Survey. Retrieved from: http://factfinder.census.gov; (2) Utah
State Department of Workforce Services. (2008) Salt Lake and
Utah Firms. Utah State Department of Workforce Services:
Information Division. Retrieved from: http://jobs.utah.gov/
jsp/firmfind welcome.do#; (3) United States Census Bureau.
(2009). 2008 Annual Survey of State and Local Government
The “Retail Trade” industry and the “Finance, Insurance, and
Real Estate” industry (Table 3, both in green) have the highest percentage (62% total) of Utah businesses with 10 to 19
employees. Most firms in these industries would qualify for
the exemption under the House’s bill because their estimated
annual payroll per firm is less than $500,000. Although most
firms in the Construction, Manufacturing, Wholesale Trade,
Services, and Public Administration industries (34%) with
10 to 19 employees would not qualify for the exemption, they
would qualify for a lower assessment rate as their annual payrolls would be less than $750,000. The remaining industries
(4%) would not be exempt. For a more detailed breakdown
please see Table 5 in the appendix.
The “Retail Trade” industry and the “Services” industry (Table
4, yellow and orange) have the highest percentage (63% total)
of Utah businesses with 20 to 49 employees. Most firms in both
of these industries would not qualify for the exemption. However, most firms in the Retail Trade industry would qualify for
the lower assessment rate. Most of those firms in the Services
4. The reduced assessment rate, based on the annual payroll amount, is as follows: none (for less than $500,000 payroll), 2% of payroll (for $500,000 to
$584,999), 4% of payroll (for %585,000 to $669,999), and 6% of payroll (for $670,000 to $749,999).
©2010 The University of Utah. All Rights Reserved.
Small Business Health Reform
65
2010 Utah’s Health: An Annual Review
industry would not as their estimated annual payroll per firm
is over $1,000,000. The remaining industries (37%) would not
qualify for the lower assessment rate. They would either have
to start providing health insurance coverage to their employees
or pay an 8% assessment on their payroll to the Health Insurance Exchange Trust Fund. For a more detailed breakdown
please see Table 6 in the appendix.
Under the Senate’s Health Insurance Mandate
Under the Senate’s exemption, firms with fewer than 50
employees would be exempt, while those with more than 50
employees would not. This is also the dividing line between a
majority and a minority of companies offering insurance coverage (see Table 2). Therefore, the Senate’s definition for the
small business exemption would do little more than reinforce
the coverage gap status quo. It would require the remaining 7%
of large employers not currently providing health insurance
coverage to provide it. It would not affect smaller employers.
We have considered the possibility that the exemption be
modified to only cover employers with 25 or fewer employees
and present our analysis in this paper (see Table 7 below). This
would require the firms within the range of 25-49 employees
who currently do not provide insurance to do so. Since health
coverage information for firms in this specific group is not
available it is difficult to say just how many firms would be affected (see Table 9 below for information on firms with 20-49
employees in Utah).
Benefits
The Kaiser Family Foundation reports that 38% of Utah firms
with fewer than 50 employees currently offer coverage (Claxton, 2009). Expanding the insurance mandate to all firms with
over 25 employees would allow employees to devote elsewhere
that 10% of their wages used for uncovered care—approximately $3,255 per employee per year, or approximately $251
million per year in Utah (The White House, 2009). It would
also decrease the amount of uncompensated care. At present,
it is estimated that providers in Utah lose $316 million in uncompensated care each year (The White House, 2009). This
amount would be reduced because approximately 100,000
small business employees would no longer be uninsured under
this plan. Cost for their care would no longer be shifted to hospitals, and then to the insured through higher insurance costs.
The Utah Department of Workforce Services provides insight
into how this bill may affect Utah’s economy (see Tables 8 and
9 below). First, small business employees tend to earn less than
those working in larger establishments (Utah Department of
Workforce Services: Workforce Development & Information
Division, 2008). Employees of businesses with 20-49 employees earn 10% less, on average, than their peers at firms with
66
Small Business Health Reform
50-99 employees. For these smaller firms, individual employees earned almost half of the median household income in
Utah (Claxton, 2009). While households of employees of larger
firms are able to reach the median with one wage earner and
one part time wage earner, ones with small business employees
need to have two full time wage earners just to reach median
income (Utah Department of Workforce Services: Workforce
Development & Information Division, 2008;Claxton, 2009).
Therefore, if this mandate were to expand, it would expand
coverage to needy working families.
Employers with between 20 and 49 employees provide jobs
for 18% of Utah’s workforce (See Table 10 in the appendix).
These jobs provide 15% of Utah families’ income from work.
Small businesses affected by this policy operate in every major
industry in Utah, however certain industries will be more affected than others, and many small businesses will be exempt
(see Table 11 and 12 in the appendix). Those industries affected
in Salt Lake County are: arts, entertainment, and recreation;
utilities; and management of companies and enterprises (67%
of total) (Department of Workforce Services, 2009). In other
parts of the state, these are: arts, entertainment, and recreation;
educational services, and public administration (64% of total).
It is apparent that the arts, entertainment and recreation industry will be most affected throughout the state. While this
industry would have the greatest burden in offering coverage,
they would benefit by being able to better find and keep skilled
employees, a problem ranked very highly on these firms’ priority problems list (Phillips, 2008). Management of companies is
the highest-paid industry in the state, with an average salary
of over $70,000 (United States Census Bureau, 2008). Most
likely these employees already receive coverage. In regard to
the other three most-affected industries, all of them are capable
of navigating regulatory framework of state, local, and federal
grants, so accommodation to the legislation should not represent an excessive burden to firms in these industries. In other
words, Utah’s most-affected industries would be expected to
be resilient through such a transition. If the currently proposed
definition were to be modified to only cover employers with 25
or fewer employees, we do not expect the state economy to face
a significant shock from this legislation.
Providing health insurance coverage benefits employers as
well as employees. Employers can expect to save money on not
just brokerage fees and the cost of administering health plans,
but also on easier recruitment and higher retention. They can
expect to earn money through improved productivity gains.
Employees can expect to enjoy the benefits of affordable health
insurance coverage for them and their families, thus improving
employee morale and job performance (Council, 2003).
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 7: A Possible Change to a 25 Employee Cap – Benefits and Further Considerations
Benefits
Further Considerations
• Facilitating increased insurance coverage
for small businesses employees
• Facilitating the transition period for businesses newly
providing coverage
• Assisting needy working families in
obtaining affordable coverage
• Recognizing that almost all Utah industries will be
affected by setting the cap at 25
• Improving employee morale, health, recruitment and retention
Table 8: Average Wage by Employer Size
Employer Size
Number of Employees
Small
Mid-Size
Large
Average Annual Wage
0-49
$32,555
50-499
$38,433
500 & Over
$42,408
Overall
$36,745
Source: Utah Department of Workforce Services, Workforce Development & Information
Division, Utah Employers, Employment and Wages by Size, 2008
Table 9: Average Annual Wages by Employer Size, Utah, 2008
Data by employer size category
Differences between categories
Employer Size
(number of
employees)
Number of
firms in each
category
Fulltime
jobs for each
category
Average annual
wage in each
Wage gap with
next larger
category
Percent
difference
Full-time jobs to reach
median household
income*
0
12,284
0
$38,532
**
1-4
36,420
71,387
$37,428
$-6,984
-19%
1.6
5-9
14,455
96,438
$30,444
$-60
0%
1.9
10-19
10,205
137,823
$30,384
$2,892
10%
1.9
20-49
7,098
214,588
$33,276
$3,480
10%
1.8
50-99
2,768
189,944
$36,756
$2,148
6%
1.6
100-249
1,258
187,562
$38,904
$1,476
4%
1.5
250-499
340
118,281
$40,380
$3,612
9%
1.5
500-999
117
78,211
$43,992
$-2,364
-5%
1.3
1000 & Over
62
158,866
$41,628
1.5
1.4
Source: Utah Department of Workforce Services, Workforce Development & Information Division, Utah Employers, Employment and Wages by Size, 2008
* Note: 2008 Utah Median household income, based on 2006-2008 yearly average is $58,820. (Source: Kaiser Family Foundation. State Health Facts. Kaiser
Family Foundation; 2009; Available from: http://www.statehealthfacts.org/profileind.jsp?rgn=46&cat=1&ind=15). The average annual wage for a full-time job
in Utah $36,745. Therefore, on average Utah households require 1.6 full time jobs to reach the median. Source: Utah Department of Workforce Services.
** Note: Wage gaps show the difference between employee earnings, and businesses in this category do not have employees.
Conclusion
Facilitating Mandated Coverage
Since the submission of this paper a legislative decision has
been made. On March 23, 2010, President Obama signed the
Patient Protection and Affordable Care Act into law. This law
works to change the relationship that patients, their employers,
and health care providers have with health insurance companies. How its provisions will be implemented (and potentially
amended) remains to be seen. The list below highlights key
points of this legislation specifically related to small business
employers (based on the Kaiser Family Foundation summary,
2010).
• Employers with more than 50 employees are required to
either provide health insurance coverage or pay a fee8.
(Those with fewer than 50 employees are exempt.)9
8. For employers with more than 50employees that do not offer coverage and have at least one full-time employee receiving a premium tax credit, the fee is
$2000/full-time employee, for the 31st employee onward. For those employers offering coverage but with at least one full time employee receiving the tax credit,
the fee is the lesser of $3,000 for each such employee or $2,000/full time employee (effective 2014) (KFF, 2010).
9. If the coverage provided requires employees with income less than 400% federal poverty level to pay a premium between 8% and 9.4% of their income, and
if those employees choose to enroll in the Exchange instead, then the employer is required to provide a free choice voucher to those employees (so as not to pay
penalties). If the employee’s portion of the premium is more than 9.5% of his/her income, then the employee will be eligible for premium tax credits (KFF, 2010).
©2010 The University of Utah. All Rights Reserved.
Small Business Health Reform
67
2010 Utah’s Health: An Annual Review
• Employers with 25 or fewer employees and average
annual wage of less than $50,000, who purchase health
insurance for their employees will be provided with a
tax credit10,11.
• State-based American Health Benefit Exchanges and
Small Business Health Options Program (SHOP) Exchanges will be create12.
• Small employers that establish wellness programs will
be provided grants in support of these efforts (for up to
five years).
Most Utah small businesses currently do not offer health insurance coverage for their employees. It is likely that few of
these firms currently have established wellness programs. This
legislation will assist more than 91% of Utah businesses with
fewer than 50 employees in accessing affordable health insurance for their employees should they so choose. Assuming that
each full time job in this category represents one person, this
would imply that up to 300,000 people (or 51%) could bring
home coverage to them and their families who have not previously had it. With this coverage, they will be able to access
preventive care as well as urgent care when they need it, and
at a price that they can afford. We expect that this increased
access to quality health care will improve the health and quality of life of people in Utah and those small businesses that
participate will also reap significant benefits. References
Blumberg, L. J. & McMorrow, S. (2009). What Would Health Care Reform
Mean for Small Employers and Their Workers? Timely Analysis of Immediate Health Policy Issues. Urban Institute. Retrieved from: http://www.urban.
org/url.cfm?ID=411997
Corporate Leadership Council. (2003). Linking Employee Satisfaction with
Productivity, Performance, and Customer Satisfaction. Corporate Executive
Board. Retrieved from: http://www.keepem.com/doc_files/clc_articl_on_
productivity.pdf
Gabel, J. et al. (2006). Generosity and Adjusted Premiums in Job-Based
Insurance: Hawaii Is Up, Wyoming Is Down. Health Affairs 25:3. Retrieved
from: http://content.healthaffairs.org/cgi/content/full/25/3/832.
Hitt, G. & Adamy, J. (2009). Democrats Secure 60 Votes on Health Bill.
The Wall Street Journal. Retrieved from: http://online.wsj.com/article/
SB126123257035198659.html
Josten, R. (2009). Letter to Chairman Baucus and Ranking Member Grassley regarding ‘America’s Healthy Future Act’. US Chamber of Commerce.
Retrieved from: http://www.uschamber.com/NR/rdonlyres/epiwcxte7ymtjcbrzwdpeqdgpos2pfoo6eosa24uhje6d7n3pe3prfynkkeb633n2qrdzzpdxdedu7j6nic6e3rz76d/090923_healthcarebaucus.pdf
Kaiser Family Foundation and Health Research & Educational Trust. (2008).
Utah: Private Sector Coverage. The Kaiser Family Foundation, Health and
Research Education Trust, and National Opinion Research Center. Retrieved
from: http://www.statehealthfacts.org/profileind.jsp?cat=3&sub=46&rgn=46
Kaiser Family Foundation and Health Research & Educational Trust. (2009).
Kaiser/HRET Employer Health Benefits Survey 2009. The Kaiser Family
Foundation, Health and Research Education Trust, and National Opinion
Research Center. Retrieved from: http://ehbs.kff.org
Kaiser Family Foundation and Health Research & Educational Trust. (2009).
Utah: Median Annual Household Income, 2006-2008. The Kaiser Family
Foundation, Health and Research Education Trust, and National Opinion
Research Center. Retrieved from: http://www.statehealthfacts.org/profileind.
jsp?rgn=46&cat=1&ind=15
Kaiser Family Foundation and Health Research & Educational Trust. (2010).
Summary of New Health Reform Law. Focus on Health Reform. Retrieved
from: http://www.kff.org/healthreform/8061.cfm
Kaiser Family Foundation and Health Research & Educational Trust. (2010).
Summary of Coverage Provisions in the Patient Protection and Affordable
Care Act. Retrieved from: http://www.kff.org/healthreform/upload/8023-R.
pdf
Kaiser Family Foundation and Health Research & Educational Trust. (2010).
Implementation Timeline. Focus on Health Reform. Retrieved from: http://
www.kff.org/healthreform/8060.cfm
National Federation of Independent Businesses. (2009). Healthcare Reform
and Small Business. National Federation of Independent Businesses. Retrieved from: http://www.nfib.com/issues-elections/healthcare/.
Nielsen, J. T. (2009). Health Reform Update Brownbag with John T. Nielsen.
Future Healthcare Leaders of America.
Phillips, B.D. & Wade, H. (2008). Small Business Problems and Priorities.
National Federation of Independent Businesses. Retrieved from: www.nfib.
com/Portals/0/ProblemsAndPriorities08.pdf
State of Utah Department of Insurance. (2008). 2008 Health Insurance
Market Report. Utah State Department of Insurance. Retrieved from: www.
insurance.utah.gov/health/documents/2008HlthInsMrktRprt.pdf
State of Utah Department of Workforce Services. (2008). Utah Employers:
Employment and Wages by Size. Utah Department of Workforce Services:
Workforce Development & Information Division. Retrieved from: http://jobs.
utah.gov/opencms/wi/pubs/em/ueews/
State of Utah Department of Workforce Services. (2009). FirmFind. State of
Utah Department of Workforce Services. Retrieved from: http://jobs.utah.
gov/jsp/firmfind/welcome.do#
Stottlemyer, T. (2009). The Voice of Small Business: Looking for a Change in
Healthcare. National Federation of Independent Businesses. Retrieved from:
http://www.nfib.com/newsroom/newsroom-item/cmsid/46829/
The White House. (2009). Remarks by the President on Small Businessess
and Health Insurance Reform. The White House. Retrieved from: http://www.
whitehouse.gov/the-press-office/remarks-president-small-businessess-andhealth-insurance-reform
United States Census Bureau. (2007). Statistics of US Businesses, All Industries, Utah: 2006. United States Census Bureau. Retrieved from: http://www.
census.gov/epcd/susb/latest/ut/UT--.HTM
United States Census Bureau. (2007). Selected Statistics by Economic
Sector: 2007. County Business Patterns Survey. US Census Bureau.
10. Phase I: (2010 – 2013) Employers with 10 or fewer employees and average annual waves of less than $25,000 would be given the full tax credit of up to 35%
of the employer’s contribution toward the employee’s health insurance premium if that contribution is 50% or more of the benchmark premium. The tax credit is
reduced as firms become larger and as the average annual wage increases (to the cap of 25 employees and $50,000 average annual wage). Similar tax exempt businesses will receive 25% tax credit (as described above) (KFF, 2010).
11. Phase II: (2014 – onward) Employers in this group who offer health insurance coverage through the Exchange and contribute at least 50% of the total premium
cost will receive a tax credit of up to 50% of what the employer pays. (tired in the same manner as Phase I). Similar tax exempt businesses will receive 35% tax
credit (as described above). The employer will be able to take advantage of this tax credit for two years (KFF, 2010).
12. At first, they will be limited to individuals and small businesses (with up to 100 employees). Beginning in 2017, larger employers will also be able to participate (KFF, 2010).
68
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Retrieved from: http://factfinder.census.gov/servlet/GQRTable?_bm=y&q r _ n a m e = E A S _ 2 0 0 7_ C B P G Q RT4 & - g e o _ i d = 0 4 0 0 0 U S 4 9 & - d s _
name=CB0700A1
United States Census Bureau. (2009). 2008 Annual Survey of State and
Local Government Employment and Payroll. US Census Bureau. Retrieved
from:http://www2.census.gov/govs/apes/08stlut.txt
United States Census Bureau. (2008). Utah: Table 1, Selected Statistics by
Economic Sector: 2007. United States Census Bureau. Retrieved from: http://
factfinder.census.gov/servlet/GQRTable?_bm=y&-geo_id=04000US49&ds_name=CB0700A1&-_lang=en.
Appendix of Tables and Figures
Figure 1: Small Business Employees in Utah
Insured Employees
Number in Small Business Market
250000
240000
230000
220000
y = 3933.x - 8E+06
R² = 0.625
210000
200000
190000
1998
2000
2002
2004
2006
2008
Year
Source: Hawley, J.E. “2008 Health Insurance Market Report.” Utah Insurance Department. December 16, 2008
Note: These data are for comprehensive insurance only, as reported by the Utah Insurance Department.
Note: Small business is defined as a business with between two and 50 employees.
Figure 2: Small Business Employees in Utah
Total Employees
Figure 3: Small Business Employees in Utah
Total Employees
540000
520000
y = 11216x - 2E+07
R² = 0.881
500000
480000
460000
440000
420000
520000
y = 19493x - 4E+07
R² = 0.984
500000
480000
460000
440000
420000
400000
1998
Number in Small Business Market
Number in Small Business Market
540000
2000
2002
Year
2004
2006
2002
2004
2006
Year
Source: These tables were created with data from Utah Department of Workforce Services, Workforce Development & Information Division, Utah Employers,
Employment and Wages by Size, 2008.
Note: As the trend seems to have changed starting in 2003, a second graph was made with a new trend line following the sharper trend.
©2010 The University of Utah. All Rights Reserved.
Small Business Health Reform
69
2010 Utah’s Health: An Annual Review
Table 5: Utah Industries (NAICS) with 10 to 19 Employees Distributed by Geographic Region and Payroll
Share of Utah businesses, by Region2
Industry
description
(NAICS)
Industry description
11
Agriculture, forestry, fishing and
hunting
1%
1%
0%
$32,771
$475,179
21
Mining
1%
1%
0%
$58,171
$843,484
Utah only
Greater Utah
Salt Lake
County
Estimated
Payroll per
employee1
Estimated
annual payroll
per firm1
22
Utilities
0%
1%
0%
$75,150
$1,089,673
23
Construction
12%
13%
10%
$38,396
$556,746
31-33
Manufacturing
6%
6%
6%
$43,223
$626,738
42
Wholesale trade
6%
4%
9%
$47,881
$694,277
44-45
Retail trade
18%
19%
16%
$23,573
$341,812
48-49
Transportation and warehousing
3%
3%
3%
$40,645
$589,350
51
Information
2%
2%
2%
$47,867
$694,068
52
Finance and insurance
5%
5%
5%
$46,403
$672,847
53
Real estate and rental and leasing
3%
2%
3%
$31,010
$449,643
54
Professional, scientific, and technical
services
7%
5%
9%
$47,432
$687,767
55
Management of companies and
enterprises
0%
0%
1%
$73,863
$1,071,010
56
Administrative and Support and
Waste Management and Remediation
Services
5%
4%
5%
$27,146
$393,611
61
Educational services
2%
2%
2%
$22,749
$329,862
62
Health care and social assistance
10%
11%
9%
$37,587
$545,017
71
Arts, entertainment, and recreation
1%
1%
1%
$18,235
$264,414
72
Accommodation and food services
13%
13%
12%
$13,055
$189,303
81
Other services (except public
administration)
5%
5%
6%
$27,691
$401,514
92
Public Administration3
3%
1%
5%
$46,300
$671,344
Sources: same as Table 3
Note: Light Gray = exempt from the mandate; Medium Gray = within the sliding assessment rate region; Dark Gray = not exempt; Gray all
the way across = highest share of Utah businesses
70
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 6: Utah Industries (NAICS) with 20 to 49 Employees Distributed by Geographic Region and Payroll
Share of Utah businesses, by Region2
Estimated
Payroll per
employee1
Estimated
annual payroll
per firm1
Industry
description
(NAICS)
Industry description
11
Agriculture, forestry, fishing and
hunting
1%
1%
0%
$ 32,771
$ 1,130,597
21
Mining
1%
1%
0%
$ 58,171
$ 2,006,910
22
Utilities
1%
1%
1%
$ 75,150
$ 2,592,670
23
Construction
10%
11%
9%
$ 38,396
$ 1,324,671
Utah only
Greater
Utah
Salt Lake
County
31-33
Manufacturing
8%
7%
9%
$ 43,223
$ 1,491,203
42
Wholesale trade
5%
3%
8%
$ 47,881
$ 1,651,899
44-45
Retail trade
13%
14%
12%
$ 23,573
$ 813,278
48-49
Transportation and warehousing
3%
3%
3%
$ 40,645
$ 1,402,246
51
Information
3%
3%
3%
$ 47,867
$ 1,651,403
52
Finance and insurance
4%
2%
5%
$ 46,403
$ 1,600,913
53
Real estate and rental and leasing
1%
1%
2%
$ 31,010
$ 1,069,840
54
Professional, scientific, and technical
services
7%
6%
8%
$ 47,432
$ 1,636,412
55
Management of companies and
enterprises
1%
1%
2%
$ 73,863
$ 2,548,266
56
Administrative and Support and
Waste Management and Remediation
Services
5%
4%
6%
$ 27,146
$ 936,522
61
Educational services
5%
7%
3%
$ 22,749
$ 784,845
62
Health care and social assistance
9%
9%
8%
$ 37,587
$ 1,296,765
71
Arts, entertainment, and recreation
2%
3%
2%
$ 18,235
$ 629,122
72
Accommodation and food services
18%
20%
16%
$ 13,055
$ 450,411
81
Other services (except public administration)
3%
3%
4%
$ 27,691
$ 955,326
92
Public Administration3
4%
6%
1%
$ 46,300
$ 1,597,337
Sources: same as Table 3
Note: Light Gray = exempt from the mandate; Medium Gray = within the sliding assessment rate region; Dark Gray = not exempt; Gray all
the way across = highest share of Utah businesses
©2010 The University of Utah. All Rights Reserved.
Small Business Health Reform
71
2010 Utah’s Health: An Annual Review
Table 10: Contribution of Firms to Utah’s Economy, by Employer Size
Employer Size (number
of employees)
Contribution to Total
State Payroll
0
Contribution to Total
State Employment
0%
Cumulative
Contribution to Total
State Payroll
0%
Cumulative
Contribution to Total
State Employment
0%
0%
1-4
6%
6%
6%
6%
5-9
7%
7%
13%
13%
10-19
9%
11%
22%
24%
20-49
15%
18%
37%
42%
50-99
15%
15%
52%
57%
100-249
16%
15%
68%
72%
250-499
10%
9%
78%
81%
500-999
8%
6%
86%
87%
1000 & Over
14%
13%
100%
100%
Source: Utah Department of Workforce Services, Workforce Development & Information Division, Utah Employers, Employment and
Wages by Size, 2008
Note: Payroll figures are based on the amount paid out by firms in this category in wages. Employment figures are based on the number of
fulltime jobs provided by employers in each category
Table 11: Salt Lake County Small Business Concentration of Industries by Employer Size
Count of
businesses
0-19
Count of
businesses
20-49
Count of
businesses
50 +
Percent
industry 0-19
Percent
industry 20-49
Percent
industry 50 +
1573
552
209
67%
24%
9%
Utilities
45
18
15
58%
23%
19%
Management of Companies
and Enterprises
145
54
66
55%
20%
25%
Food Manufacturing
1239
272
217
72%
16%
13%
Educational Services
408
89
257
54%
12%
34%
Industry
Arts, Entertainment, and
Recreation
Air Transportation
753
104
104
78%
11%
11%
Information
693
90
69
81%
11%
8%
Motor Vehicle and Parts
Dealers
3040
376
292
82%
10%
8%
85
10
10
81%
10%
10%
Mining, Quarrying, and Oil
and Gas Extraction
Source: Department of Workforce Services. FirmFind. Salt Lake City, UT: Department of Workforce Services; 2009 [cited 2009 December 18, 2009]; Available from: http://jobs.utah.gov/jsp/firmfind/welcome.do.
72
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 12: Other Utah Counties Small Business Concentration of Industries by Employer Size
Industry
Arts, Entertainment, and
Recreation
Count of
businesses
0-19
Count of
businesses
20-49
Count of
businesses
50 +
Percent
industry 0-19
Percent industry
20-49
Percent
industry 50 +
2443
895
271
68%
25%
8%
Educational Services
612
279
451
46%
21%
34%
Public Administration
1029
254
136
73%
18%
10%
Food Manufacturing
1646
288
250
75%
13%
11%
Utilities
215
30
11
84%
12%
4%
Information
726
101
52
83%
11%
6%
Mining, Quarrying, and Oil
and Gas Extraction
359
51
53
78%
11%
11%
Management of Companies
and Enterprises
185
25
19
81%
11%
8%
Agriculture, Forestry,
Fishing and Hunting
285
36
12
86%
11%
4%
Motor Vehicle and Parts
Dealers
4624
532
318
84%
10%
6%
Source: Department of Workforce Services. FirmFind. Salt Lake City, UT: Department of Workforce Services; 2009 [cited 2009 December 18, 2009]; Available from: http://jobs.utah.gov/jsp/firmfind/welcome.do.
Figure 4: Distribution of Full Time Jobs by Employer Size in Utah
6%
8%
Eligible for Assistance
11%
Required to Provide
Health Insurance
c
58%
17%
Not Eligible for Assistance
Employer Size:
©2010 The University of Utah. All Rights Reserved.
0
1-4
5-9
10-19
20-49
50-99
Small Business Health Reform
73
2010 Utah’s Health: An Annual Review
Figure 5: Distribution of Firms
by Employer Size in Utah
Required to Provide
Health Insurance
8%
Not Eligible for Assistance
5%
14%
12%
17%
Employer Size:
0
1-4
43%
5-9
10-19
20-49
Eligible for Assistance
50-99
Figures 4 and 5 present information given in Table 9 with the addition of information regarding key points of the Patient Protection and Affordable Care Act
as they relate to particular business sizes. Fifty eight percent of jobs in Utah are at firms with more than 50 employees (5% of all Utah firms), firms that will be
required to provide health insurance--93% of firms in this group already do (see Figures 4 & 5, Table 13, and their sources). Of the remaining 42% of jobs (those
in the 95% of Utah firms with fewer than 50 employees), over 51% of jobs are at firms that will be eligible for assistance should the firms choose to provide health
insurance to their employees--38% of firms in this group already do. Of those firms with fewer than 50 employees, over 91% will be eligible for assistance should
they choose to provide health insurance to their employees.
Table 13: Utah Industries (SIC) with 10 to 19 Employees Distributed by Geographic Region and Payroll
Industry Sector
(SIC Divisions)
Share of Utah businesses, by Region2
Industry description
Utah only
Greater Utah
Salt Lake
County
Estimated
Payroll per
employee1
11
Agriculture, Forestry, and Fishing
1%
1%
0%
$ 32,771
21
Mining
1%
1%
0%
$ 58,171
48-49
Transportation, Communications and
Public Utilities
3%
3%
3%
$ 57,897
23
Construction
11%
13%
10%
$ 38,396
31-33
Manufacturing
6%
6%
6%
$ 43,223
42
Wholesale Trade
6%
4%
9%
$ 47,881
44-45
Retail Trade
31%
31%
32%
$ 32,672
51, 54, 56, 61, 62,
71, 81
Services
8%
8%
8%
$ 38,707
52-53
Finance, Insurance, and Real Estate
31%
31%
32%
$ 32,672
55
Management of companies and
enterprises (parts of all divisions)
0%
0%
1%
$ 73,863
92
Public Administration 3
3%
1%
5%
$ 46,300
Sources: same as Table 3
Over two thirds of Utah small businesses with 10 -19 employees are in the retail trade (one third) and in finance, insurance and real estate (one third). As their
average annual wages are under $50,000, they will be able to take advantage of this assistance, should they choose to do so. The small businesses of this size that
will not be able to take advantage of this assistance are those in mining, transportation communication and public utilities, and management of companies and
enterprises–comprising four percent of Utah businesses in this category. Larger small businesses (with more than 25 employees) will not be eligible for this assistance. Two thirds of Utah businesses in this category are in the retail trade (about one third) and in services (one third).
74
Small Business Health Reform
©2010 The University of Utah. All Rights Reserved.
UH Review 2010
Utah’s Health: An Annual Review
2010 Utah Legislative Review
Pages 77─87
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu
2010 Utah’s Health: An Annual Review
Legislative Review
Author:
Michael J. Rasmussen
The 2010 General Legislative Session saw state officials continuing to deal with the effects of the previous year’s staggering
budget shortfall. The 2010 budget continued the trend of budget
cuts, although not nearly as drastic as in 2009. The Department
of Health saw an overall budget decrease of $45,214,500 (2.0%)
from the previous year’s allocation. On a more positive note,
the General Fund increased by $38,067,700 (14.3%). However,
this increase from 2009 to 2010 can mostly be explained by the
swapping of General Fund monies for federal stimulus monies.
The following are notable budget items from the current year’s
activities:
•
Medicaid saw a $17,137,500 increase to address inflation
and anticipated caseload growth.
•
Medicaid received $3,000,000 to update and replace a
1975-style Medicaid Management Information System.
•
edicaid received $3,386,800 for the Department to
M
decrease fraud, waste, and abuse in Medicaid.
•
An Executive Order that reduced Department of Health
personnel services by 3%, or $687,000.
•
ne-time funding swaps exchanged ($4,226,100) in
O
FY 2010 and ($7,180,000) in FY 2011 for other funding
sources, primarily from the Medicaid Restricted and
Tobacco Settlement Accounts.
Aside from these budget issues, the 2010 General Legislative
Session focused on the debate (and subsequent passage) of federal health care reform. The legislature largely voted against
the federal efforts, and it continued support for state innovation and reform efforts.
In its formally declared opposition to the federal health care
reform, and the requirements of individuals to purchase private
health care coverage, the legislature listed out health care market reform efforts and innovations that they have implemented
in the State to show their ability to reform the health care market without federal intervention.
©2010 The University of Utah. All Rights Reserved.
Passed Bills
HOUSE BILL 12
Criminal Homicide and Abortion Amendments
Sponsor: C. Wimmer
Cosponsors: J. Anderson, C. Frank, K. Gibson, K. Grover, C.
Herrod, G. Huges, R, Lockhart, M. Morley, C. Oda. K. Sumison
This bill amends provisions of the Utah Criminal Code. The
bill describes the difference between an abortion and criminal homicide and removes prohibitions against prosecution
of a woman for killing or committing criminal homicide of
an unborn child. It clarifies that a woman is not criminally
liable for seeking to obtain, or obtaining, an abortion that is
permitted by law. It also declares that a woman is not guilty
of criminal homicide of her unborn child if the death of the
unborn child is caused by a criminally negligent act or by an
intentional, knowing, or reckless act of the woman. This bill
passed through the legislature, but was vetoed by the governor.
HOUSE BILL 20 Substitute
Amendments to Health Insurance Coverage in State Contracts
Sponsor: J. Dunnigan
This bill amends and clarifies provisions related to the requirement that contractors and subcontractors with state design,
construction, or transit entities must provide qualified health
insurance to their employees and the dependents of the employees who work or reside in the state. This bill clarifies a
minimum standard for coverage and that the application of a
waiting period for health insurance may not exceed the first of
the month following 90 days of the date of hire.
HOUSE BILL 25
Health Reform – Administrative Simplification
Sponsor: M. Newbold
This bill provides uniform language for divorce decrees and
child support orders related to the coordination of health insurance benefits when a dependent child of the marriage is covered
by both parents’ health insurance policies. The bill establishes
a coordination of benefits process for health insurance claims
based primarily on national standards. Also included in the
2010 Legislative Review
77
2010 Utah’s Health: An Annual Review
bill is a coordination of benefits guide will be published and
also posted on the state insurance exchange. Additional work
will be done to develop uniform standards for the electronic
exchange of health insurance claims.
HOUSE BILL 28
Controlled Substances Database Amendments
Sponsor: B. Daw
Cosponsors: T. Beck, P. Ray, F.J. Seegmiller
By amending and recoding the provisions relating to the
Controlled Substance Database, this bill requires individuals,
other than a veterinarian, who are currently licensed, renewing a license, or applying to become licensed to prescribe a
controlled substance to register to use the database. As part of
this registration, the individual must also take an online tutorial and pass a test that is to be developed by the Division of
Occupational and Professional Licensing (DOPL). To pay for
this requirement, DOPL will impose a fee on the individual
who takes the test.
HOUSE BILL 35 Second Substitute
Controlled Substance Database Reporting of Prescribed Controlled Substance Overdose or Poisoning
Sponsor: B. Daw
Cosponsors: T. Beck, P. Ray, F.J. Seegmiller
The bill amends the Utah Health Code, the Utah Controlled
Substances Act, and related provisions to require that when a
person 12 years of age or older is admitted to a hospital for
poisoning or overdose of a controlled substance the hospital
must report the incident to the Division of Occupational and
Profession Licensing (DOPL). DOPL must then notify each
practitioner who may have written a prescription for the controlled substance. To pay for this requirement, the licensing
fee for manufacturing, producing, distributing, dispensing,
conducting research, will be increased by DOPL.
HOUSE BILL 39 Substitute
Insurance Related Amendments
Sponsor: J. Dunnigan
This bill modifies the Insurance Code and related provisions to
make various amendments. This bill modifies Utah mini-COBRA benefits for employer group coverage to allow an insured
to extend the employee’s group coverage under the current employer’s group policy beyond 12 months to the period of time
the insured is eligible to receive assistance according with the
American Recovery and Reinvestment Act of 2009. The bill
also makes an employee or dependent of an employee eligible
to enroll for group coverage within 60 days if the employee or
dependent loses coverage of Medicaid or a state child health
benefit plan.
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HOUSE BILL 52
Uniform Electronic Standards – Insurance Information
Sponsor: M. Newbold
The bill amends provision related to uniform electronic
standards for health insurance claims processing, electronic
insurance eligibility information, and electronic information
regarding the coordination of benefits. Beginning January 1,
2011 all health benefit, dental, and vision plans must provide
uniform information through electronic exchange regarding
eligibility and coverage information and coordination of benefits information. Uniform claim forms and billing information
will also be established.
HOUSE BILL 66 Second Substitute
Prosthetic Limb Health Insurance Parity
Sponsor: D. Litvack
This bill amends the Insurance Code to require an insurer that
provides a health benefit plan to offer at least one benefit plan
that covers prosthetic devices beginning January 1, 2011. At
that time the insurer must also provide at least one plan with
prosthetic coverage with a coinsurance rate of at least 80% to
be paid by the insurer, with 20% to be paid by the insured if the
prosthetic is purchased by from provider who is approved by,
or contracted with, the insurer.
HOUSE BILL 67 Substitute
Health System Amendments
Sponsor: C. Wimmer
Cosponsor: J. Anderson, B. Daw, B. Dee, J. Dougall, C. Frank,
G. Froerer, F. Gibson, K. Gibson, R. Greenwood, K. Grover,
W. Harper, C. Herrod, G. Hughes, E. Hutchings, R. Lockhart,
J. Mathis, M. Morley, M. Newbold, M. Noel, C. Oda, P. Painter,
P. Ray, S. Sandstrom, K. Sumison, R. Wilcox, B. Wright
This bill prohibits a state agency or department from implementing federal health care reform passed by the United States
Congress unless that state agency reports to the Legislature
regarding cost and impact on state reform efforts. This bill
presents the Legislature findings that federal health reform
threatens Utah’s efforts made towards state health reform. The
bill prohibits an individual in the state from being required to
obtain or maintain health insurance and declares individuals
not liable for any penalty or fee as a result of that. Reiterated in
the bill is the provision that the Legislature may pass legislation specifically authorizing or prohibiting the state’s compliance with, or participation in, federal health care reform.
HOUSE BILL 86
Department of Human Services – Review and Oversight
Sponsor: R. Lockhart
This bill amends provision of the Open and Public Meetings
Act to require that meetings of the Health and Human Services
Interim Committee and the Child Welfare Legislative Over-
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
sight Panel where individual cases are reviewed to be closed
meetings. The bill requires that investigations of abuse or neglect of a child who is in the custody of the Division of Child
and Family Services shall be conducted by an independent
child protective service investigator from the private sector.
The bill amends the Government Records Access and Management Act to permit the disclosure of fatality review reports and
related documents to the Office of Legislative Research and
General Counsel, the chairs of the Health and Human Services
Interim Committee, and the Child Welfare Legislative Oversight Panel.
HOUSE BILL 88
Electronic Cigarette Restrictions
Sponsor: R. Menlove
This places restrictions on the provision, obtaining, and possession of an electronic cigarette. The bill defines an electronic
cigarette as any device, other than a cigarette or cigar, intended
to deliver vapor containing nicotine into a person’s respiratory
system. This bill makes it a class A misdemeanor to knowingly
acquire, use, display, or transfer a false or altered driver license
certificate or identification card to procure an electronic cigarette. The bill makes it a class C misdemeanor for an 18 year
old person to buy or attempt to buy, or to accept or possess an
electronic cigarette.
HOUSE BILL 92 Substitute
Moist Snuff Taxation Revisions
Sponsor: B. Daw
Cosponsors: T. Beck, L. Black, R. Lockhart
This bill amends the definition of “moist snuff” to include a
designation of at least 45% moisture content and provides additional packaging and distribution clarifications. The bill also
places greater documentation requirements regarding moisture
content on the manufacturer. The bill places responsibility for
payment of any underpaid on nonpaid tobacco taxes on the
manufacturer and not on a person.
HOUSE BILL 110
County Jail Inmate Medical Costs
Sponsor: B. Daw
This bill provides that a county will pay for the medical needs
of a person charged with or convicted of a criminal offense and
committed to the county jail, to the extent that the expenses exceed any private insurance in effect that covers those expenses.
The bill also provides that the county may seek reimbursement
for the costs of medical care, treatment, hospitalization, and
related transportation from an inmate who has resources or the
ability to pay for expenses incurred by the county in behalf
of the inmate. This can be done by deducting the costs from
the inmate’s cash account on deposit with the jail during the
inmate’s if the incarceration occurs within the same county
©2010 The University of Utah. All Rights Reserved.
and the incarceration is within three years of the date of the
expense in behalf of the inmate. Can also be done by placing a
lien against the inmate’s personal property held by the jail and/
or requiring an inmate who receives medical care treatment,
hospitalization, or related transportation to cooperate with the
jail facility seeking reimbursement for expense incurred by the
county for the inmate.
HOUSE BILL 121 Fourth Substitute
Emergency Medical Services Act Transport Amendments
Sponsor: G. Huges
This bill provides that when the Department of Health finds
that a complaint against a non-911 provider has merit, they
will issue a notice of that finding to the political subdivision in
which the non-911 provider is operating. The bill permits the
political subdivision to determine any appropriate corrective
actions after receiving the notice of meritorious finding.
HOUSE BILL 184
Medicaid Autism Waiver
Sponsor: P. Ray
This bill requires the Division of Health Care Financing
through consultation with providers of autism services, families of those with autism, and other specialists to develop a
range of options for a Medicaid autism waiver. Before October
1, 2010 the division will report to the Health and Human Services Interim Committee with their findings as to whether the
state should apply for a Medicaid waiver to provide autism services. By December 1, 2010, the Health and Human Services
Interim Committee will decide whether to sponsor legislation
that requires the Department of Health to apply for a Medicaid
waiver.
HOUSE BILL 186 Substitute
Controlled Substance Database Revisions
Sponsor: R. Menlove
Bill permits employees of the Department of Health to conduct
scientific studies regarding the use or abuse of controlled substances. The bill also gives designated Department of Health
employees access to information in the controlled substance
database if the department suspects that person may be improperly obtaining or providing a controlled substance.
HOUSE BILL 196 Substitute
Tobacco Tax Revisions
Sponsor: P. Ray
This bill amends the Cigarette and Tobacco Tax Act by increasing the tax rates on the sale, use, storage, or distribution of
cigarettes and other tobacco products in the state for the 201011 fiscal year. The bill also provides for the calculation and
adjustment of the tobacco rates on or before every third fiscal
year following 2010-11. The bill more than doubles the existing
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tax rate for cigarettes and moist snuff. Designated in the bill is
$250,000 of the revenue generate from the tax increase to be
annually appropriated to the Department of Health for use in
the Gold Medal Schools Program.
HOUSE BILL 200
Informed Consent Amendments
Sponsor: C. Wimmer
This bill amends provisions of the Utah Criminal Code relating
to providing informed consent to a woman who is seeking an
abortion. The bill requires that if an ultrasound is performed
on a woman before an abortion is performed, the ultrasound
images will be simultaneously displayed in a manner so that
the woman may choose to view or not to view the images. If
the woman desires, she shall be given a detailed description of
the ultrasound images, including: the dimensions of the unborn
child, any cardiac activity, and the presence of external body
parts or internal organs. The bill also describes the printed
materials and informational video relating to abortion that the
Department of Health is to produce and make available to a
woman free of charge by the performing facility at least 24
hours before the abortion is performed. The materials must
also be available for viewing on the Department of Health’s
website. Also in the bill is the requirement for the Department
of Health to make an annual report on statistics relating to the
provisions in the bill. Reporting requirements for physicians
are included in the bill as well.
HOUSE BILL 206
Ban on Sale of Smoking Paraphernalia to Minors
Sponsor: P. Ray
This bill explicitly defines tobacco paraphernalia. The bill also
amends Utah Criminal Code provisions by making it a class
C misdemeanor to provide any person under19 years of age
with tobacco paraphernalia. If subsequent offenses occur the
misdemeanor will be elevated to a class B.
HOUSE BILL 215
Amendments to Public Employees’ Benefit and Insurance Program Act – Risk Pools
Sponsor: K. Garn
This bill amends the Public Employee’s Benefit and Insurance
Program Act risk pools. The bill changes the number of eligible
full-time enrolled students an institution of higher learning
must have in order to participate in the program’s risk pools.
State institutions now with less than 18,000 full-time enrollees
(previously 12,000) are able to participate. Institutions with
over 1,000 or more plan enrollees must establish a rate based
100% on experience. If the risk pool rate that is then established is greater that the state employees’ risk pool, a new risk
pool must be established for the institution of higher education.
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HOUSE BILL 232
Medical Language Interpreter Amendments
Sponsor: R. Chavez-Houck
This bill recodifies the Medical Language Interpreter Act and
amends the act by providing standards for expiration and renewals of certification, denial or certification, and disciplinary
actions. The bill specifies a two-year renewal cycle for certification, while also allowing by rule to extend or shorten a
renewal cycle by as much as one year so that renewal cycles
may be staggered.
HOUSE BILL 260
Children’s Health Insurance Plan Simplified Renewal
Sponsor: M. Newbold
This bill requires the Children’s Health Insurance Plan to apply
for grants to fund a simplified renewal process. If funding is
available, the bill requires the Children’s Health Insurance Plan
to establish a simplified renewal process in which the eligible
worker may, if the applicant provides consent, confirm the adjusted gross income of the applicant from the Utah State Tax
Commission and requires the Utah State Tax Commission to
work with the Children’s Health Insurance Fund to provide the
program with access to an applicant’s adjusted gross income.
HOUSE BILL 294
Health System Reform Amendments
Sponsor: D. Clark
This bill makes numerous amendments to health system reform for the insurance market, health care provider, the Health
Code and the Office of Consumer Health Services. This bill
authorizes the Department of Health’s all payer database to
analyze the data it collects to provider consumer awareness
of costs and transparency in the health care market including
reports on geographic variances in medical costs and cost
increase for health care. This bill establishes the electronic
standards for delivering the uniform health insurance application and appoints an independent actuary to monitor the risk
and underwriting practices of small employer group carriers
to ensure that the carriers are using the same rating practices
inside the Health Insurance Exchange and in the traditional
insurance market.
HOUSE BILL 299 Substitute
Amendments Related to Substances Harmful to Pregnancy
Sponsor: R. Menlove
This bill requires the posting of a warning by alcohol retailers
that states the negative effects of consuming alcohol during
pregnancy. The language and layout of the warning’s text is
described. The bill also repeals outdated language related to a
public education and outreach program. This bill coordinates
with Senate Bill 167 to take effect July 1, 2011.
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
HOUSE BILL 311 Substitute
Autism Treatment Fund
Sponsor: R. Lockhart
This bill creates a restricted account within the General Fund
to be known as the Autism Treatment Account for the receipt
and expenditure of certain gifts, donations, and appropriations
to be used for services relating to autism for Utah residents less
than 8 years of age. The bill also provides for the administration of the Fund.
HOUSE BILL 397 Second Substitute
Medicaid Program Amendments
Sponsor: J. Dougall
The bill requires the Department of Health to conduct internal
audits of the Medicaid program in proportion to at least the
level of funding it receives from Medicaid to conduct internal audits. The bill also requires the Department of Health to
study and report direct contracting for primary care services
and the feasibility of establishing a medical homes model of
care. The bill allows the Department of Health to apply for
and, if approved, implement a program for health opportunity
accounts. A requirement is included for funds to be deposited
in the Medicaid Restricted Account, along with the expansion
of use of the Nursing Care Facilities Account.
HOUSE BILL 408 Substitute
Hospital Claims Management
Sponsor: B. Last
The bill authorizes the Department of Health to establish a
voluntary project to promote and monitor intervention and
resolution of unanticipated outcomes from medical care between providers and patients. This dialogue aims to help avoid
litigation and assist in timely and cost effective resolutions
from these unexpected outcomes. Results from report will be
present to the Legislature’s Judiciary, Law Enforcement, and
Criminal Justice Interim Committee no later than November
30, 2012.
HOUSE BILL 421
Medical Financial Records Amendments
Sponsor: B. Last
Effective July 1, 2010, a bank or other financial institution is
required to release financial records to a hospital if they will be
used to determine if a patient qualifies for Medicaid. The bill
specifies the information requirements before such records are
released.
HOUSE BILL 440 Substitute
Veterans’ Nursing Home Reimbursement Restricted Account
Sponsor: R. Bigelow
This bill creates a restricted account within the General Fund
for reimbursement funds from the federal government for the
©2010 The University of Utah. All Rights Reserved.
construction of veterans’ nursing homes. The bill requires that
all interest and other amounts generated by the account be
deposited into the General Fund and restricts use of the account to match federal funding for the construction of future
veterans’ homes.
HOUSE BILL 459 Substitute
Health Amendments
Sponsor: D. Clark
This bill requires internal audits of the Medicaid program at
a level at least in proportion to the percent of funding for the
program that comes from state funds. Also required is for
health benefits plans to provide written detailed disclosure
of prescription drug benefits, copayments, deductibles, and
requirements for generic substitution. The bill requires greater
choice of benefits plans for employers in the defined contribution market of the health insurance exchange.
HOUSE BILL 461
Children’s Health Insurance Program
Sponsor: J. Dougall
This bill deletes provisions requiring the Department of Health,
when contracting services for the Utah Children’s Health
Insurance Program, to accept a bidder that offers or provides
access to two different provider networks.
HOUSE BILL 462
Criminal Homicide and Abortion Revisions
Sponsor: C. Wimmer
This bill revises the vetoed House Bill 12. The bill describes
the difference between an abortion and criminal homicide and
removes prohibitions against prosecution of a woman for killing or committing criminal homicide of an unborn child. It
clarifies that a woman is not criminally liable for seeking to
obtain, or obtaining, an abortion that is permitted by law. It
also declares that a woman is not guilty of criminal homicide
of her unborn child if the death of the unborn child is caused
by a criminally negligent act or by an intentional, knowing, or
reckless act of the woman.
This bill adds the provisions that a person is not guilty of
criminal homicide of an unborn child if the sole reason for the
death of the unborn child is that the person refused to consent
to medical treatment or a cesarean section or that they failed to
follow medical advice.
HOUSE BILL 464
Family Health Services RFPs – Tobacco Settlement Funds
Sponsor: J. Dougall
This bill require the Department of Health to use the request
for proposal (RFP) process to provide non-state supplied services with Tobacco Settlement funds. Effective July 1, 2010 at
least every five years after the Department of Health will issue
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2010 Utah’s Health: An Annual Review
RFP for new or renewing contracts. Using those same Tobacco
Settlement funds the bill also makes a one-time deposit of
$11,350,900 into the General Fund.
HOUSE CONCURRENT RESOLUTION 8
Concurrent Resolution on Federal Health Insurance Reform
Sponsor: D. Clark
Cosponsors: E. Hutchings, P. Ray
This resolution urges Congress and the President to refuse to
sign any legislation that further restricts a state’s ability to regulate health care payments and delivery. It also urges Congress
and the President to pass and sign legislation that grants states
greater flexibility to create their own health reform demonstration projects with the potential for replication elsewhere in the
country. The resolution also recognizes that should Congress
and the President pass and sign legislation that may restrict
states, that this resolution supports states’ efforts of grandfathering any laws, regulation, or practices they have already
passed that are intended to improve health care system reform.
HOUSE JOINT RESOLUTION 11
Joint Resolution Regarding Federal Health Insurance Reform
Sponsor: M. Morley
Cosponsors: E. Hutchings, P. Ray
This resolution urges the United State Congress to refrain from
instituting a new federal review, oversight, or preemption of
state health insurance laws, to refrain from creating a federal
health insurance exchange or connector, and to refrain from
creating a federal health insurance public plan option.
HOUSE JOINT RESOLUTION 27
Authentic Charity Health Care Joint Resolution
Sponsor: M. Newbold
This resolution recognizes authentic charity care as a key
component of state healthcare policy and expresses support for
preserving the integrity of authentic charity care as medical
care provided without cost to patients and without payment or
government reimbursement to providers. The resolution urges
community leaders and Utah citizens to become community
partners with existing authentic charity care clinics and to assist in establishing clinics in communities where they do not
currently exist. The resolution also urges Utah’s medical professionals and health care providers to turn their collective attention to providing authentic charity care throughout the state.
HOUSE JOINT RESOLUTION 34 Substitute
Joint Resolution on Hospital Claims Management
Sponsor: B. Last
This joint resolution amends a rule of evidence relating to expressing of apology in medical malpractice actions by making
expressions of apology, sympathy, condolences, or other generally benevolent statements inadmissible against the health care
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2010 Legislative Review
provider to prove liability for an injury.
HOUSE RESOLUTION 1
Healthy Family Partnership House Resolution
Sponsor: C. Oda
This resolution urges that age appropriate materials on family
violence prevention be made available in Utah’s public schools
and that state government continue community partnerships to
help youth prevent family and dating violence. The resolution
also encourages the Department of Human Services to ensure,
as resources permit, that high risk families receive violence
prevention services which have shown to be effective and provide a significant cost benefit advantage.
SENATE BILL 21
Amendments to Social Worker Licensing
Sponsor: D.C. Buttars
Bill amends the Social Worker Licensing Act by defining the
term “program accredited by the Council on Social Work
Education” to include a program that was accredited, and a
program that was in candidacy for accreditation on the day on
which the applicant for licensure satisfactorily completed the
program.
SENATE BILL 39
Health Insurance Prior Authorization Amendments
Sponsor: K. Mayne
Beginning January 1, 2011 an accident or health insurer who
requires preauthorization or preapproval for coverage will be
required to provide by mail or electronic means their insured
a statement of preauthorization by if billing (CPT) codes have
been submitted to the insurer to determine if a procedure is
covered under their policy. The preauthorization statement
will need to clarify that preauthorization is not a guarantee of
payment by the insurer and that the preauthorized services are
subject to the policy and contract provisions of the coverage.
SENATE BILL 41 Substitute
Drug Utilization Review Board Amendments
Sponsor: P. Knudson
This bill permits the Drug Utilization Review Board to be able
to now consider cost, as well as other criteria, as it determines
whether a drug should be placed on the prior approval program
within the state’s Medicaid program. The bill also shortens the
time requirement of when the board must hold a public hearing before placing a drug on prior approval to 30 days, and
shortens the required time of public notice given prior to the
meeting to 14 days. The bill allows an approval or denial of a
request for prior approval to now be sent through electronic
transmission. The bill also gives more discretion to the Drug
Utilization Review Board regarding the use of a drug for off
label indications.
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
SENATE BILL 88 Fifth Substitute
Pharmacy Practice Act Amendments
Sponsor: C. Bramble
This bill amends the Pharmacy Practice Act. The bill amends
provisions related to exemptions from licensure and defines the
terms “cosmetic drug” and “injectable weight loss drug”. The
bill exempts prescribing physicians from licensure under the
Pharmacy Practice Act when a physician dispenses a cosmetic
drug or injectable weight loss drug only to the physician’s patient. Also included are requirements of certain drug labeling
and record keeping standards for the dispensing physician.
SENATE BILL 90 Second Substitute
Mental Health Professional Practice Act Amendments
Sponsor: L. Hillyard
This bill amends provisions of the Mental Health Professional
Practice Act. The bill modifies requirements for licensure by
endorsement, but provides that a license by endorsement that
was valid immediately before passage of the bill continues to
be valid. The bill defines the term “program accredited by the
Council on Social Work Education” to include a program that
was accredited, and a program that was in candidacy for accreditation, on the day on which the applicant for licensure satisfactorily completed the program. The bill also modifies the
membership of the Social Worker Licensing Board, modifies
the qualifications for a social worker license, and establishes
a continuing education requirement for a social worker. The
bill changes the classification of “certified marriage and family
therapist intern” to “associate marriage and family therapist”.
The classification of “certified professional counselor intern” is
changed to “associate professional counselor”.
SENATE BILL 139
Physician Assistant Amendments
Sponsor: C. Bramble
This bill modifies provisions in the Utah Code relating to
physician assistants. This bill changes membership requirements for the Physician Assistant Licensing Board. The bill
also permits a supervising physician to temporarily delegate
to a licensed physician assistant the supervision of physician
assistant students and extends a temporary license up to 120
days to physician assistant students to pass the national exam.
SENATE BILL 144 Substitute
Vision Screen Amendments
Sponsor: W. Niederhauser
This bill amends provisions related to vision screening in
schools. It specifies the training requirements of a person who
serves as a vision screener for a free vision screen clinic for
children aged 3-1/2 to seven. The bill also allows a licensed
health professional who provides vision care to private patients
to participate as a screener in a free vision screening program
©2010 The University of Utah. All Rights Reserved.
for children eight years of age or older, but prohibits them from
marketing or advertising while doing so.
SENATE BILL 145 Third Substitute
Medical Malpractice Amendments
Sponsor: J. S. Adams
This bill amends the Utah Health Care Malpractice Act. The
bill amends the cap on non-economic damages that may be
awarded in a malpractice action to $450,000 for a cause of
action arising on or after May 15, 2010. The bill requires an
affidavit of merit from a health care professional to proceed
with an action if the pre-litigation panel makes a finding of
non-meritorious. The bill limits the liability of a health care
provider, in certain circumstance, for the acts of omissions of
an ostensible agent.
SENATE BILL 160
Utah State Developmental Center Amendments
Sponsor: M. Dayton
This bill amends the Utah Human Services Code to now allow a person who qualifies to receive services under the home
and community-based services to be placed in the Utah State
Developmental Center or another Intermediate Care Facility
for the Mentally Retarded if that person, or the person’s legal
guardian or representative, decides to do so.
SENATE BILL 178
Utah Emergency Medical Services System Act Amendments
Sponsor: D. Stowell
This bill expands the coverage area for allocating grants to
assist with the delivery of emergency services from certain
rural areas of the state to the entire state. Instead of a 50%
distribution, the bill also permits the State Emergency Medical
Services Committee to determine what percentage of the funds
at or above a 25% rate will be used as per capita block grants.
SENATE BILL 273
Hospital Assessments
Sponsor: L. Hillyard
This bill enacts the Hospital Provider Assessment Act in the
health code. The bill creates a Hospital Policy Review Board
to review Medicaid state plan amendments that effect hospital
reimbursements and requires a Hospital Policy Review Board
to review Medicaid state plan amendments that effect hospital
reimbursements. The bill repeals the hospital provider assessment on July 1, 2013.
SENATE BILL 274 Second Substitute
Online Pharmacy Amendments
Sponsor: C. Bramble
This bill creates an Online Prescribing, Dispensing, and Facilitation Licensing Act. The bill establishes the requirement of,
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and the requirements for, licenses with the state to engage in
online prescribing, online dispensing, or Internet facilitation.
The bill limits the type of drugs that can be prescribed online.
The bill requires the use of an Internet facilitator and an online
contract pharmacy to prescribe online.
SENATE CONCURRENT RESOLUTION 1
Alzheimer’s and Dementia Awareness Concurrent Resolution
Sponsor: K. Morgan
This resolution recognizes Utah’s citizens and caregivers who
are battling Alzheimer’s or related dementia as courageous
and part of a 21st century healthcare battle. The resolution
encourages Utahns to support and promote open discussion
and increase their awareness of the impact of Alzheimer’s or
related dementia. It also continues to urge Utah’s brain health
research and medical communities to continue their efforts to
treat, prevent, and ultimately cure Alzheimer’s disease and
related dementias.
SENATE CONCURRENT RESOLUTION 04
Dental Health Care Concurrent Resolution
Sponsor: P. Jones
This concurrent resolution expresses support for the efforts of
the Regence Caring Foundation for Children to provide dental
care to children from low-income families who earn too much
to qualify for public assistance.
SENATE CONCURRENT RESOLUTION 05
Concurrent Resolution Recognizing the 100 Year Anniversary
of the McKay-Dee Hospital
Sponsor: J. Greiner
This resolution recognizes the 100th anniversary of McKayDee Hospital and the tremendous contribution the hospital, and
those who have guided it through the years, have made to the
citizens of the state of Utah.
SENTAE JOINT RESOLUTION 16
Health Care Facility Disclosure Joint Resolution
Sponsor: P. Knudson
This joint resolution urges health care facilities to adopt, implement, publish, and inform patients of certain financial and
payment policies such as any discounts provided for prompt
payment, procedures for collecting unpaid bills, and criteria
for financial assistance eligibility. The resolution urges the
Utah Department of Health to publish a list of the procedures
for which health care facilities most frequently bill patients,
beginning January 1, 2011 for health care facilities themselves
to publish the amount they charge to perform a procedure.
Unpassed Bills
HOUSE BILL 22
Inmate Health Insurance Amendments
Sponsor: P. Ray
Last Action: 2 February 2010, House/filed
This bill would have modified the Insurance Code by requiring
an insurance company providing health or dental policies to
coordinate benefits for an individual housed in a correctional
facility, county jail, or who is in the custody of the Department
of Corrections.
HOUSE BILL 71 Third Substitute
Nicotine Product Restrictions
Sponsor: P. Ray
Last Action: 11 March 2010, House/filed
This bill would have amended provisions of the Uniform
Driver License Act, provisions relating to the state system of
public education, the Utah Criminal Code, and the Utah Code
of Criminal Procedure to place restrictions on the provision,
obtaining, and possession of a nicotine product and to enforce
those restrictions.
HOUSE BILL 87
Medical Assistance Asset Test Amendments
Sponsor: R. Chavez-Houck
Last Action: 11 March 2010, House/strike enacting clause
This bill would have required the Department of Health to
amend the state Medicaid plan to remove the use of, and to
then prohibit, an asset test in determining eligibility for a child
or for a foster care adolescent for Medicaid or for the Utah
Children’s Health Insurance Program.
HOUSE BILL 101
Anesthesiologist Assistants
Sponsor: Julie Fisher
Cosponsors: S. Allen, J. Anderson, J. Bird, R. Edwards, G.
Froerer, K. Grover, T. Kiser, B. Last, C. Oda, S. Sandstrom,
C. Wimmer
Last Action: 11 March 2010, House/strike enacting clause
This bill would have created a new licensing chapter in the
Division of Occupational and Professional Licensing for Anesthesiologist Assistants and placing it under supervision of the
Physician Assistant Licensing Board. It would have required
and established qualifications and terms for licensure.
HOUSE BILL 104
Unlawful Provision of Identifiable Prescription Information
Sponsor: J. Biskupski
Last Action: 11 March 2010, House/strike enacting clause
This bill would have made it a class B misdemeanor to provide,
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2010 Utah’s Health: An Annual Review
sell, exchange, purchase, obtain, or use identifiable prescription information for a commercial purpose.
HOUSE BILL 105
Public School Employee Auditory Protection Requirements
Sponsor: L. Black
Last Action: 11 March 2010, House/strike enacting clause
This bill would have required a local school board or charter
school governing board to set safety standard for employees
exposed to a certain level of sound and to provide employees
at risk of hearing damage with a minimum level of hearing
protection.
HOUSE BILL 111
Small Group Health Insurance – Statewide Risk Adjustment
Sponsor: J. Biskupski
Last Action: 11 March 2010, House/strike enacting clause
This bill would have expanded the Utah Statewide Risk Adjuster Act to include any health benefit plan offered to a small
employer group on or after January 1, 2011, including a plan
offered to a small employer group not participating in a defined
contribution arrangement in the Utah Health Exchange.
HOUSE BILL 127 Substitute
Reproductive Health Education Amendments
Sponsor: L. Hemingway
Last Action: 11 March 2010, House/strike enacting clause
This bill would have directed the State Board of Education
to prepare instructional materials related to contraception
in compliance with state law and board rules. It would have
provided that a local school board may adopt those materials,
and if they did not use the materials prepared they would then
have been available for review and use by parents and legal
guardians.
HOUSE BILL 135
Pharmacy Benefit Managers Act
Sponsor: E. Vickers
Last Action: 11 March 2010, House/strike enacting clause
This bill would have required a pharmacy benefit manager to
be licensed by the Insurance Department. The bill would have
also established the licensing requirements as well as penalties
for any violation of them. This bill would have required the
insurance commissioner to establish and impose a fee to pay
the costs of administering the requirements of the bill.
HOUSE BILL 177
Public Employees’ Health Care
Sponsor: D. Litvack
Last Action: 11 March 2010, House/strike enacting clause
This bill would have extended health insurance coverage for
state employees to include an adult designee who is not the
spouse of the state employee but was either directly dependent
upon or interdependent with the employee.
HOUSE BILL 190
Disclosure of Methamphetamine Contaminated Property Act
Sponsor: S. Mascaro
Last Action: 11 March 2010, House/filed
This bill would have modified a provision that allows an owner
or lessor of a property to report methamphetamine contamination to instead be required to report the contamination to a
government agency responsible for monitoring the decontamination process.
HOUSE BILL 253
Transfer of the Bureau of Emergency Medical Service from the
Department of Health to the Department of Public Safety
Sponsor: P. Ray
Last Action: 11 March 2010, House/strike enacting clause
This bill would have changed the name of the State Emergency
Medical Services Committee to the State Emergency Medical
Services Board and moved it from the Department of Health
to the Department of Public Safety. The bill would have also
changed the name of the Trauma System Advisory Committee
to the Trauma System Advisory Council and moved it as well
from the Department of Health to the Department of Public
Safety.
HOUSE BILL 356
Emergency Medical Services Amendments
Sponsor: P. Ray
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
HOUSE BILL 384
Psychologist Licensing Act Amendments
Sponsor: M. Newbold
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
HOUSE BILL 144
Hospital Lien Revisions
Sponsor: B. King
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
No information was made available for this bill.
This bill would have enacted the Phlebotomy Certification
©2010 The University of Utah. All Rights Reserved.
HOUSE BILL 437
Phlebotomy Certification Act
Sponsor: F.J. Seegmiller
Last Action: 1 March 2010, House/filed
2010 Legislative Review
85
2010 Utah’s Health: An Annual Review
Act. It would have required a phlebotomist to be certified and
have established certification and continuing education requirements. It would have granted rulemaking authority to the
Division of Occupational and Professional Licensing and have
required them to charge a fee to recover the cost of issuing
certification.
HOUSE BILL 454
Maternity Leave for School Employees
Sponsor: Janice Fisher
Last Action: 11 March 2010, House/strike enacting clause
opment, healthy relationships, and reproductive health. The
curriculum would have included a general discussion of contraception with its benefits and limitations. It would also have
required that materials provide opportunities for interaction
between a student and the student’s parent or guardian.
SENATE BILL 80
Physician Licensing – Visiting Professors
Sponsor: P. Knudson
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have required a school district or charter school
to allow a public school employee to use up to six weeks of
accrued leave for the birth or adoption of a child. The bill
would have required a public school employee to give 30 days
notice before taking accrued leave for the birth or adoption and
provide certain requirement to be met before taking certain
accrued leave.
This bill would have amended the Utah Medical Practice Act
and the Utah Osteopathic Medical Practice Act. It would have
provided that a physician or surgeon that is licensed and in
good standing in another jurisdiction may obtain a license to
practice medicine or osteopathic medicine in Utah if the applicant was appointed as faculty at medical school in the state.
It would have limited the applicant’s practice to the medical
school facilities and designated clinical settings.
SENATE BILL 44 Second Substitute
Health Amendment for Legal Immigrant Children
Sponsor: L. Robles
Last Action: 11 March 2010, Senate/strike enacting clause
SENATE BILL 101
Drug Amendments
Sponsor: P. Knudson
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have removed the five-year residency requirement for a legal immigrant child to be eligible for coverage
under Medicaid or the Children’s Health Insurance Program
and allow coverage to an eligible legal immigrant child under
those plans regardless of the length of time the child has been
in the United States.
This bill would have amended the Accident and Health Insurance part of the Insurance Code and prohibited an insurer from
requiring a cancer patient to pay more for chemotherapy treatment that is administered orally rather than intravenously.
SENATE BILL 46
Utah Child Care Licensing Act Amendments
Sponsor: R. Romero
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have exempted a summer camp provided by a
tax exempt 501 (c)(3) organization from the provisions of the
Utah Child Care Licensing Act.
SENATE BILL 49 Fourth Substitute
Vending Machines in Public Schools
Sponsor: P. Jones
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have provided a list of allowed beverages and
non-beverage items that may be sold in vending machines at
public schools.
SENATE BILL 54
Health Education Amendments
Sponsor: S. Urquhart
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have directed the State Board of Education to
establish curriculum requirements that include human devel-
86
2010 Legislative Review
SENATE BILL 159
Taxation of Dedicated Medical Aircraft
Sponsor: M. Madsen
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
SENATE BILL 163
Health Regulation of Geothermal Pools and Baths
Sponsor: M. Madsen
Last Action: 11 March 2010, Senate/filed
This bill would have described the authority of the Department of Health to adopt rules and enforce minimum health
and safety standards relating to public and member-owned
geothermal pools and baths.
SENATE BILL 168
Amendments to the Integrated Health System Fair Practices
Act
Sponsor: M. Madsen
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
SENATE BILL 214
Testing of Newborn Infants Amendments
Sponsor: D. Hinkins
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
SENATE BILL 249
Hospital Financial Assistance Transparency Act
Sponsor: P. Knudson
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
No information was made available for this bill.
SENATE BILL 229
Hospital Licensing Amendments – Emergency Medical Treatment and Active Labor Act
Sponsor: D.C. Buttars
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
SENATE BILL 257
Health Care Facility Disclosure Requirements
Sponsor: P. Knudson
Last Action: 11 March 2010, Senate/strike enacting clause
SENATE BILL 230
Pharmaceutical Marketing to Consumers Amendment
Sponsor: D. Liljenquist
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have amended the Health Care Facility Licensing and Inspection Act by requiring the Department of Health
to publish a list of the procedures for which health care facilities most frequently bill patients. It would also have required a
health care facility to publish the amount the facility charges
for each procedure on the Department of Health list as well as
the amount the facility is paid for each procedure by Medicaid
and Medicare.
This bill would have amended the Insurance Code by prohibiting a pharmaceutical company from offering to pay or rebate
the copayment or out-of-pocket costs to induce a patient to
order or purchase a drug that will be paid for in whole or in
part by an accident and health insurance policy.
SENATE BILL 276
Promoting Health Lifestyles in Public Schools
Sponsor: P. Jones
Last Action: 11 March 2010, Senate/strike enacting clause
No information was made available for this bill.
SENATE BILL 238
Long-term Care Facility – Medicaid Certification for Bed Capacity Amendments
Sponsor: L. Robles
Last Action: 11 March 2010, Senate/filed
This bill would have required the State Board of Education to
report data related to vending machine contents and students’
physical activity.
This bill would have allowed the Division of Health Care Financing within the Department of Health under certain conditions to renew Medicaid certification of a nursing care facility.
SENATE BILL 241
Health Code Amendments
Sponsor: A. Christensen
Last Action: 11 March 2010, Senate/strike enacting clause
This bill would have amended the Medicaid program in the
Health Code. The bill would have allowed mental health drugs
to be placed on the prior approval program and appropriated
money saved from doing so to fund physician reimbursement,
mental health services, and dental services in the Medicaid
program.
SENATE BILL 245
Anesthesiologist Assistants Amendments
Sponsor: D. Liljenquist
Last Action: 5 February 2010, Bill Numbered by Title Without
any Substance
No information was made available for this bill.
©2010 The University of Utah. All Rights Reserved.
2010 Legislative Review
87
UH Review 2010
Utah’s Health: An Annual Review
Utah health Data Review
Pages 91─179
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu
2010 Utah’s Health: An Annual Review
Birth and Death Rates: Utah and National Trends
Compiled by JB Flinders, MPH, MBA
Utah was the fastest growing state from 2007-2008, with a 2.5% increase in population
Birth and death rates are commonly used indicators of population growth and decline. The crude birth rate is the most often
reported fertility measure and is calculated from the number of
babies born in a given time period divided by the mid-period
population and expressed as the number of births per 1,000
people. The death rate measures the amount of a population
that dies each year, but the comparison of death rates between
populations does not show imply one is healthier or lives longer than another. Both of these rates are strongly influenced by
the age structure of the population.1
the total number of live births in the population, but the birth
rate calculation involves the total population ─ including the
young, old, male, and female; whereas the general fertility rate
is calculated using only females ages 15 through 44 years, or
those considered of reproductive age, residing in a specific area
during a specified time period. This rate allows for greater
sensitivity in the study of population growth and change. Utah
also has the highest general fertility rate in the U.S.2 Figure
2 shows the trend in general fertility rate between Utah and
the U.S. from 2001 through 2008.4 Although both trends are
relatively stable, Utah has averaged greater than 20 births more
per 1,000 women ages 15-44 than the rest of the U.S.
Utah has the highest birth rate in the U.S.2 Figure 1 shows
the trends in birth rates between Utah and the U.S. from 2001
through 2008.3 In 2008, there were 20.0 births per 1,000 persons in Utah representing a slight decrease from 20.4 in 2007.
The 20.4 births per 1,000 persons in Utah were significantly
higher than the 14.3 births per 1,000 people nationwide. Of
similar value is the computation of the general fertility rate,
which is more precise in detecting birth rate patterns in a system. Both the crude birth rate and general fertility rate involve
Figure 3 shows death rates from all causes in the Utah and
U.S. from 1995 to 2008.5 In 2008, Utah‘s death rate of 707.9
deaths per 100,000 was far lower than the U.S. average of
810 deaths per 100,000 and Utah’s death rates have been well
below the national average consistently since the early 1990’s
due to Utah’s much younger population. Figure 4 shows the
age-adjusted death rates for the State of Utah. Age-adjusted
Figure 1: Birth Rates of Utah and the U.S., 2001-2008
Births per 1,000 Individuals
25
20
15
Utah
10
U.S.
5
0
2001
2002
2003
2004
2005
2006
2007
2008
Year
©2010 The University of Utah. All Rights Reserved.
Population Indicators
91
2010 Utah’s Health: An Annual Review
death rates eliminate the bias of age in the makeup of the
populations being compared, as older populations tend to have
a greater number of deaths due to chronic conditions while
younger populations tend to have higher numbers of death due
to unintentional injuries, thus providing a reliable rate for comparison purposes.6 Diseases of the heart, malignant neoplasms
(cancer), and unintentional injuries are the leading causes of
death for Utah, regardless of sex, race, or ethnicity.7
2.5% increase in population. From 2000-2008 Utah’s population grew 22.5% nearly three times that of the United States
(8.0%). Last year, the percent growth was 2.6% in the state of
Utah compared to 1% in the U.S. The United States growth rate
has stayed relatively stable at 1%, whereas the rate in Utah has
increased substantially from 1.4% in 2003 to 2.5% in 2008.8
Rationales for this include a stable economy, healthy population, sociocultural factors, and relatively inexpensive costs of
living.
Utah was the fastest growing state from 2007-2008, with a
Figure 2: General Fertility Rates, Utah and U.S., 2001-2008
Live Births per 1,000 Women Ages 15-44
100
90
80
70
60
50
Utah
40
U.S.
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
Year
1000
900
800
700
600
500
400
300
200
100
0
Utah
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
U.S.
1995
Deaths per 100,000 People
Figure 3: Death Rates of Utah and the U.S., 2001-2008
Year
92
Population Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 4: Leading Causes of Death In Utah by Age-adjusted Rate, Deaths Per 100,000
Population, 2008
Nephritis, Nephrotic Syndome and …
Influenza and Pneumonia
Intentional Self-Harm
Alzheimer's Disease
Diabetes Mellitus
Chronic Lower Respiratory Diseases
Number of Deaths
Cerebrovascular Diseases
Unintentional Injuries
Malignant Neoplasms
Diseases of the Heart
0
500
1000
1500
2000
2500
3000
Number of Deaths per 100,000 Individuals
Information on this page was gathered from:
1 Population Reference Bureau, Population Bulletin, Population: A Lively Introduction. Available online at http://www.prb.org/pdf07/62.1LivelyIntroduction.
pdf. Accessed April 22, 2010.
2 Centers for Disease Control and Prevention, National Vital Statistics, Births. Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf.
Accessed April 22, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health, Birth Rates. Available online at http://ibis.health.utah.gov/
indicator/view/BrthRat.UT_US.html. Accessed March 17, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health, General Fertility Rates. Available online at http://ibis.health.
utah.gov/indicator/view_numbers/FertRat.UT_US_Age.html. Accessed March 17, 2010.
5 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health, Death Rates. Available online at http://ibis.health.utah.gov/
indicator/view_numbers/DthRat.UT_US.html. Accessed March 31, 2010.
6 Pennsylvania Department of Health, Tools of the Trade- Age Adjusted Rates. Available online at http://www.health.state.pa.us/hpa/stats/techassist/ageadjusted.htm. Accessed April 22, 2010.
7 Department of Health, Utah’s Indicator-Based Information System for Public Health, Mortality. http://ibis.health.utah.gov/query/result/mort/MortCntyICD10/Top10Count.html. Accessed March 17, 2010.
8 United States Census Bureau, Utah QuickFacts. Available online at http://quickfacts.census.gov/qfd/states/49000.html. Accessed March 17, 2010.
©2010 The University of Utah. All Rights Reserved.
Population Indicators
93
2010 Utah’s Health: An Annual Review
Chronic Homelessness
Compiled by Gregg A. Jones
15,340 Utahans were homeless in 2008
Chronic homelessness is functionally defined as unaccompanied persons who have been homeless who have either been
on the street for at least one year or those who have a disabling
condition that have experienced at least four episodes of homelessness with three years. Virtually all chronically homeless
people have a disability. Many chronically homeless people
have a serious mental or physical illnesses, and alcohol or
drug addictions. These illnesses and addictions can be a major
cause of chronic homelessness. Other causes include: loss of
job, death of, or abandonment by, a breadwinner, bankruptcy,
and under-education.1
the time period from June 2007 to June 2008. This data also
only includes homeless individuals enrolled in shelter or housing programs in Utah. Based on data collected by UHMIS the
total number of individuals enrolled in shelter and housing
programs was 7,342. That is roughly 48% of the total homeless population in Utah.2 Roughly 70% of homeless were male
and 30% female. As Figure 1 illustrates, the largest majority of
individuals were in the range of 24 to 44 years of age. According to the UHMIS reports, out of 4,467 homeless individuals
who were asked if they were “chronically homeless”, 40.5% of
clients answered yes.3
The Utah Homelessness Management Information System
(UHMIS) maintains an information sharing system that promotes cooperation between homeless agencies as they strive
to create quality programs while supplying accurate information on homelessness in Utah. The data collected represents
Many counties in Utah offer services for the homeless. In Salt
Lake County, these services include medical clinics, mental
health services, housing shelters, food services, veterans’ programs, and family programs.2
Figure 1: Share of the Utah Homeless By Age
0 to 5
6 to 11
12 to 17
18 to 23
24 to 44
45 to 54
55+
Information on this page was gathered from:
1 Northern Alliance to End Homelessness. Available online at: http://www.endhomelessness.org/content/article/detail/620. Accessed online on November 29,
2009.
2 Fourth Street Clinic 2008 Annual Report. Available online at: www.forthstreetclinic.org Accessed online on November 29, 2009.
3 Utah Homeless Management Information Center annual report 2008. Available online at: www.uhmis.org Accessed online on November 29, 2009.
94
Population Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Cost of Urban Living
Compiled by JB Flinders, MPH, MBA
Utah’s Cost of Living Index for health care is well below the national average
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
150
100
3rd Q - 2008
50
©2010 The University of Utah. All Rights Reserved.
3rd Q - 2009
Dallas, TX
New York, NY
Boston, MA
Chicago, IL
Washington DC
Seattle, WA
Denver, CO
San Diego, CA
St. George, UT
0
Salt Lake City, UT
Figure 1 shows the
change in the CPI for all
items and health care
items nationally. The CPI
for all items peaked at
a high of 220 in July of
2008 but quickly dropped
to 210.2 in December of
2008, showing a deflation
rate of 4.6%. The CPI for
all items has gradually
increased in 2009 from
211.1 in January to 216
COLI
Jan
CPI
The Consumer Price Index (CPI) estimates the nationwide rate in December, showing an inflation rate of 2.3%.4 The CPI for
of inflation, both monthly and annually, for a standard selec- health care items throughout 2009 was 150 points higher than
tion of goods and services purchased by households. Calculat- that of all items.
ing the percentage change between two time periods provides
an estimate of the rate of inflation or deflation and can be used The American Chamber of Commerce Research Association
to adjust wages or rents, or to measure whether revenues or (ACCRA) Cost of Living Index compares cost of living difincomes are keeping pace with other price increases.1 The CPI ferences among urban areas based on the price of consumer
is based on prices of food, clothing, shelter, and fuels, trans- goods and services in six major categories: grocery items,
portation fares, charges for doctors’ and
dentists’ services, drugs, and other goods
Figure 1: Consumer Price Index, All Items and Health Care, 2009
and services that people buy for day-to2
400
day living. Prices, including taxes as380
sociated with purchase and use, for these
360
goods are collected from 87 urban areas,
340
4,000 housing units, and 25,000 retail
320
and/or service organizations. These price
300
changes for certain items are averaged
280
CPI - All Items
together and weighted, representing their
260
CPI - Health Care
importance in the spending of the appro240
2
priate population groups. Medical care
220
is one of the eight major groups in the
200
CPI, and has two classifications, medical
care commodities (MCC) and medical
care services (MCS). MCS, is the larger
Month
of the two, and comprises three expenditure categories: professional services, hospital
and related services, and
Figure 2: ACCRA Cost of Living Index, Select Cities, 2008-2009
health insurance. The
250
other classification, MCC,
includes medications, and
200
medical equipment and
supplies.3
Population Indicators
95
2010 Utah’s Health: An Annual Review
health care, housing, transportation, utilities, and miscellaneous goods and services. The share of consumer spending
devoted to the category determines that category’s importance
in the Index.5 Figure 1 illustrates a comparison of the Cost of
Living Index (COLI) for major cities as of third quarter 2008
and 2009.6,7 A score of 100 on the COLI index represents the
national average for the United States. Overall, the United
States COLI increased from 113.4 in the third quarter of 2008
to 117.8 in the third quarter of 2009, or an almost 4% increase.
The Salt Lake metropolitan area has remained relatively near
the national average with a slight increase from 100.9 in third
quarter 2008 to 101.7 in third quarter 2009. Other metropolitan
areas in Utah have remained below the national average, in-
cluding St. George and Logan (although Logan’s overall COLI
did increase from 94.9 to 99.9 between third quarter 2008 and
third quarter 2009).
Figure 2 illustrates the Cost of Living Index for Health Care as
of third quarter 2008 and 2009.2,3 The Salt Lake metropolitan
area has dropped below the national average in these health
care categories, from 100.8 in third quarter 2008 to 94.5 in
third quarter 2009, revealing a decrease in average prices for
health care in this area. Elsewhere, the health care CPI in the
Logan metropolitan area has increased from 100.2 to 102.3
while the St. George metropolitan area decrease from 89.3 to
88.0 over that same period.
Figure 3: ACCRA Cost of Living Index - Health Care, Select Cities, 2008-2009
160
140
120
COLI
100
80
60
3rd Q - 2008
40
3rd Q - 2009
20
Tampa, FL
Dallas, TX
New York, NY
Boston, MA
Chicago, IL
Washington DC
Seattle, WA
Denver, CO
San Diego, CA
St. George, UT
Logan, UT
Salt Lake City, UT
0
Information on this page was gathered from:
1 Utah Department of Workforce Services, Consumer Price Index. Available online at http://jobs.utah.gov/opencms/wi/pubs/costofliving/costof.html#accra.
Accessed April 22, 2010.
2 United States Department of Labor, Bureau of Labor Statistics, Consumer Price Index Summary. Available online at http://www.bls.gov/news.release/cpi.
nr0.htm. Accessed March 18, 2010.
3 United States Department of Labor, Bureau of Labor Statistics, Measuring Price Change for Medical Care in the CPI. Available online at http://www.bls.
gov/cpi/cpifact4.htm. Accessed March 21, 2010.
4 United States Department of Labor, Bureau of Labor Statistics Data. Available online at http://data.bls.gov/cgi-bin/surveymost. Accessed April 29, 2010.
5 The Council for Community and Economic Research, Review of the ACCRA Cost of Living Methodology. Available online at http://www.coli.org/Method.
asp. Accessed April 27, 2010.
6 Utah Department of Workforce Services, ACCRA Comparison of Cost-of-Living for Selected Metropolitan Areas. Available online at http://jobs.utah.gov/
opencms/wi/pubs/costofliving/accra309.pdf. Accessed March 18, 2010.
7 Utah Department of Workforce Services, ACCRA Comparison of Cost-of-Living for Selected Metropolitan Areas. Available online at http://jobs.utah.gov/
opencms/wi/pubs/costofliving/accra308.pdf. Accessed March 21, 2010.
96
Population Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Education
Compiled by JB Flinders, MPH, MBA
In 2008, 90.3% of Utahans over the age of 25 had graduated from high school
The value of education, both for economic and individual
health, has never been more apparent. Individuals with schooling greater than a high school diploma can expect to live nearly
82 years versus 75 years without. From 1990 to 2000, those
with greater education increased life expectancy by 1.6 years
while those with less education has no increase or, in the case
of females, actually had a decline in life expectancy. This is
likely due to lower income, crime, poor housing conditions, or
decrease access to health care.1 Economists have found that an
additional year of schooling, on average, raises an individual’s
earning power between 8 and 15 percent, and a full four years of
college boost earnings nearly 65 percent.2 Specifically, workers
with a bachelor’s degree earned about $26,000 per year more
on average than workers with a high school diploma.3 Education levels also correlate with higher social support networks,
improved cognitive and critical thinking skills, greater senses
of control, increased ability to use more complex technologies
(with may assist in healthier behaviors), and other activities
that reduce morbidity (reduced alcohol and tobacco usage,
increased exercise, etc.).4
In 2008, the pupil to teacher ratio in Utah elementary and secondary schools was 23.7 to 1 with per student expenditures
of $5,876.5 However, although Utah students tested at the national average on standardized tests, States with similar poverty levels, parent education levels, and ethnic profiles scored
significantly higher than Utah on many National Assessment
of Educational Progress (NAEP) tests. In fact, Utah was the
lowest achieving state in its demographic peer group in 20062007, which many say is a consequence of spending almost
$3,000 less per student on education.6
In 2008, 90.3% of Utahns over the age of 25 had graduated
from high school (or greater) and 29.1% had a bachelor’s degree
Figure 1: Percent of Adults (25 or Older) with a Bachelor's Degree or Higher, Utah
and U.S., 2000-2008
30
Percent with Bachelor's Degree
29
28
27
26
Utah
25
US
24
23
22
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
©2010 The University of Utah. All Rights Reserved.
Population Indicators
97
2010 Utah’s Health: An Annual Review
(or greater). These levels are higher than the national averages
of 84.9% and 27.7% respectively. However, 10.1% of the nation
had a graduate or professional degree, compared to only 9.4%
of Utahns. Utah also had 4.4% more individuals in the labor
force and 3.2% less individuals below the poverty level.7 However, while Utah consistently surpasses the national average in
bachelor’s degrees, Utah’s ranking fell from fifth to 16th in the
nation from 1940-2000, and has continued to slide to 18th in
2008. Although the percent of bachelor’s degrees continues to
rise in the State of Utah, it is increasing at a slower rate than
that of other states (see Figure 1). From 2000-2008 bachelor’s
degrees in Utah increased from 30.0% to 32.1% in males and
22.3% to 26.1% in females. Although more Utahns are graduating from higher education, Utah women are below the national
level while Utah men surpassing the national average.8
Information on this page was gathered from:
1 The Washington Post, Life Expectancy Tied to Education. Available online at http://www.washingtonpost.com/wp-dyn/content/article/2008/03/11/
AR2008031100925.html. Accessed March 17, 2010.
2 Board of Governors of the Federal Reserve System, Speech – Ferguson, The Importance of Education. Available online at http://www.federalreserve.gov/
newsevents/speech/ferguson20060224a.htm. Accessed March 17, 2010.
3 United States Census Bureau, US Census Press Releases, Relationship Between Education and Earnings. Available online at http://www.census.gov/PressRelease/www/releases/archives/education/013618.html. Accessed March 17, 2010.
4 National Poverty Center. Education and Health: Evaluating Theories and Evidence. Available online at www.npc.umich.edu/news/events/healtheffects_
agenda/cutler.pdf. Accessed March 17, 2010.
5 National Center for Education Statistics, State Profiles – Utah. Available online at http://nces.ed.gov/nationsreportcard/states. Accessed March 17, 2010.
6 Utah Foundation, Research Report, School Testing Results 2006 & 2007. Available online at http://www.utahfoundation.org/img/pdfs/rr681.pdf. Accessed
March 17, 2010.
7 United States Census Bureau, Utah – Selected Social Characteristics in the United States. Available online at http://www.factfinder.census.gov/servlet/
ADPTable?_bm=y&-context=adp&-ds_name=ACS_2008_1YR_G00_&-tree_id=308&-redoLog=true&-_caller=geoselect&-geo_id=04000US49&format=&-_lang=en. Accessed March 17, 2010.
8 Utah Foundation Research Brief, Educational Attainment: Utah Falling Behind National Average. Available online at http://www.utahfoundation.org/
reports/?page_id=532#_edn4. Accessed March 17, 2010.
98
Population Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Population by Race and Ethnicity
Compiled By Jose R. Morales
Minorities contributed 35% of the state’s population growth in the 1990s
Race categories, as used by the Census Bureau, are sociopolitical constructs that reflect self-identification by people
according to the race or races with which they most closely
identify. They include both racial and national-origin groups
(such as the classifications used in this report). Hispanic and
Latino is another designation used by the Census Bureau which
is independent of any race.1
Population Percentage
In 2008, a study of the distribution of race within the state
of Utah (as measured by the U.S. Census Bureau’s Population
Estimates Program) found that Utah’s population is racially
composed of approximately 93% white, 1% black or AfricanAmerican, 1% American Indian or Alaskan Native, 2% Asian,
and 1% Native Hawaiian or Other Pacific Islander. In addition,
nearly 2% of Utah’s population considered themselves part of
two or more races. The same source also considered 88% of
the Utah population non-Hispanic/Latino of origin and 12%
Hispanic/Latino (compared to 11.2 in 2007).2 In Utah, persons
that consider themselves white but not Hispanic accounted for
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
81.7% of the population (65.6% nationally).3
Utah’s population is increasing and diversifying at a rapid
rate. Data shows that Hispanics make up the second largest
population in Utah. Minorities contributed 35% of the state’s
population growth in the 1990s and is expected to continue
growing.4 In the same decade, Salt Lake City became known
as an emerging national community with a 174% growth in the
city’s foreign-born population. Summit County recorded the
largest growth with respect to the Latino/Hispanic population
within Utah during the 1990s with a Latino/Hispanic growth
rate of 638%.5
This growth in diversity within the state of Utah is creating a
demand to better understand population characteristics to help
improve social programs like education and health care as well
as to address population disparities that arise with increased
diversity. For policy makers to better address these issues, understanding the distinctions and characteristics with the Utah
population will be
vital to create policies and methods
Figure 1: Population Percentage by Race and Hispanic Ethnicity, Utah and the U.S., 2008
that address Utah’s
social
problems.
Utah’s continued
growth,
similar
to that seen in the
1990’s, will necessitate a greater
United States
understanding of
Utah
racial and ethnic
population characWhite
Black or American
Asian
Native
Two or Hispanicsteristics at both a
African
Indian
Hawaiian more races
of Any
state and national
American Alaskan
and Other
Race
Native
Pacific
level.
Islander
Information on this page was gathered from:
1 U.S. Census Bureau. 2000 Census of Population and Housing. Summary Social, Economic, and Housing Characteristics. Selected Appedixes, PHR-2-A.
Washington DC, 2003
2 Utah Department of Health, Utah’s Indicator-Based Information system for Public Health. Published December 10, 2009. Available online at: http://www.
ibis.health.utah.gov . Accessed Tue, 29 Dec 2009 12:58:38 MST
3 US Census Bureau, Quick Facts. Available online at: http://quickfacts.census.gov/qfd/states/49000.html. Published April 22, 2010. Accessed Tuesday 13
January 2009
4 Perlich, Pamela S. Ph. D, Bureau of Economic and Business Research, University of Utah. Long Term Demographic Trends Impacting Higher Education in
Utah. Published March/April 2006. Vol. 66 Numbers 3 & 4.
5 The Hispanic/Latino Population in Utah. Prepared by the State Office of Ethnic Affairs. www.ethnicoffice.utah.gov. Presented March 5, 2005.
6 Estimates of the Resident Population by Race and Hispanic Origin for the United States and States. Population Division, U.S. Census Bureau. May 14, 2009.
©2010 The University of Utah. All Rights Reserved.
Population Indicators
99
2010 Utah’s Health: An Annual Review
Unemployment Rate
Compiled By Jose R. Morales
In 2008, Utah ranked 5th best in the nation with a statewide unemployment rate of 3.4%
The unemployment rate has been the gold-standard indicator
for the condition of the labor market and business cycles. This
rate is the proportion between unemployed and the number of
people within the civilian work force. In 2008, the unemployment rate at the national level was measured at 5.8%. The lowest unemployment rate (the most favorable value) within a state
was reported from South Dakota at 3.0%. The highest value for
unemployment rate was reported from the state of Michigan,
which measured 8.4%.
Employment in the state of Utah fares well compared to the
rest of the nation. In 2008, Utah ranked 5th best with a statewide unemployment rate of 3.4%. For the majority of the last
ten years, Utah has had a below-average unemployment rate.
The highest-ranking year occurred in 2002, where the unemployment rate soared to 5.8% in two years and ranked Utah
35th in the country. Since then, the unemployment rate has
seen a continual decrease that has been linked by some reports
to a population increase (total employment in Utah increased
19.1%, while growth in population was 17.1%).2 In 2007, the
unemployment rate bottomed out at 2.7% and has begun to rise
along with the national trend. From 2007-2008, the unemployment rate in Utah increased .7% which coincided with the national trend that also saw an increase of 1.2%. Coincidentally,
this is when the recession began (officially, the recession began
December 2007).3
A limitation to unemployment measures is the lack of data representing key issues associated with a recessionary job market.
These issues are associated with (1) not accounting for workers
who exit the labor market altogether and (2) the under-employed.3 It is well noted that these types of individuals can have
a lasting effect on the economy and, somehow, they should be
factored in. Julius Shiskin, Commissioner of Labor Statistics
in the 1970’s, said, “no single way of measuring unemployment
can satisfy all analytical or ideological interests.”4
Figure 1: Average Unemployment Rate, Utah and the U.S., 1999-2008
Rate of Unemployment
7
6
5
4
3
Utah
2
U.S.
1
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Information on this page was gathered from:
1 Bureau of Labor Statistics Current Population Survey. Available online at: http://www.bls.gov/cps/home.htm. Accessed January 21, 2010
2 The Impacts of Utah’s Population Growth. The Utah Foundation: Research Brief. Available at: http://www.utahfoundation.org/reports/?page_id=270
3 An Historical Look at Utah, the US and Recessions by Janice Houston, Sr. Policy Analyst, CPPA. http://www.imakenews.com/cppa/e_article001354997.
cfm?x=b6Gdd3k
4 Measures of Labor Underutilization from the Current Population Survey. Steven E. Haugen, U.S. Bureau of Labor Statistics. Working Paper 424. March 2009
100
Population Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Air Quality
Compiled by JB Flinders, MPH, MBA
Utah’s concentrations of criteria air pollutants either remained the same or followed a decreasing trend in 2009.
Air quality consistently ranks as one of Utah residents’ major
concerns.1 The variability of its topography, its rapidly growing population, and diversity of its business activities provide a
multitude of problems for the State’s air quality. Despite these
factors, Utah’s concentrations of criteria air pollutants either
remained the same or followed a decreasing trend in 2009.2
The major air quality issue in Utah is caused by inversions,
which occur when a dense layer of cold air is trapped under a
layer of warmer air. This acts like a “lid”, trapping pollutants
within the cold air near the valley floor. Topographically, the
Wasatch Front valleys and the surrounding mountains hold
the air in the valleys which, over time, cause a stronger and
stronger level of concentrated pollutants within it .
Table 1 shows the six major air pollutants that cause damage
to individual, environmental, and/or property health. They
include ozone (O3), particulate matter (PM), carbon monoxide
(CO), nitrogen dioxide (NO2), lead (Pb), and sulfur dioxide
(SO2). The United States Environmental Protection Agency
(EPA) has established National Ambient Air Quality Standards
(NAAQS) for each of these pollutants, which are monitored in
Utah by the Department of Environmental Quality.4 The two
pollutants of most concern currently are ozone and particulate
matters, known as PM2.5, as exposure to these two pollutants are much more dangerous than previously understood.2
Ozone is formed when volatile organic compounds (VOCs)
and nitrogen oxides (NOx) mix with sunlight and heat. Also
known as smog, it is mainly a problem when temperatures are
high and daylight hours are long, but it may also create issues
in winter months as well. Particulate matter refers to the tiny
particles found in the atmosphere which are less than one tenth
of a micrometer (about one-tenth the size of a human hair) up
to 50 micrometers in diameter. Those finer particles, known
as PM2.5—or those up to 2.5 micrometers in diameter—are
a more serious health problem.1 Along the Wasatch Front, 60
percent of particulate matter and 70 percent of carbon monoxide emissions come from vehicles. Industrial sources account
for 70 percent of sulfur dioxide emissions, with vehicles accounting for the remaining 30 percent.2
©2010 The University of Utah. All Rights Reserved.
Table 1 also shows the long-term health effects of these types
of air pollution which can include lung cancer, heart disease,
chronic respiratory disease, and damage to the brain, nerves,
and other internal organs.2 It also affects the lungs of growing
children and can aggravate medical conditions in the elderly.
While research into these effects is ongoing, it is estimated
that healthcare costs, productivity losses in the workplace, and
the impact on human welfare costs the U.S. billions of dollars
each year.3
A number of regulatory changes in recent years have affected
Utah’s air quality standards. In 2006, the EPA revoked the
annual standard for PM10, but retained the 24-hour standard,
which is set at 150 μg/m3. For PM2.5 the EPA lowered the
24-hour PM2.5 standard from 65 μg/m3 to 35 μg/m3. These
24-hour standards are met when the probability of exceeding
the standard is no greater than once per year for a 3-year averaging period. In 2008, the EPA lowered the ozone standard
from 0.084 parts per million (ppm) to 0.075 ppm, based on a
3-year average of the annual 4th highest daily 8-hour average
concentration. This is currently under review with final specifications expected in 2010.2
These regulatory changes have caused Utah to adjust their
state implementation plans. The State is implementing specialized computer systems to gather data on particulate matter and
create atmospheric models of Utah for the EPA. The Division
of Air Quality, in conjunction with local health departments
and local governments, continues to provide air quality assessments, speak at public meetings, and implement health assessments in communities and neighborhoods throughout the state.
The Utah’s Clean School Bus Retrofit Project is continuing in
2010 to equip most school busses in the State with emissions
control devices, which are expected to reduce particulate matter
by 30%, carbon monoxide by 50% and VOCs (hydrocarbons)
by 74%. Grant and loan programs continue to provide financial
support to business and government to operate vehicles on
clean fuel or to purchase new clean fuel vehicles.2 The intent of
these programs is to help meet EPA standards and continue to
improve the health of Utah’s citizens.
General Health Indicators
101
2010 Utah’s Health: An Annual Review
Table 1: EPA Designated Pollutants2
Name
Sources
Health Effects
Carbon Monoxide Burning of gasoline, wood, natural gas, coal, Reduces the ability of blood to transport oxygen to body
(CO)
oil, etc.
cells and tissues. Hazardous to people who have heart or
circulatory problems and/or damaged lungs or breathing
passages.
Lead (Pb)
Paint (houses, cars), smelters (metal refineries); Damages nervous systems and causes digestive system
manufacture of lead storage batteries.
damage. Children are at special risk. Can also cause
cancer in animals.
Nitrogen Dioxide Burning of gasoline, natural gas, coal, oil, and Causes lung damage and other illnesses of the respiratory
(NO2)
other fuels. Cars are also an important source system.
of NO2.
Ozone (O3)
Chemical reaction of pollutants; VOCs and Causes breathing problems, reduced lung function,
NOx.
asthma, irritated eyes, and reduced resistance to colds
and other infections. May also speed up aging of lung
tissue.
Particulate Matter Burning of gasoline, natural gas, coal, oil Causes nose and throat irritation, lung damage,
(PM10, PM2.5)
and other fuels; industrial plants; agriculture bronchitis, and early death.
(plowing or burning fields); unpaved roads,
mining, construction activities. Also formed
from the reaction of VOCs, NOx, SOx, and
other pollutants in the air.
Sulfur Dioxide
Burning of coal and oil (including diesel and Causes breathing problems and may cause permanent
gasoline); industrial processes.
damage to lungs.
Information on this page was gathered from:
1 Utah Foundation Research Brief, Addressing Utah’s Air Quality and Environmental Concerns, Available online at http://www.utahfoundation.org/
reports/?page_id=256. Accessed March 31, 2010.
2 Utah Division of Air Quality, Utah Department of Environmental Quality, 2009 Annual Report http://www.airquality.utah.gov/Public-Interest/annualreport/2009AnnualReportFinal.pdf. Accessed online March 15, 2010.
3 Utah Division of Air Quality, Utah Department of Environmental Quality, Air Quality Health Effects. Available online at http://www.deq.utah.gov/references/FactSheets/AQ_Health_Effects.htm. Accessed March 15, 2010
4 Utah Division of Air Quality, Utah Department of Environmental Quality, About Pollutants. Available online at http://www.airquality.utah.gov/PublicInterest/about_pollutants/About_pollutants.htm. Accessed March 15, 2010
102
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
All-Cause Mortality
Compiled by JB Flinders, MPH, MBA
The death rate in Utah is 12% lower than the national average.
All-cause mortality is a measure of the proportion of persons
dying in any given year compared to the total population. This
can also reflect the population’s life expectancy in that allcause mortality demonstrates as a death rate decreases, life expectancy increases. This mortality is influenced by incidence,
and severity, of diseases and the effectiveness of both policies
and treatments for those diseases.1
Funeral directors in Utah are mandated to file death certificates
after obtaining demographic information from a close family
member of the decedent and the cause of death, which is certified by the decedent’s physician or the physician who was present at the time of death. Death certificate data is extensively
reviewed for completeness and consistency after which they
are keyed into software locally by the Utah Department of the
Office of Vital Records and Statistics (OVRS), then shipped
to the National Center for Health Statistics where they are
machine coded to federal standards and returned to OVRS
for updating.1 OVRS also maintains records of specific characteristics such as cause of death, age of deceased, and other
incident-related factors.2
In 2008, 13,920 Utah residents died. The crude death rate for
the State of Utah is 500.37 deaths per 100,000 individuals.
Within the state, Summit County Local Health District had the
lowest crude death rate at 330.68 deaths per 100,000 people,
while Southeastern County Local Health District had the highest at 873.04 deaths per 100,000.3 The Utah age-adjusted death
rate has decreased since 1997 and is now 12% lower than the
overall death rate for the U.S (see Figure 1). This low death rate
is credited to a number of different factors, including an extremely low rate of tobacco and alcohol use (and other healthy
lifestyles), low rates of poverty, and better access to quality
health care.2 However, heart disease, cancer, stroke, and other
leading causes of death are similar for Utah and the U.S. overall, adjusted for sex, race, and ethnicity.2
Figure 1: Death Rates, All Causes, Utah and U.S., 1990-2008
1000
Deaths per 100,000 individuals
900
800
700
600
500
U.S.
400
Utah
300
200
100
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator Based Information System for Public Health, Leading Causes of Death by Crude Rate. Available online at
http://ibis.health.utah.gov/query/result/mort/MortCntyICD10/Top10CrudeRate.html. Accessed March 16, 2010.
2 Utah Department of Health, Utah’s Indicator Based Information System for Public Health, Death Rates : Deaths from All Causes. Available online at http://
ibis.health.utah.gov/indicator/complete_profile/DthRat.html. Accessed March 16, 2010.
3 Utah Department of Health, Utah’s Indicator Based Information System for Public Health, Mortality ICD-10 Query Modules for Utah Counties and Local
Health Districts. Available online at http://ibis.health.utah.gov/query/result/mort/MortCntyICD10/CrudeRate.html. Accessed March 16, 2010.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
103
2010 Utah’s Health: An Annual Review
Emergency Department Visits
Compiled by Gregg A. Jones
The total number of Utah Emergency Department visits in 2007 was 765,062. Of those visits, 726,859 (95%) were Utah
residents
For the better part of the last decade, Utah has experienced
a steady increase in the volume of Emergency Department
visits. Comparing the volume of Emergency Department visits
from year to year is critical in understand the health trends in
Utah. Emergency Departments treat people for a vast amount
of medical issues and conditions. This explains the continuous growth of Emergency Department visits. These statistics
include both residents of Utah along with nonresidents. Also
included are all patients who received treatment and were discharged as well as all inpatient admissions that came through
the Emergency Departments.1
Figure 1 shows the steady incline of Emergency Department
visits during the last nine years. In 1999 the amount of Emer-
gency Department visits totaled 605,915. With Emergency
Department visits in 2007 reaching 765,062, the last nine years
have shown an increase in Emergency Department visits of
20.8%.2
The World Health Organization and the U.S. National Center
for Health Statistics have an international system used to classify causes of death on death certificates as well as diagnoses,
injury causes, and medical procedures for emergency department visits. Using these different classifications of Emergency
Department visits allows for comparison of different specific
issues. Figure 2 shows the rate of visit based on specific medical issues for the year 2007.3
Figure 1: Total Emergency Department Visits, Utah, 1999-2007
900000
800000
700000
Number of Visits
600000
500000
400000
300000
200000
100000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
104
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
Drug and Alcohol Related
Injuries
Multiple Significant Trauma
Pregnancy/childbirth Related
Burn Related
Infections
Circulatory System Related
Respiratory System Related
Digestive System Related
8575
33514
1022
22651
2885
19640
52528
51790
94238
2010 Utah’s Health: An Annual Review
Figure 2: Emergency Department Visits by Specific Medical Issues for 2007
100000
90000
Number of Visits
80000
70000
60000
50000
40000
30000
20000
10000
0
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at: http://ibis.health.utah.gov/query/result/ed/
EDCntyHospED/Count.html. Accessed September 23, 2009.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at: http://ibis.health.utah.gov/query/result/ed/
EDCntyHospED/Count.html. Accessed September 23, 2009.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at: http://ibis.health.utah.gov/query/result/ed/
EDCntyHospED/Count.html. Accessed September 23, 2009.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
105
2010 Utah’s Health: An Annual Review
Health Insurance Coverage
Complied by Priti D. Shah
In 2008, the percentage of uninsured in Utah was 10.7%, which is lower than the national rate.
Both the Utah Department of Health’s Utah Healthcare Access
Survey (UHAS) and the Census Bureau’s Current Population
Survey (CPS) include information on physical and mental
health status, health insurance coverage, and access to care.
The 2008 UHAS was conducted with 3,165 households (9,746
persons) which represent non-institutionalized adults and
children living in Utah with telephones. The CPS uses an area
probability design that includes households with and without
active analogue telephone lines.1,2 Per UHAS data, persons
with health insurance were more likely than those without
health insurance to have a regular source of primary health
care and were more likely to have routine preventive care;
73.3% insured persons had a routine medical check-up in the
last 12 months compared to 56.6% of uninsured persons. Also,
persons without health care coverage often delayed seeking
needed care, found services difficult to afford, and were more
likely to be hospitalized for conditions most effectively treated
in outpatient settings.1
Figure 1 shows the percentage of persons who lacked health
insurance coverage in Utah (UHAS and CPS) and the U.S.
(CPS) from 1988-2008. An estimated 298,200 Utahans (10.7%)
were without health insurance in 2008, which is an increase
of 0.1% from 2007 in both surveys. Based on 2008 figures,
Utah ranks as the 27th best state in the U.S. for percentage of
persons covered by health insurance, down from the 23rd rank
in 2007.1 The reasons for discrepancy between surveys are not
entirely clear, but may include differences in question wording,
data weighting, and data imputation for missing values.1,2
Figure 2 shows the distribution of the uninsured individuals in
Utah according to gender and age in 2008.1 Males aged 19-26
were most likely to be uninsured, at 30.5%. Furthermore, the
percentage of uninsured children in 2008 was 8.4% down from
10.4% (UHAS), and 9.9% down from 11.0% (CPS) in 2007.
Those with household incomes less than $20,000 had the highest rates of being uninsured (25.4%). Among Utah adults, those
who had not graduated high school had the highest rates of being uninsured (41.5%) compared to those who had completed
four or more years of college (4.9%). Approximately two-thirds
(66.5%) of uninsured Utah adults in 2008 were employed either
part-time or full-time.1
To improve conditions, the Utah Department of Health administers programs to improve access to care, such as Medicaid,
Children’s Health Insurance Program (CHIP), the Primary
Care Network, and Utah’s Premium Partnership for Health
Insurance. The Utah Department of Health also works to provide primary care grants to rural areas and clinics for children
with disabilities. Local health departments provide preventive
services such as immunizations and screenings at low or no
cost to eligible persons.1 The Healthy People 2010 initiative to
Figure 1. Percentage of Persons Who Lacked Health Insurance Coverage, Utah and U.S., 1988-2008
20%
18%
Percentage of Persons
16%
14%
12%
UT UHAS
10%
UT CPS
8%
U.S. CPS
6%
4%
2%
0%
Year
106
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
eliminate health disparities and increase quality and years of
healthy life, has a stated goal to insure 100% of individuals
under age 65 this year.1,3
Health Maintenance Organizations (HMOs) attempt to balance patient needs with the need to hold down medical costs.
The odd years in Figure 3 account for adult enrollees of Utah
HMOs, while the even years show child enrollees.4 Medicaid
enrollees have expressed higher overall satisfaction than commercial enrollees; however, those surveyed reported needed
improvement in customer service satisfaction.4 In Utah, 10%
of the population is enrolled in Medicare compared to 15%
in the U.S. as of January 2008.5 Of all Utah businesses, 76%
are small businesses, and only 38% offer health insurance.6
For persons that are uninsured and are not covered by other
health insurance, the Primary Care Network provides primary
preventive health coverage.7 Utah’s Premium Partnership for
Health Insurance (UPP) helps people pay their health insurance
premiums through their employer’s health insurance plan or
COBRA coverage up to $150 per adult and up to $120 per child
per month if they qualify.8 The UHAS’s Utah’s Health Care
Safety Net provides health care and related services to the uninsured, Medicare, Medicaid, under insured, and other vulnerable patients who experience geographical, cultural, language,
economic or other barriers to care.9 For private insurance, Utah
health insurers are required to provide individual coverage to
residents of Utah that are not eligible for health insurance via
other programs.10
About 8.4% of Utah children aged 0-18 years did not have
health insurance in 2008, which has decreased from 9.9% in
the previous year, as shown in Figure 4.11 Children can be insured with Medicaid or CHIP if they are not insured by private
or employer-provided plans. Children are eligible for Medicaid
if they are 0-5 years old and live in homes with incomes at
or below 133% of poverty; children 6-18 years must live at or
below 133% of poverty and pass an asset test. To be eligible for
CHIP, all children aged 0-18 years must live in homes below
200% of the poverty level and cannot be eligible for Medicaid
or have any other type of insurance, whereas children can still
qualify for Medicaid even with other insurance. The 2008
UHAS estimates that approximately 80% of insured children
were income eligible for health care services through CHIP
or Medicaid programs, but were not enrolled.11 Of children
with CHIP or Medicaid, 4.9% did not have a usual source of
medical care in 2008, and 21% of uninsured children were the
most likely subgroup to be deficient in a usual place of care.
The inability to access care because of cost, lack of services
in the area, or the refusal of insurance to pay was also higher
for children with Medicaid or CHIP (7.8%) than children with
other types of insurance coverage (4.7%).11
Figure 2. Percentage of Persons Who Lacked Health Insurance Coverage by Age and
Sex, Utah, 2008
35%
Percentage of Persons
30%
25%
20%
Female
15%
Male
10%
5%
0%
Less than 1
1 to 5
6 to 18
19 to 26
27 to 34
35 to 49
50 to 64
65 and
Over
Age Group
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
107
2010 Utah’s Health: An Annual Review
Rating Scale (0-10)
Figure 3. Average Rating of Health Plan by Enrollees in Commercial and Medicaid
HMOs, Utah, 2001-2009
10
9
8
7
6
5
4
3
2
1
0
Medicaid HMOs
Commercial HMOs
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
Figure 4. Health Insurance Coverage and Plan Type, Utah Children Aged 0-18, 2008
Medicaid
CHIP
No Health Insurance Coverage
Some Other Insurance Coverage
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Complete Indicator Profile of Health Insurance Coverage. Available online at: http://ibis.health.utah.gov/indicator/complete_profile/HlthIns.html. Accessed March 28, 2010.
2 State Health Access Data Assistance Center, State Health Insurance Coverage Estimates: A Fresh Look at Why State Survey Estimates Differ from CPS.
Available Online at: http://www.shadac.org/files/IssueBrief12.pdf. Accessed March 28, 2010.
3 Healthy People 2010. Available Online at: http://www.healthypeople.gov/About/goals.htm/ Accessed on March 28, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Complete Indicator Profile of Managed Care (CAHPS) Survey.
Available online at: http://ibis.health.utah.gov/indicator/complete_profile/ManCarSurv.html. Accessed on April 5, 2010.
5 State Health Facts. Individual State Profiles: Utah, Medicare. Medicare Enrollment: Medicare Enrollment as a Percentage of Total Population. Available
online at: http://www.statehealthfacts.org/profileind.jsp?ind=291&cat=6&rgn=46 Accessed on April 5, 2010.
6 Health Insurance Reform and You. Health Insurance Reform and Utah. Available online at: http://www.healthreform.gov/reports/statehealthreform/utah.
html. Accessed on April 5, 2010.
7 Utah Department of Health, Primary Care Network. Frequently Asked Questions: Do I Qualify? Available online at: http://health.utah.gov/pcn/faq.html.
Accessed on April 5, 2010.
8 Utah Department of Health, What is UPP? Available online at: http://health.utah.gov/upp/whatisupp.htm. Accessed on April 5, 2010.
9 Utah Department of Health, Utah’s Health Care Safety Net. Available online at: http://health.utah.gov/safetynet/aboutus.htm. Accessed on April 5, 2010.
10Health Insurance Sort. Available online at: http://www.healthinsurancesort.com/quotes/utah-health-insurance.htm. Accessed on April 5, 2010.
11Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Complete Indicator Profile of Medicaid and CHIP Penetration.
Available online at: http://ibis.health.utah.gov/indicator/complete_profile/MedCHIPPen.html. Accessed on April 5, 2010.
108
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Hospital Discharge by Major Disease Category
Compiled by Cici Zhou
Issues relating to pregnancy and newborns were the primary reasons for hospitalization in Utah in 2008
Hospital Discharge data are useful as primary indicators of the
health of a population in a given state. Hospital discharge refers
to the formal release of a person who was officially admitted
to the hospital. The different possible discharge conditions include: release to self care, release to home health care, transfer
to another short-term hospital, transfer to a skilled nursing
facility, release against medical advice, and death.1
All hospitals in the state of Utah are required to report discharge data for each patient they serve on an inpatient basis.
The entirety of discharge data includes compete billing, medical, personal, services, and charges information regarding each
patient that experienced a hospital stay. Discharge data are
then submitted to the Utah Department of Health quarterly,
where it is entered into the Hospital Discharge Data Base. This
information is also made available for public access through
the Department of Health’s Indicator-Based Information System (UDOH-IBIS).1
The distribution of Utah’s 2008 hospital discharge rate,
which was 942.28 per 10,000 population 2, is shown in Table
1. There were 279,504 total discharges, 40.5% of which were
maternity or newborn related. Although they represented the
highest number of discharges, maternity and newborn issues
accounted for only 15.0% of total facility charges. Surgeries
for all ages were 23.7% of all discharges and accounted for
50.7% of total facility charges while medical cases for all ages
totaled 30.7% of all discharges and represented 28.8% of the
total facility charges. 49.8% of all discharges were classified as
emergency or urgent admissions. The Utah Health Data Committee directs the statewide effort to collect, analyze, and distribute data that facilitates the promotion and accessibility of
quality health care and to encourage interaction among those
concerned with health care issues.2
Table 1: Hospital Discharges by Category, Utah, 2008
Hepatobiliary and Pancreas
Infectious and Parasitic Disease
Female Reproductive System
Kidney & Urinary Tract
Nervous System
Digestive System
Respiratory System
Circulatory System
Musculoskeletal System
Newborn and Other Neonates
Pregnancy, Childbirth, Puerperium
0
10000 20000 30000 40000 50000 60000 70000
Information on this page was gathered from:
1 Utah Health Data Committee, Utah Hospital Inpatient Discharge Data Standard Report I-2008. Available online at http://health.utah.gov/hda/reports/
ST1_08.pdf. Accessed April 6, 2010
2 Utah Hospital Discharge Query System. Available online at http://health.utah.gov/hda/hi_iq/hi_iq.html. Accessed May 11, 2010.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
109
2010 Utah’s Health: An Annual Review
Life Expectancy
Compiled by Charlene Hill
Utah Male
Utah Female
U.S. Male
U.S. Female
1980
72.4
78.6
69.9
76.9
Life expectancy at birth in1981
Utah remains equal to72.7
or above U.S. average
78.8
70.3
77.1
1982 measurement of the73.4
70.7disparity by race
77.4 as well as gender. In
Life expectancy is a statistical
expected Life78.7
expectancy shows
1983
73.9
79
70.9
77.4
average life span for individuals born into a particular popu- Utah, as illustrated by Figure 2, Asian/Pacific Islanders have
1984
73.3overall the highest
79.2
71
77.4
lation. This measurement is
often used to gauge the
life expectancy
(84.9 years),
followed by White (78
1985expectancy at birth 73.6
79.2American Indian/
71 Alaskan Native(74.5
77.5
health of a community. Life
measures years),
years), and then
1
1986
74.1
79.6
71
77.6
health status across all ages. Factors that affect these statistics Black (74.2 years).
1987
74.4 etc.
79.2
71.2
77.6
include heredity, physical condition,
occupation, nutrition,
The
recent
record
high
life
expectancy
rates can be attributed
1988
74.5
79.3
71.2
77.6
Life expectancy shifts are 1989
indicative of trends in 74.8
mortality. to a79.1
few factors. One71.5
factor was a drop
77.8in deaths in 2005 by
Being able to predict how populations
will age allows
the nation’s age-adjusted
death rate by
1990
74.9for the 21,753,
80.1which dropped
71.7
78
2
planning and provisions of1991
services and support associated
2.8%79.6
to a record low.71.8
Another factor 78.1
was a decline in the age75
with the elderly. As the life 1992
expectancy of a population
length- adjusted
10 of the 15 top
causes of death in the
75.3
80 death rate of
72.1
78.3
2
ens, the number of chronic illness
cases
tends
to
increase,
since
nation.
These
include
heart
disease,
cancer,
stroke, chronic
1993
74.9
79.5
72
78.1
1
chronic illnesses are more common
in older age groups.
lower
respiratory disease,
pneumonia,
1994
74.8
79.8
72.2 diabetes, Alzheimer’s,
78.2
septicemia,
chronic 72.4
liver disease, hypertension,
and Parkin1995
75.2
79.5
78.2
In 2006, life expectancy reached an all time high in the United son’s disease.2
1996
75.5
79.9
72.8
78.3
States.2 The life expectancy at birth for Utah women was ap1997
75.5
79.6
73.3
78.5
proximately 80, and the same for U.S. women. For Utah men Ways to increase an individual’s life expectancy include many
1998
75.4
79.6
73.6
78.6
the life expectancy at birth was 76; for U.S. men, 75.1 The life simple activities. Such activities include plenty of sunlight to
1999
75.6
79.8
73.6
78.5
expectancy at birth of Utah citizens has been as high or higher get required amounts of Vitamin D, socializing, daily exercise,
2000
76.3
80
73.8
78.6
than the average U.S. citizen life expectancy between the years a balanced diet, relaxation time, regular check-ups, and avoid2001
76.4
80
74.4
79.8
of 1980 to 2006 as shown by Figure 1. As shown by Figure 1, ing risky behavior.3 A lack of such activities has been con2002
76.3
79.9
74.5
79.9
women had a higher life expectancy than men from 1980 to nected to a higher risk of heart disease, diabetes, and other top
2003
76.4
79.9
74.8
80.1
2006, but the life expectancy of U.S. men is currently increas- causes of death of the nation.3
2004
75.9
79.1
75.2
80.4
ing at a greater rate than that of U.S. women.2
2005
76.3
79.3
75.2
80.4
2006
76.4
79.1
75.3
80.6
Figure 1: Life Expectancy at Birth, Utah and U.S., 1980-2006
82
Life Expectancy (Age)
80
78
76
74
Utah Male
72
Utah Female
70
U.S. Male
U.S. Female
68
66
64
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006
Year
110
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
Race
Age in Years
merican Indian/ Native Alask
74.5
Asian/Pacific Islander
84.9
Black
74.2
White
78
2010 Utah’s Health: An Annual Review
Figure 2. Life Expectancy at Birth by Race, Utah, 1998-2003
White
Race
Black
Age in Years
Asian/Pacific Islander
American Indian/ Native Alaskan
65
70
75
80
85
90
Life Expectancy (Age)
Information on this page was gathered from:
1 Utah Department of Health. Utah’s Indicator Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view/
LifeExpect.UT_USSexYear.html. Accessed December 21, 2009.
2 U.S. Life Expectancy Rises to Record Level. Available Online at http://www.medicinenet.com/script/main/art.asp?articlekey=99625. Accessed December
23, 2009.
3 Manhattan Policy for Policy Research. Medical Progress Report. Available online at http://www.manhattan-institute.org/html/mpr_04.htm. Accessed December 23, 2009.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
111
2010 Utah’s Health: An Annual Review
Poverty
Compiled by Charlene Hill
Utah’s poverty rate has increased by 11.4% this decade
Each year, the U.S. Census Bureau issues a report on poverty
in the United States that makes known the national poverty
threshold. The national poverty threshold is defined as the
minimum level of income deemed necessary to achieve an
adequate standard of living.1 The factors taken into consideration in the determination of the poverty threshold include
the number of people per household, the ages of the household
members, and income of each household member. Poverty is
associated with housing instability, food insecurity and hunger, increased suicide rates, depression, and drug abuse.2
Many health and social issues for children are connected to the
causes and consequences of poverty. Although Medicaid and
SCHIP cover healthcare for some children below or near the
poverty level, they do not cover everyone below the poverty
level2, and sometimes-eligible people experience other barriers
to enrollment. Due to lack of health insurance, many women
in poverty do not receive proper prenatal care or treatment for
medical conditions such as diabetes or high blood pressure.
This leads to increased risk of infant mortality and developmental issues.2 Depression often develops in children subject to
poverty more often than in children considered to be of middle
class. This is in part due to stressful situations that often are
co-existent with poverty, such as parental job loss, housing and
food insecurity, drug addiction, and parental divorce, which
can create feelings of anxiety in children.2 Children who live
in low-income neighborhoods may receive substandard education due to the increased likelihood of attending under-funded
schools.
For the year 2009, the poverty threshold for a household of
four members was $22,050, adding $3,740 for each additional
member.7 The average personal income of Utahns fell 1.7% in
2009 and nationally it fell 1.6% as reported by the U.S. Bureau
of Economic Analysis.8 Utah’s per capita income for 2009 was
$30,875, which dropped Utah’s per capita income ranking to
49th.8
Between 2008 and 2009 the U.S. has seen an increase in
Americans below the national poverty level to a percentage
of 13.3%. The percentage of Utahns living below the national
poverty level in 2009 is a reported 10.3%, about a quarter less
than the national percentge.5 However; Utah’s poverty rate
has increased 11.4% this decade, more than the average in the
country. Figure 1 illustrates the number of poverty-stricken
Utahns found in each county for the year 2008.
Figure 1: Utahans in Poverty by County, 2008
Uintah
Tooele
San Juan
Iron
Washington
Cache
Davis
Weber
Utah
Salt Lake
Individuals in Poverty
0
20
40
60
80
100
Thousands
112
General Health Indicators
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Citizens at or near the national poverty level tend to have increased unmet health needs due to the inability to afford health
insurance and adequate health care. In 2008, 17% of U.S. citizens were found to be uninsured and 20% of American adults
were unable to afford basic health care.3 In 2008, a reported
14.3% of Utahns under the age of 65 were uninsured, and in
2007 11.4% of Utahns could not afford basic health care.4
Several programs have been instigated by the Utah Department of Health to cover the costs of healthcare for Utahns
below or near the national poverty level, including Medicaid,
the Children’s Health Insurance Program (CHIP), the Primary
Care Network (PCN), and several others, but they do not cover
everyone, and there are gaps in this safety net. Utah’s federally qualified Community Health Centers (CHCs) offer lowcost health care to low-income patients, but have had to turn
patients away due to an increased demand for care with the
economy’s downturn. In April 2009, CHCs in Utah received
2.9 million in federal stimulus funds. The U.S. Department of
Health and Human Services estimates these funds will allow
11 centers statewide to provide care to an additional 14,572
patients.6
Information on this page was gathered from:
1
2
3
4
5
6
7
8
U.S. Census Bureau. http://www.census.gov/hhes/www/poverty/threshld/thresh08.html. Accessed December 23, 2009.
Poverty. http://www.newworldencyclopedia.org/entry/Poverty#Effects_of_poverty. Accessed December 23, 2009.
Centers for Disease Control and Prevention. Health Insurance Coverage. http://www.cdc.gov/nchs/fastats/hinsure.htm. Accessed December 23, 2009.
The Salt Lake Tribune. State Sees Drop in Uninsured. http://www.sltrib.com/ci_13309173?source=rss. Accessed December 23, 2009.
2009 Annual Report on Poverty in Utah. http://www.utahcap.org/uploads/429845_CAPUAnnualReport09_Final.pdf. Accessed April 4, 2010.
http://www.auch.org/newsnotes/AUCHNews.html. Accessed December 23, 2009.
Institute for Research on Poverty. Poverty Thresholds and Guidelines. http://www.irp.wisc.edu/faqs/faq1.htm#year2000. Accessed April 4, 2010.
Deseret News. http://www.deseretnews.com/article/700019493/Utahns-sees-personal-income-drop-in-2009-per-capita-ranking-falls-to-49th.html. Accessed April 3, 2010.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
113
2010 Utah’s Health: An Annual Review
Self-Reported Health Status
Compiled by JB Flinders, MPH, MBA
In 2008, 13.2% of Utah adults reported having seven or more days in the past 30 days when their physical health was
not good.
Health status is defined as the impact of disease on selfreported patient function or, more specifically, the range of
disease manifestation in a given patient including symptoms,
functional limitation, and quality of life, in which quality of
life is the difference between actual and desired function.1
and older age group (20.4% for males and 22.6% for females).
Figure 2 shows an estimate of self-reported health status by
Health District, where reporting of having seven or more days
in the past 30 days not being good is highest in Southeastern,
Tooele, and Tri-County regions.
In 2008, an estimated 13.2% of Utah adults reported having
seven or more days in the past 30 days when their physical
health was not good. This estimated statistic has remained
fairly constant since 1993, with a low of 12.4% in 2002 and a
high of 15.9% in 1997. Looking at age-adjusted rates for 19932008, Utah and the U.S. have had similar percentages of adults
who reported seven or more days when their physical health
was not good in the past 30 days. These rates in 2008 were
14% in Utah and 15.3% in the U.S. These rates have been age
adjusted as Utah has a younger population compared to the
rest of the U.S., and younger adults are generally less likely to
experience poor physical health.2
Other disparities in self-reported health status included education level, income level, and obesity. 22.6% of those with less
than a high school education reported having seven or more
days in the past 30 days when their physical health was not
good, compared to 11.0% of those who had graduated from
college. By income, 24.4% of those whose income was less
than $25,000 annually reported having seven or more days
in the past 30 days when their physical health was not good,
compared to 15.9% of those whose income was $25-49,999
annually, 11.3% of those whose income was $50-74,999 annually, and 8.8% of those whose income was greater than $75,000
annually. In terms of obesity, 11.3% of those considered to be
of normal weight reported having seven or more days in the
past 30 days when their physical health was not good compared
to 12.6% of those considered overweight and 20.0% of those
considered obese.2
Figure 1 shows the variation between age and sex in self-reported health status. In general, women in Utah reported higher rates of seven or more days in the past 30 days when their
physical health was not good. These rates are almost double in
women between the ages of 18-24 versus their male counterparts ages 18-24 (6.4% to 12.6% respectively). This disparity
decreases with age to where males and females are relatively
similar in their reporting of having seven or more days in the
past 30 days with their physical health not being good in the 65
114
General Health Indicators
Self-reported health status data indicates a need to reduce
morbidity and improve disease self-management from Utah’s
chronic disease prevention and control programs. The continuing goal from this data would be to decrease the percentage of
adults who experience poor physical health days.2
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 1: Percentage of Adults Aged 18 and Older Who Reported Seven or More
Days When Their Physical Health Was Not Good in Past 30 Days by Sex and Age
Group, Utah, 2007 and 2008
Percentage of Adults
25
20
15
Utah Male
10
Utah Female
5
0
18-34
35-49
50-64
65+
Age Group
Figure 2: Percentage of Adults Aged 18 and Older Who Reported Seven or More Days
When Their Physical Health Was Not Good in the Past 30 Days by Local Health
District, Utah, 2006-2008
Weber-Morgan
Wasatch
Local Health District
Utah
Tri-County
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis
Central
Bear River
0
2
4
6
8
10
12
14
16
18
20
Percentage of Adults
Information on this page was gathered from:
1 Rumsfield, J.S. (2008). Health Status and Clinical Practice: When Will They Meet? Available online at http://circ.ahajournals.org/cgi/content/full/106/1/5.
Accessed March 16, 2010.
2 Health Status: Physical Health Past 30 Days. Available online at http://ibis.health.utah.gov/indicator/complete_profile/HlthStatPhys.html. Accessed March
16, 2010.
©2010 The University of Utah. All Rights Reserved.
General Health Indicators
115
2010 Utah’s Health: An Annual Review
Alcohol Use - Utah and the United States
Compiled by Gregg A. Jones
7.1% of adults in Utah reported binge drinking compared to 13.7% nationally
Alcohol, a depressant of the central nervous system, is widely
used in the United States, with levels ranging from abstinence
to alcoholism. Alcoholism is a typically progressive disease
with genetic, psychological, social, and environmental components, and is typically characterized by preoccupation with,
and impaired control over, the intake of alcohol despite adverse
consequences. Nearly 18 million Americans abuse alcohol, and
more than 100,000 Americans die yearly from alcohol-related
causes.1
The abuse of alcohol has some severe implications including heart disease, cirrhosis, dependence, and fetal alcohol
disorders if consumed by pregnant women. Moderating one’s
alcohol intake can lower the risks of stroke, reduce incidence
of heart disease due to plaque, and slow bone loss in postmenopausal women.2
Binge Drinking, defined as consuming 5 or more drinks in a
row for men and 4 or more drinks for women, is one indicator
of potentially serious alcohol abuse.3 As illustrated in Figure
1, in 2008, 7.1% of adults in Utah reported binge drinking
compared to 13.7% nationally. Between 2007 and 2008 binge
drinking has decreased by almost 1.5% in Utah. As Figure
2 shows, the highest numbers of binge drinkers in Utah are
males ages 18-34.4
Although Utah reported a lower amount of alcohol consumption in high school students versus the national average in
2008, it experienced a sharp increase from 2005 levels, from
8.9% to 13.2% in males and 8.7% to 9.4% in females.4 This
is important because the number of adults who reported first
alcohol use at age 14 or under reported an alcohol abuse or
dependence at a rate of 17.5%, compared with 3.7% of adults
who first used at 18 or older, and 2.4% of those who first used
after the age of 21.5
Figure 1. Percentage of Adults who Reported Binge Drinking, Utah and US
18
16
% of Population
14
12
10
UT
8
US
6
4
2
0
2001
2002
2003
2004 2005
Year
2006
2007
2008
Figure 2. Percentage of Adults Who Reported Binge Drinking by Age
and Sex, Utah
Percentage
116
18
16
14
12
10
Behavioral Influences on Health
8
Male
©2010 The Female
University of Utah. All Rights Reserved.
US
% of P
8
6
2010 Utah’s Health: An Annual Review
4
2
0
2001
2002
2003
2004 2005
Year
2006
2007
2008
Figure 2. Percentage of Adults Who Reported Binge Drinking by Age
and Sex, Utah
18
Percentage
16
14
12
10
Male
Female
8
6
4
2
0
18-34
35-49 Age
50-64
65+
Information on this page was gathered from:
1 Mayo Clinic, Alcoholism. Available online at http://www.mayoclinic.com/health/alcoholism/DS00340. Accessed April 10, 2010.
2 Centers for Disease Control and Prevention. Available online at http://www.cdc.gov/alcohol/index.htm. Accessed March 22, 2010.
3 U.S. Department of Health and Human Services, Binge Drinking in Adolescents and College Students. Available online at http://ncadi.samhsa.gov/govpubs/
rpo995. Accessed April 10, 2010.
4 Utah Department of Health, Utah’s Indicator-Based system for Public Health. Available online at http://ibis.health.utah.gov/indicator/view_numbers/AlcConBinDri.UT_US.html. Accessed March, 22, 2010.
5 Substance Abuse and Mental Health Services Administration (2007). Available online at http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6results.cfm#Ch7.
Accessed March, 22, 2010.
©2010 The University of Utah. All Rights Reserved.
Behavioral Influences on Health
117
2010 Utah’s Health: An Annual Review
Homicide
Compiled by Anthony Tran
Utah’s Homicide rate is lower than the national average for both Males and Females
Homicide is the death of a person caused by the deliberate force
of another person. Examples of homicide include: voluntary
manslaughter, involuntary manslaughter, intoxicated manslaughter, dangerous driving causing death to another person,
reckless manslaughter, and negligent manslaughter.1 Homicide
is often considered an act of criminal activity and vindictive
behavior, but it can also result from acts of self-defense, such
as protecting oneself, family, or attack by another country.2
From 2004-2008, Utah’s age adjusted homicide rate was 2.0 per
100,000 persons, an average of 52 homicides per year, or once
every 8.5 days. Figure 1 shows homicide rates in both Utah
and U.S.3 Homicide rates for males in the U.S. are consistently
higher than that of rates for females in the U.S., and both male
and female rates in the State of Utah. Although Utah’s rates
are consistently lower than the national average, homicide is
still the third leading cause of death for Utahans ages 1-4 and
15-24 years old. Figure 2 show that both male and female rates
are similar in each age group, with the exception of the teen-
age and early adulthood years in males.3 The target number for
U.S. homicide rates in 2010 is 2.8 per 100,000 population and
the State of Utah target is 2.0 per 100,000 population. According to the Utah Department of Health, Utah’s 2008 rate is 1.7
per 100,000 population.4
The Utah Department of Health Violence and Injury Prevention Program (UDOH-VIPP) is funded by the U.S. Center of
Disease Control and Prevention, and implements the Utah
Violent Death Reporting System (UTVDRS). The UTVDRS
is a data collection and monitoring system that provides information to decision makers about the trends, characteristics,
and magnitude of violent deaths such as homicide. Data are
collected from the Office of the Medical Examiner, Vital Records, and law enforcement agencies. UTVDRS is in its fifth
year of operation and continues to help identify risk factors,
understand circumstances, and better characterize perpetrators of violent death.5
Figure 1: Homicide Rates by Sex and Year, Utah and U.S., 2003-2008
Homicide Rate per 100,000
12
10
8
Utah Males
6
Utah Females
4
U.S. Males
U.S. Females
2
0
2003
2004
2005
2006
2007
2008
Year
118
Behavioral Influences on Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2: Data and Confidence Limits for Homicide Rates by
Sex and Age Group, Utah, 2004-2008
9
Rate of Homicides per 100,000
8
7
6
5
Male
4
Female
3
2
1
0
Under 1
Year
age 1-14 age 15-24 age 25-44 age 45-64 age 65-84
Age groups
Information on this page was gathered from:
Wikipedia, Homicide. Available online at http://en.wikipedia.org/wiki/Homicide, accessed on April 4, 2010
Utah Department of Health. Utah’s Indicator-based System for Public Health: Homicide. Available online at http://ibis.health.utah.gov/indicator/view/Homicide.AgeSex.html. Accessed March 29, 2010
Utah’s Indicator-based information system for Public Health, Homicide rates by sex, year, and age, Utah and U.S., 2003-2008 available online at http://ibis.
health.utah.gov/indicator/view/Homicide.UT_USYear.html accessed on March 25, 2010
Utah Department of Public Safety Bureau of Criminal Investigation. Available online at http://bci.utah.gov/Stats/2006.pdf. Accessed March 29, 2010
Utah Department of health, Injury in Utah. Available online at http://health.utah.gov/vipp/ accessed March 25, 2010
©2010 The University of Utah. All Rights Reserved.
Behavioral Influences on Health
119
2010 Utah’s Health: An Annual Review
Motor Vehicle Crash Deaths and Seat Belt Utilization
Compiled by JB Flinders, MPH, MBA
Seat Belt Usage of 86.8% in 2007 is down from the 2006 level
Motor vehicle crashes (MVC) are one of the leading causes of
injury, hospitalization, and death in Utah.1 In Utah in 2008,
MVCs accounted for 268 deaths making them the second leading cause of injury death.2 As shown in Figure 1, Utah’s rates
of MVC’s have declined since 2004 and remained lower than
national rates in 2006, 12.0 per 100,000 population in Utah
versus 14.5 per 100,000 population nationally. In 2008, Utah’s
rate of MVC’s was 10.2 per 100,000 population.2
When analyzed by demographics, MVC death rates from 20062008 were significantly higher for males (14.5 per 100,000
population) than females (7.4 per 100,000 population) from
2006-2008 in Utah. Males aged 65 and above had the highest
rates of MVC death rates (22.4 per 100,000 population) closely
followed by males aged 15-24 (22.3 per 100,000 population). In
females, those aged 65 and above had the highest rates of MVC
deaths (13.4 per 100,000 population). Geographically, from
2006-2008, Utah residents in rural areas tend to have higher
MVC death rates than urban area residents. For example, the
TriCounty (27.8 per 100,000 population), and Southeastern
(25.0 per 100,000 population) health districts had the highest
MVC death rates, while Davis County (7.6 per 100,000 population) and Salt Lake Valley (9.4 per 100,000 population) health
districts had the lowest.3
According to the National Highway Traffic Safety Administration (NHTSA), seat belts are the single most effective safety
measure for reducing fatalities in MVCs, with deaths and serious injuries reduced by approximately 50% with proper and
consistent use of safety belts. The average inpatient hospitalization cost for crash victims not wearing safety belts was 55%
higher than for those wearing safety belts.2 Figure 2 shows the
percent change of no injuries, injuries, and deaths in MVCs for
individuals either wearing or not wearing seat belts in Utah in
2006. Those not wearing seat belts accounted for nearly half
(46.3%) of deaths in MVC’s.1
Utah’s Safety Belt Use Law mandates seat belt use for individuals up to 19 years of age, and an officer can stop the vehicle
if an unrestrained occupant is observed. For a person age 19
or older, failure to wear a seat belt can only be cited when the
person has been stopped for another offense, such as speeding.4
Other motor vehicle safety laws include HB290 which prohibits texting and emailing while driving. The Utah Department
of Public Safety conducts annual safety belt observational
surveys to determine seat belt usage in Utah. In 2007 seat belt
usage in Utah was 86.8%, a decrease from the 2006 level of
88.6%. Law enforcement agencies and transportation agencies
assist with reducing MVC’s through designing and constructing safer roadways and enforcing traffic laws.3
Figure 1: Motor Vehicle Traffic Crash Death Rates, Utah and the
U.S., 1999-2008
Rate per 100,000 Population
16
14
12
10
8
Utah
6
U.S.
4
2
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
120
Behavioral Influences on Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2: Likelihood of Injury and Death, Belted and Unbelted
Occupants in Motor Vehicle Crash, Utah, 2006
90
80
Percent Chance
70
60
50
Belted
40
Not Belted
30
20
10
0
No Injury
Injury
Death
Information on this page was gathered from:
1 Utah’s Indicator-Based Information System, Seat Belts: Safety Restraint Use. Available online at http://ibis.health.utah.gov/indicator/view/SeatBelt.InjSev.
html. Accessed April 24, 2010.
2 Utah’s Indicator-Based Information System, Motor Vehicle Crash Deaths. Available online at http://ibis.health.utah.gov/indicator/view/MVCDth.Ut_
US.html Accessed April 24, 2010
3 Utah’s Indicator-Based Information System, Motor Vehicle Crash Deaths. Available online at http://ibis.health.utah.gov/indicator/complete_profile/
MVCDth.html. Accessed April 24, 2010
4 Utah Department of Public Safety, Highway Safety Office, Seatbelts. Available at http://publicsafety.utah.gov/highwaysafety/seatbelts.html. Accessed April
30, 2010.
©2010 The University of Utah. All Rights Reserved.
Behavioral Influences on Health
121
2010 Utah’s Health: An Annual Review
Suicide
Compiled by Anthony Tran
Utah has higher Suicide rates by both male and female
Suicide is defined as the intentional destructive act of taking
one’s own life. In 2006, over 33,000 people committed suicide,
equivalent to 91 suicides per day and one suicide every 16 minutes.1 Suicide is the 11th leading cause of death in the United
States. Suicidal behavior is complex and often researched.
Risk factors vary with age, gender, and ethnic group and are
known to occur in the combination and change in severity and
abundance over time. The most common risk factors for suicide include depression and other mental disorders, but other
risk factors can include stress, substance abuse, physical and/
or sexual abuse, prior suicide attempts, keeping firearms in
the home, and exposure to the suicidal behavior of others. The
most common methods of suicide are firearms, suffocation,
and poisoning among adults, and firearms in youth populations.2 Ninety percent (90%) of those who do commit suicide
suffer from drug or alcohol dependency or major depressive
disorder. In 2004, 41% of the over 106,000 drug-related suicide
attempts admitted to emergency rooms were diagnosed with
a psychiatric condition in persons aged 18 years or older. The
major clinical diagnosis was depression.¹
Suicide accounted for 1.4% of the total deaths in the United
States in 2006.3 Although women and teens report more suicide attempts, white men take their own lives at nearly four
times the rate of females and represent a total of 79.4% of all
U.S. suicides.1 Figure 1 shows that the national rate of suicide
deaths in males was 18.0 deaths per 100,000 and 4.5 deaths per
100,000 for females.4 In 2008, rates in Utah were significantly
higher for both genders, with 23.8 deaths per 100,000 for males
and 5.8 deaths per 100,000 for females.
Of Utah high school students who completed the Youth Risk
Behavior Survey in 2007, almost an identical number of male
(15.4%) and female (15.8%) respondents had seriously considered attempting suicide.5 The percent of suicides related
to depression were 75.4% of females and 39.9% of males.1
Figure 2 shows the trends in suicide-related behaviors from
2001, 2003, 2005, and 2007. The national Youth Risk Behavior
Survey (YRBS) monitors priority health risk behaviors that
contribute to the leading causes of death, disability, and social
problems among youth and adults in the United States. The
national YRBS is conducted every two years during the spring
semester and provides data representative of 9th through 12th
grade students in public and private schools throughout the
United States.
The Department of Health and Human Services has created Healthy People 2020 which establishes the major risks
to health and wellness, changes public health priorities, and
provides information about emerging issues related to health
preparedness and prevention.3 The Healthy People Objective
for Utah is to reduce suicide deaths among adolescent males
age 15-19 years to 10 per 100,000 by 2020.³ In order to educate
Utah residents about the prevalence, trends, and characteristics
of violent deaths, such as suicide, and improve state violence
prevention policies and programs, the Utah Violent Death Reporting System, UTVDRS, has been implemented to collect
and monitor data for dissemination to Utah’s decision making
bodies.¹
Figure 1: Suicide Rates by Sex, Utah and U.S., 2003-2008
Rate per 100,000 Population
30
25
20
Utah Males
15
Utah Females
10
U.S. Males
U.S. Females
5
0
2003
2004
2005
2006
2007
2008
Year
122
Behavioral Influences on Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2: Trends in the Prevelance of Suicide-related behaviors, Youth Risk
Behavior Survey, Utah, 2001, 2003, 2005, 2007
20
18
16
Percentage
14
2001
12
2003
10
2005
8
2007
6
4
2
0
Seriously considered
attempting suicide
Made a plan about
how they would
attemp suicide
Attempted Suicide
Suicide attempt
resulted in serious
injury
Groups
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, Suicide. Available online at http://www.cdc.gov/ncipc/dvp/Suicide/default.html Accessed March 25, 2010
2 U.S. Department Of Health And Human Services: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Available online at www.samhsa.gov. Accessed March 25, 2010
3 Centers for Disease Control and Prevention, Suicide and Self-Inflicted Injury. Available online at http://www.cdc.gov/nchs/fastats/suicide.htm. Accessed
April 12, 2010.
4 Utah’s Indicator-Based Information System for Public Health, Suicide Deaths. Available online at http://ibis.health.utah.gov/indicator/view_numbers/
SuicDth.Ut_US.html. Accessed April 14, 2010.
5 Utah’s Indicator-Based Information System for Public Health, Youth Risk Behavior Survey, Seriously Considered Attempting Suicide. Available online at
http://ibis.health.utah.gov/query/result/yrbs/YRBS/ConsidAttemptSuicide.html. Accessed April 12, 2010.
©2010 The University of Utah. All Rights Reserved.
Behavioral Influences on Health
123
2010 Utah’s Health: An Annual Review
Tobacco Use: Utah and the U.S.
Compiled by Gregg A. Jones
In 2008, Utah reached an all-time low for percentage of adult smokers at 9.1%
According to the Centers for Disease Control and Prevention
(CDC), tobacco use is the most preventable cause of disease,
disability, and death in the United States. Each year, an estimated 443,000 people die prematurely from smoking or exposure to secondhand smoke, and another 8.6 million contract
a serious illness caused by smoking.1 Despite these risks, approximately 46 million U.S. adults smoke cigarettes. Although
cigarette smoking is the largest contributor to tobacco related
death and disease, over 7.6 million Americans reported using
smokeless tobacco, cigars, and pipes, which also have deadly
consequences, including lung, larynx, esophageal, and oral
cancers.2 Exposure to secondhand smoke is also dangerous
and life threatening, and is thought to cause over 45,000 heart
diseases deaths each year.3
In 2008, Utah reached an all-time low for percentage of adult
smokers at 9.1%. As seen in Figure 1, Utah has consistently
been around 10% lower than the national average for smoking
adults. In the past decade, the United States has experienced a
decline in smokers and, as of 2008, individuals who smoke are
18.6% of the population.4
State and National programs have been established to help
eliminate tobacco use. More popular campaigns, like the Truth,
provide facts and information about the dangers of smoking
so individuals can make educated health decisions.5 The Utah
Department of Health uses a wide variety of programs that
prevent young adults from initiating tobacco use, to help current tobacco users to quit, and to eliminate the exposure of
secondhand smoke to nonsmokers.4
Figure 1. Percentage of Adults Who Smoke, Utah and U.S.
Percentage of Smokers
25
20
15
Utah
U.S.
10
5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, BRFSS. Available online at http://www.cdc.gov/chronicdisease/resources/publications/AAG/osh.htm. Accessed March 24, 2010.
2 National Cancer Institute, Smokeless Tobacco and Cancer. Available online at http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless. Accessed
March 25, 2010.
3 National Cancer Institute, Secondhand Smoke: Questions and Answers. Available online at http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS.
Accessed April 9, 2010.
4 Utah Department of Health, Utah Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view_numbers/CigSmokAdlt.Ut_US.html. Accessed March 24, 2010.
5 The Truth.org. Available online at http://www.thetruth.com/aboutUs.cfm. Accessed April 9, 2010.
124
Behavioral Influences on Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Violent Crimes
Compiled By Gregg A. Jones
Utah’s forcible rape rate is significantly higher than the national rate
Rapeper
Cases
per 100,000
Rape Cases
100,000
People People
Cases
per 100,000
Cases per
100,000
People People
A violent crime is one in which the victim is threatened or Utah employs a relatively low amount of police officers and is
harmed with robbery, aggravated assault, forcible rape, non- 43rd in the United States in the rate of full-time sworn officers.
negligent manslaughter, or homicide. Utah’s violent crime However, Utah ranks 26th in the nation in expenditures for
rate is well below that of the national average, making Utah a police protection.3
relatively safe place to live. Only South Dakota, New HampFigure 1. Violent Crimes, Cases per 100,000 population, Utah and U.S.
shire, Vermont, North Dakota,
and Maine have lower rates of
800
Figure 1. Violent Crimes, Cases per 100,000 population, Utah and U.S.
violent crime. Of all the crimes
700
committed in Utah in 2006, vio800
lent crimes accounted for only 6%
600
700
of the total, with property-related
500
Utah
crimes accounting for the remain600
400
1
ing 94%. Figure 1 shows Utah’s
U.S.
500
violent crime rates compared to
Utah
300
400
the national rates. Utah’s violent
200
U.S.
crime rate of 224.4 per 100,000
300
100
people is well below that of the
200
0
national average of 473.5 per
1
100
1960 1965 1970 1975 1980 1985 1990 1995 2000 2006
100,000 people.
Year
0
Although the violent crime rate
1960 1965 1970 1975 1980 1985 1990 1995 2000 2006
overall is lower in Utah than the
Year
U.S. overall, Utah’s forcible rape
rate is considerably higher than the
national rate. Figure 2 illustrates
Figure 2. Forcible Rape, Cases per 100,000 Population, Utah and U.S.
the rate of forcible rapes in Utah
compared to the national average.
50 Figure 2. Forcible Rape, Cases per 100,000 Population, Utah and U.S.
Although Utah is only 46th in the
45
nation in terms of violent crime,
40
50
Utah had the 21st highest rape rate
35
45
among states in 2006.2 Although
30
40
Utah
a large reason for this rate could
25
35
U.S.
be attributed to an improvement
20
30
Utah
in reporting, recently studies have
15
25
found that Utah ranked second
U.S.
10
20
in the nation in the estimated
5
15
percentage of rape victims, with
0
10
20.6% of the state’s female popu5 1960 1965 1970 1975 1980 1985 1990 1995 2000 2006
lation estimated to be a victim of
Year
3
0
rape.
Information on this page was gathered from:
1960 1965 1970 1975 1980 1985 1990 1995 2000 2006
Year
1 Sun Advocate, Utah Data Confirm Dipping Crime Rate. Available online at http://www.sunad.com/index.php?tier=1&article_id=14836. Accessed April 10,
2010.
2 Utah’s Indicator-Based Information System in Public Health, Rape. Available online at http://ibis.health.utah.gov/indicator/view/Rape.Year.html. Accessed
April 10, 2010.
3 Utah Foundation Research Brief, Utah’s Crime Situation. Available online at http://www.utahfoundation.org/reports/?page_id=342. Accessed April 11,
2010.
©2010 The University of Utah. All Rights Reserved.
Behavioral Influences on Health
125
2010 Utah’s Health: An Annual Review
Newborn Screening
Compiled by JB Flinders, MPH, MBA
In 2008, 99.3% of all Utah Children were screened for 37 genetic or functional disorders
The Utah Newborn Screening Program (NSP) began in 1979
with screening tests for Phenylketonuria, Galactosemia, and
Congenital Hypothyroidism. As of 2009, 33 additional screening tests, including a test for cystic fibrosis, have been added
to allow screening for 37 different disorders.1 To detect any of
these 37 metabolic, exocrine, endocrine, and hematologic disorders, each baby born in the State of Utah undergoes a special
blood test shortly after birth. Early detection of these disorders
is vital, as screening allows for identifying the disorder prior
to symptom onset. Screening also allows for early treatment of
disorders with severe clinical symptoms, including permanent
brain damage, mental retardation, sepsis, severe anemia, and
increased risk of death.1
Utah State law mandates that screening tests collect two specimens, using heel stick blood spots, between 48 hours and five
days after birth (or before discharge) and a second screening
between 7 and 28 days following birth to confirm the findings.2
In Utah, parents or legal guardians may refuse to allow the
screening for religious reasons only. If an abnormal result is
found, The Utah State Health Department notifies the signing
medical practitioner, who then may be required to collect and
submit additional specimens in order to make a final diagnosis
within 30 days of the abnormal result notification letter. Additional tests may also be recommended.3
In 2004, The Maternal and Child Health Bureau commissioned
the American College of Medical Genetics to draft standardized guidelines for state newborn screening programs, define
responsibilities for collecting and evaluating the data, and
recommend a uniform panel of conditions to include in screening programs. This panel identified 29 conditions for which
screening should be mandated and an additional 25 conditions
to consider for screening as they are clinically significant
(though they may lack efficacious treatment).4 In the U.S., all
states and territories now require that every baby be screened
for 21 or more of the 29 serious genetic or functional disorders
recommended by the American College of Medical Genetics
(ACMG) and endorsed by the March of Dimes.5 In Utah, newborns are screened for 37 disorders (Table 1), including amino
acid metabolism disorders, fatty acid oxidation disorders, organic acid metabolism disorders, cystic fibrosis, and hearing
loss.
As of 2008 99.3% of newborns born in Utah underwent heelstick newborn screening. The state target for 2010 is that all
newborns undergo screening, and the state is funding newborn
screening education to achieve this goal.6
Information on this page was gathered from:
1 Utah’s Indicator-Based Information System of Public Health. Newborn Heelstick Screening. Available online at http://ibis.health.utah.gov/indicator/important_facts/NewHeelScr.html. Accessed March 15, 2010.
2 Utah Department of Health. Utah Newborn Screening. Available online at http://www.health.utah.gov/newbornscreening.html. Accessed March 15, 2010
3 Utah Division of Administrative Rules. UT Admin Code R398-1, Newborn Screening. Available online at http://www.rules.utah.gov/publicat/code/r398/
r398-001.htm#T6. Accessed March 16, 2010
4 ACMG Newborn Screening Report. Available at http://www.acmg.net/resources/policies/NBS/NBS_Exec_Sum.pdf. Retrieved March 15, 2010.
5 E! Science News. States Expand Newborn Screening for Life-Threatening Disorders. Available online at http://esciencenews.com/articles/2009/02/18/states.
expand.newborn.screening.life.threatening.disorders. Accessed March 16, 2010
6 Utah’s Indicator-Based Information System of Public Health. Newborn Heelstick Screening. Available online at http://ibis.health.utah.gov/indicator/
view_numbers/NewHeelScr.Year.html. Accessed March 15, 2010.
126
Women and Children’s Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Table 1: Disorders for which Utah’s Children are Screened. 3
Amino Acid Metabolism Disorders:
I. Phenylketonuria (phenylalanine hydroxylase deficiency and variants);
II. Tyrosinemia type 1(fumarylacetoacetate hydrolase deficiency);
III. Tyrosinemia type 2 (tyrosine amino transferase deficiency);
IV. Tyrosinemia type 3 (4-OH-phenylpyruvate dioxygenase deficiency);
V. Maple Syrup Urine Disease (branched chain ketoacid dehydrogenase deficiency);
VI. Homocystinuria (cystathionine beta synthase deficiency);
VII. Citrullinemia (arginino succinic acid synthase deficiency);
VIII. Argininosuccinic aciduria (arginino succinic acid lyase deficiency);
IX. Argininemia (arginase deficiency);
X. Hyperprolinemia type 2 (pyrroline-5-carboxylate dehydrogenase deficiency);
Fatty Acid Oxidation Disorders:
I. Medium Chain Acyl CoA Dehydrogenase Deficiency;
II. Very Long Chain Acyl CoA Dehydrogenase Deficiency;
III. Short Chain Acyl CoA Dehydrogenase Deficiency;
IV. Long Chain 3-OH Acyl CoA Dehydrogenase Deficiency;
V. Short Chain 3-OH Acyl CoA Dehydrogenase Deficiency;
VI. Primary carnitine deficiency (OCTN2 carnitine transporter defect);
VII. Carnitine Palmitoyl Transferase I Deficiency;
VIII. Carnitine Palmitoyl Transferase 2 Deficiency;
IX. Carnitine Acylcarnitine Translocase Deficiency;
X. Multiple Acyl CoA Dehydrogenase Deficiency;
Organic Acids Disorders:
I. Propionic Acidemia (propionyl CoA carboxylase deficiency);
II. Methylmalonic acidemia (multiple enzymes);
III. Isovaleric acidemia (isovaleryl CoA dehydrogenase deficiency);
IV. 2-Methylbutiryl CoA dehydrogenase deficiency;
V. Isobutyryl CoA dehydrogenase deficiency;
VI. 2-Methyl-3-OH-butyryl-CoA dehydrogenase deficiency;
VII. Glutaric acidemia type 1 (glutaryl CoA dehydrogenase deficiency);
VIII. 3-Methylcrotonyl CoA carboxylase deficiency;
IX. 3-Ketothiolase deficiency;
X. 3-Hydroxy-3-methyl glutaryl CoA lyase deficiency;
XI. Holocarboxylase synthase (multiple carboxylases) deficiency;
Other Disorders:
I. Biotinidase Deficiency;
II. Congenital Adrenal Hyperplasia;
III. Congenital Hypothyroidism;
IV. Galactosemia;
V. Hemoglobinopathy and Sickle Cell Disease;
VI. Cystic Fibrosis;
VII. Hearing Loss.
©2010 The University of Utah. All Rights Reserved.
Women and Children’s Health
127
2010 Utah’s Health: An Annual Review
Overweight Children and Adolescents
Compiled By Jose R. Morales
Utah is well below the national average in the prevalence of obesity in adolescents
Percentage
Percent Obese
Rates of obesity and overweight have been on the rise for critical age of 8, obesity in adulthood is likely to be more seadults, adolescents, and children. The Centers of Disease vere.3
Control labels American society as “obesogenic” (meaning
that it is generating obesity). In
2007-2008 in the United States,
Figure 1: Obese Adolescents in Utah, 2008
the CDC measured the preva20%
lence of age-adjusted obesity
18%
and overweight adults being
33.8% and 34.8%, respectively
16%
indicating that two-thirds of the
14%
U.S. population is either over12%
weight or obese.1 This issue is
10%
Obese Adolescent Females
labeled a national epidemic.
8%
Obese Adolescent Males
Utah has slightly lower rates
6%
of obesity than the U.S. with a
4%
60.1% prevalence of obesity or
2
2%
overweight among adults. The
CDC reports that obese children
0%
and adolescents are more likely
9th Graders 10th Graders 11th Graders 12th Graders
to become obese as adults.
One study
found that
approxiFigure 2: Obese and Overweight Children in Utah, 2008
mately 80%
60%
of children
who were
over weight
50%
at age 10–15
years were
obese adults
at age 25.
40%
Another
study found
Overweight Female Children
that
25%
30%
Overweight Male Children
of
obese
Obese Female Children
adults were
over weight
Obese Male Children
as children,
20%
and a subsequent study
also found
10%
that if a person begins
to become
0%
over weight
First Grade
Third Grade
Fifth Grade
before the
128
Women and Children’s Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
The National Health and Nutrition Examination Surveys
(NHANES) gave a preliminary indicator to the national
prevalence of obesity and overweight in children. Data from
the NHANES surveys measuring during 1976–1980 and
2003–2006 showed that the prevalence of obesity for children
has been on the rise along with the national trend. For children
aged 2–5 years, obesity and overweight increased from 5.0%
to 12.4%; for those aged 6–11 years, it increased from 6.5% to
17.0%. For those aged 12–19 years, prevalence increased from
5.0% to 17.6%.4
Interestingly, the trend for children is much different than that
seen in adolescents. In 2008, the Utah Department of Health
reported that approximately 1 in every 10 first, third, and fifth
grader was found to be obese. The prevalence of obesity seems
to increase in the higher grade levels in children, unlike the
trend seen in adolescents where the prevalence of obesity is
lower in higher grade levels (see Figures 1 and 2), evidenced
by a 10% difference between values recorded for first and third
grades versus those for fifth graders that were classified as
either obese and overweight.6 Nevertheless, its trend is not as
clear as seen in adolescents. Future data, perhaps a seventhgrade representation, would be helpful in uniting these data
sets.
Percent Obese
Figure 3 shows that Utah is well below the national average
when comparing the prevalence of obesity in adolescent cases,
and Utah has not seen as steady an increase in terms of obesity
and overweight prevalence in adolescent and childhood obesity. While the data still shows an upward trend, there have
been decreasing periods
seen during particular
Figure 3: Trends in Obese Adolescents, Utah and the
time intervals. The 2003U.S., 1999, 2001, 2003, 2005, 2007, and 2009
2005 data showed that
14%
obesity in adolescents decreased 1.4%. However,
12%
in the following period
from 2005-2007, obesity
10%
cases jumped back up
from 5.6% to 8.7%, a
8%
3.1% increase. The latest evaluation of these
6%
data sets showed that
the prevalence of obe4%
sity among adolescents
again decreased to 6.4%.
2%
Figure 1 shows that the
prevalence of adolescent
0%
obesity decreases as chil1999
2001
2003
2005
2007
2009
dren get older.1,5
Utah
United States
Year
Information on this page was gathered from:
1 Centers of Disease Control. Available online at: http://www.cdc.gov/obesity/index.html. Accessed February 1, 2010
2 Utah Department of Health, Utah BRFSS data 2008. Available online at: http://health.utah.gov/obesity/pages/Obesity/The_Facts.php. Accessed January 21,
2009
3 Centers of Disease Control. Available online at: http://www.cdc.gov/obesity/childhood/index.html. Accessed February 10, 2010
4 Centers of Disease Control. Available online at: http://www.cdc.gov/obesity/childhood/prevalence.html. Accessed February 10, 2010
5 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health Available online at: http://ibis.health.utah.gov/indicator/view_
numbers/OvrwtChild.Adol_UT_US.html. Accessed February 10,2010
6 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health Available online at: http://ibis.health.utah.gov/indicator/view_
numbers/OvrwtChild.Child_Grade_Sex.html. Accessed February 10, 2010
©2010 The University of Utah. All Rights Reserved.
Women and Children’s Health
129
2010 Utah’s Health: An Annual Review
Vaginal Birth and Caesarean Section
Compiled by Priti D. Shah
The 2008 rate of Caesarean deliveries for Utah women giving birth for the first time is 18.6%.
A Caesarean section (C-section) occurs when an infant is
delivered by a surgical incision through the abdomen and
uterus as opposed to a natural vaginal birth. A C-section is
usually performed when a vaginal birth would pose risk to the
mother or the child. C-section prevalence in the U.S. increased
significantly between 1970 and 1988, from 5% to 25%; likely
due to increased pressure on physicians, discouraging them to
perform vaginal breech deliveries and midpelvic forceps deliveries. Although the World Health Organization (WHO) recommends natural vaginal births unless there are valid safety
concerns, mothers that are considered low risk are choosing
to have a C-section, a controversial aspect known as Cesarean
delivery on maternal request (CDMR).
There is a growing trend to increasingly perform C-sections
for all subsequent births. Evidence suggests there is increased
risk in the next birth.1,2 Post-surgical complications for the
mother include postpartum hemorrhage, infection, anesthetic
complications, and placenta previa and placenta accrete in
subsequent pregnancies. There is an increased risk of complications in cases of maternal obesity.1,2 Effects of a C-section on
the newborn may include difficulty with initiation of breastfeeding, prematurity, lacerations, and respiratory problems.
Post-surgical maternity hospital stays last longer and are more
costly compared to vaginal births.1
From Figure 1, the 2008 rate of primary C-section among low
risk women giving birth for the first time was 18.6 per 100
births in Utah, down from 19.2 in 2007. The C-section rate
for all women in Utah in 2008 was 22.8 per 100 births.1 In
Figure 2, 83.3% of the total number of low risk deliveries in
Utah were repeat C-sections in 2008 compared to 90% in the
U.S. in 2006 (most recent data available).1 A set of health objectives developed by the U.S. Department of Health and Human
Services, called Healthy People 2010, set a goal to have a 15%
C-sectional birth for women giving birth for the first time by
the year 2010; beginning in 2003, Utah rates surpassed the
target and continue to increase. Of all U.S. newborns in 2006,
31% were born by Cesarean delivery, an increase of 50% over
the last decade, from 20.7% in 1996.1
The Utah Department of Health is promoting education regarding healthy weight and lifestyle beginning in the teen years
and planned pregnancy and preconception to insure the best
possible outcomes regardless of the mode of delivery. Women
are also advised of the benefits and risks of vaginal birth after
C-section (VBAC).1 Some studies indicate that VBAC is a reasonable and safe choice for a majority of women and a way to
decrease the Cesarean delivery rate in the U.S.3,4
Rate per 100 Births to Low Risk Women
Figure 1. Rate of Primary Cesarean Among Low Risk Women Giving Birth for the First
Time, Utah vs. U.S., 1998-2008
30
25
20
Utah
15
U.S.
10
5
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
130
Women and Children’s Health
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Rate per 100 Births to Low Risk Women
Figure 2. Rate of Repeat Cesarean Among Low Risk Women, Utah vs. U.S., 1998-2008
100
90
80
70
60
Utah
50
U.S.
40
30
20
10
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Information on this page was gathered from:
1 Utah Department of Health. Utah’s Indicator-Based System for Public Health. Complete Indicator Profile of Cesarean Delivery. Available online at http://
ibis.health.utah.gov/indicator/complete_profile/CesDel.html Accessed on April 1, 2010.
2 Kennare, Robyn. Risks of Adverse Outcomes in the Next Birth After a First Cesarean Delivery. Obstetrics and Gynecology. 2007 Feb; 109: 270-276.
Abstract Available online at http://www.ncbi.nlm.nih.gov/pubmed/17267823. Accessed on April 1, 2010.
3 Vaginal Birth After Cesarean: New Insights, Structured Abstract. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. Available
online at: http://www.ahrq.gov/clinic/tp/vbacuptp.htm#Report. Accessed on April 1, 2010.
4 ACOG Practice Bulletin. Vaginal Birth After Previous Cesarean Delivery. Clinical Management Guidelines for Obstetrician-Gynecologists. 2004 July; 54.
Available online at: http://www.acog.org/acog_districts/dist9/pb054.pdf. Accessed on April 1, 2010.
©2010 The University of Utah. All Rights Reserved.
Women and Children’s Health
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2010 Utah’s Health: An Annual Review
HIV/ AIDS
Compiled by Charlene Hill
In 2009, over 2450 people in Utah are infected with HIV or AIDS
HIV, or the Human Immunodeficiency Virus, is the antecedent
of Acquired Immune Deficiency Syndrome (AIDS). A functional human immune system has the ability to identify, target,
and build immunity to bacterial and viral diseases. HIV infects certain cells and tissues of the immune system, rendering
them incapable of performing their normal tasks. Specifically
targeted are the white blood cells called T-cells or CD4 cells,
which fight diseases. Without these white blood cells, a person
infected with HIV has a weakened immune system and is more
susceptible to diseases that a normally healthy immune system
could resist. AIDS is diagnosed when a patient has acquired
one or more specific infections, or when there is a marked decrease in T-Cell count.
HIV can be transmitted by sexual contact (anal, vaginal, or
oral) with an infected person, sharing of needles (primarily
for drug injection), or less commonly through blood transfusions of infected blood. Infants of HIV positive women may
become infected with HIV before or during birth, or through
breast-feeding.
steady increase. As illustrated by Table 1, there has been a
slight increase of reported HIV and AIDS cases in Utah each
year. From January 2009 to September 2009 fifty-one HIV and
fifty-one AIDS cases have been reported as compared to the
ninety-eight HIV and sixty-five AIDS cases reported in 2008.1
In 2007 Utah had a total of 2334 AIDS cases and in September
2009 a total of 2450 AIDS cases.1 California, the state with
the highest reported AIDS cases, had 4952 cases in 2007.2 The
national total for 2007 of reported AIDS cases was 1,018,428.3
Utah continues to stay below the average reported cases of
AIDS per state in the U.S.
Organizations across the nation contribute to the effort to
spread knowledge of HIV and AIDS prevention. One of the
main contributing organizations is the CDC, or Centers for
Disease Control and Prevention. Along with providing knowledge of prevention, CDC is conducting trials of pre-exposure
prophylaxis for HIV prevention. Pre-exposure prophylaxis is
the prevention procedure of taking an FDA approved HIV drug
called tenofovir disoproxil fumarate used alone or in combination with emtricitabine (Truvada) daily as an oral preventative
drug.4 Researchers are conducting other such studies in an effort to decrease the number of HIV cases.4
Symptoms of HIV may not become evident for
years after infection. Although symptoms may
be absent for a time the virus will multiply until
the immune system is overwhelmed. The most
assured way to know if a person is infected is to
be clinically tested.
Within the last decade the number of reported
cases of HIV and AIDS in Utah has had a
U.S. State
A person of any race, age, or sex is at risk of infection, but
certain risk factors can increase these chances. These risk
factors encompass unprotected sex with an
HIV positive partner, sharing of needles durFigure 1: 2007 Data for Ten States with Highest HIV/AIDS Cases
ing intravenous drug use, or receiving a blood
transfusion prior to 1985. Before 1985 blood
North Carolina
transfusions were not thoroughly scanned for
New Jersey
HIV due to lack of required safety measures.
Illinois
Maryland
Pennsylvania
Georgia
Texas
Florida
New York
California
Number of AIDS cases in
2007
0
2000
4000
6000
Number of AIDS Cases in 2007
Information on this page was gathered from:
1
2
3
4
Available online at http://health.utah.gov/cdc/hivsurveillance/hiv%20docs/utahusa083109.pdf. Accessed October 9, 2009.
Available online at http://www.cdc.gov/hiv/topics/surveillance/basic.htm#area. Accessed October 9, 2009.
Available online at http://www.cdc.gov/hiv/resources/factsheets/us.htm. Accessed October 10, 2009.
Available online at http://www.cdc.gov/hiv/prep/resources/qa/index.htm. Accessed October 11, 2009.
132
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Chlamydia
Compiled by JB Flinders, MPH, MBA
Utah ranked 45th among 50 states in chlamydial infections in 2007.
Chlamydia infections, caused by the bacteria Chlamydia trachomatis, are the most frequently reported bacterial disease in
the U.S., with 1,108,374 cases reported in 2007. Nearly 71% of
these reported infections occurred among 15 to 24 year olds.1
However, because of the “silent” nature of chlamydia, as up
to 75% of women and 50% of men are unaware of their symptoms and infection status, it is estimated that over 2,300,000
non-institutionalized U.S. civilians between the ages of 14-39
are infected.2 In 2007, Utah ranked 45th among 50 states in
chlamydial infections with 224.3 cases per 100,000 persons .
Females with chlamydia are at risk for developing pelvic inflammatory disease (PID) which can cause permanent damage
to the uterus, fallopian tubes and other tissues. This occurs in
40% of women with untreated infections. It can also lead to
chronic pelvic pain, ectopic pregnancies and, in both men and
women, infertility. Contracting a serious sexually transmitted
infection such as HIV is also up to five times more likely with
untreated chlamydia. Women with chlamydia who become
pregnant can pass the infection to their infant during delivery,
as chlamydia is the leading cause of early infant pneumonia
and conjunctivitis (pink eye).2
Figure 1 shows chlamydia cases in Utah by age and sex.1,4
During the 2003-2007 reporting period, chlamydia cases in
Utah increased 50%, with over two-thirds (69%) of those cases
among females. This has remained fairly steady with those
between 15 and 24 years of age, or 2500 per 100,000 population members, accounting for 66% of chlamydia cases in 2008.
During the 2003-2007 period, females ages 15-24 accounted
for 51% of all cases, and accounted for 73% of all female
chlamydia morbidity during this same time period. 62% of
chlamydia cases among males from 2003-2007 occurred in the
20-29 age range. It is theorized that better detection methods,
due to technological advances, may explain part of the increase
in chlamydia cases; however, the increase is most likely due
to increased infections themselves.5 Figure 2 shows chlamydia
cases by race and ethnicity in Utah.1,6 Black females had the
highest rate of 726.8 cases per 100,000, followed by Hispanic
females at 627.2 per 100,000 persons. Compared to White nonHispanic females, the rate is almost four times higher for Black
females and over three times higher for Hispanic females.
Figure 1: Cases per 100,000 Population for Chlamydia by Age and
Sex, Utah, 2008
1400
Cases per 100,000
1200
1000
800
600
Males
Females
400
200
0
15-19
20-24
25-29
30-34
35+
Age Group
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
133
2010 Utah’s Health: An Annual Review
Similarly, the rate for Black males is eight times higher than
that of White non-Hispanic males. However, as the number of
reported cases for most minority populations in Utah is low,
results should be interpreted with caution.4
The Utah State Health Department, with funding from the
CDC, runs a Comprehensive STD Prevention System (CSPS)
grant program which helps prevent STD’s through behavioral
interventions, medical and laboratory services, outbreak response, surveillance of disease, professional development, and
awareness and education campaigns3, including the Catch the
Answers campaign for young adults.7
Figure 2: Cases per 100,000 Population for Chlamydia by Race and
Ethnicity, Utah, 2008
Hispanic, Latino
White
Native Hawaiian, Pacific Islander
Black, African American
Asian
American Indian, Alaskan Native
0
100
200
300
400
500
600
700
800
Cases Per 100,000
Information on this page was gathered from:
1 Utah’s Indicator-Based Information System for Public Health, Chlamydia Cases. Available online at http://ibis.health.utah.gov/indicator/view/ChlamCas.
UT_US.html. Accessed March 16, 2010.
2 Centers for Disease Control, STD Facts – Chlamydia. Available online at http://www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm. Accessed March 16,
2010.
3 Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Utah Profile. Available online at http://www.cdc.gov/
nchhstp/stateprofiles/pdf/Utah_profile.pdf. Accessed March 16, 2010.
4 Utah’s Indicator-Based Information System for Public Health, Chlamydia Cases. Available online at http://ibis.health.utah.gov/indicator/view/ChlamCas.
AgeSex.html. Accessed March 16, 2010.
5 Utah Department of Health, Bureau of Communicable Disease Control, STD Epi Profile. Available online at http://health.utah.gov/cdc/hivsurveillance/
std%20docs/STD%20Epi%20Profile.pdf. Accessed March 16, 2010.
6 Utah’s Indicator-Based Information System for Public Health, Chlamydia Cases. Available online at http://ibis.health.utah.gov/indicator/view/ChlamCas.
Race.html. Accessed March 16, 2010.
7 Utah Department of Health, Utah Health News Item, Report Shows Chlamydia and Gonorrhea Cases are Skyrocketing in Utah. Available online at http://
health.utah.gov/uthealthnews/2009/20090430-ChlamydiaGonorrhea.html. Accessed March 16, 2010.
134
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
E. Coli 0157:H7
Compiled by JB Flinders, MPH, MBA
E. Coli infections in Utah per 100,000 people are down significantly from 2006 levels.
Escherichia coli, or E.Coli, represents a large and varied
bacterial group. Although many strains are harmless, others,
like E.Coli 0157, can make members of a population quite ill.
E.Coli 0157 causes disease by producing a toxin called Shiga
toxin (also known as STEC for Shiga toxin-producing E.Coli
or ETEC for enterohemorrhagic E.Coli). These bacteria live
in the intestines of some healthy cattle, and contamination
can occur during the slaughtering process. Consuming inadequately cooked ground beef, unpasteurized milk or juice, or
contaminated fruits and vegetables are the major causes of
infection, but ingesting or swimming in contaminated water
(usually containing sewage), or being in contact with infected
animals can also cause infections. Although most infections
specifically refer to E.coli O157, other bacteria, referred to as
non-O157 STEC (or E.coli serogroups O26, O111, and O103)
can also often cause illness in people in the United States.1
fever. STEC’s incubation period is usually between 3-4 days
after exposure, but can vary from 1-10 days. The symptoms
often begin with mild stomach pain or non-bloody diarrhea
which worsens over the following days. Most people with an
STEC infection get better within 5-7 days. From 5-10% of
those with an STEC infection can develop hemolytic uremic
syndrome (HUS) around 7 days after infection, which is a
dangerous illness that causes the kidneys to stop functioning.1
As shown in Figure 1, STEC infections were down significantly
from 2006 levels of 3.1 infections per 100,000 to 0.9 infections
per 100,000 in 2008. Other E. coli bacterial infections have
increased steadily from 2002, however, with 1.5 infections per
100,000 noted in 2008.2 It is difficult to relate this to national
data as many infected people do not seek medical care or submit
a stool specimen for testing.1 Title 26, Chapter 6, Section 6 of
the Utah Code lists individuals and facilities, including but not
Symptoms of E.Coli (STEC) infections include severe stomach limited to physicians, hospitals, health care facilities, HMO’s,
cramps, diarrhea, vomiting, and, in some cases, a low-grade schools, day care centers, and laboratory and other testing
sites, that are required to
report known or suspected
Figure 1: Reported E. coli Infections per 100,000 Population in Utah, 1998-2008
communicable diseases to
5
the Health Department.3
4.5
Infections per 100,000 People
4
3.5
3
2.5
E. coli Other
2
E. coli 0157:H7
1.5
1
0.5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
To prevent E.Coli infections, the CDC recommends washing your hands
after using the bathroom,
changing diapers, preparing or eating food, and
contacting animals or
their environments, cooking meats thoroughly and
avoiding cross contamination in preparation areas,
avoiding
unpasteurized
foods, and avoiding swallowing water in lakes,
ponds, streams, and pools.1
Year
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, Escherichia Coli 0157:H7. Available online at http://www.cdc.gov/nczved/divisions/df bmd/diseases/ecoli_
o157h7/index.html. Accessed March 17, 2010.
2 Utah’s Indicator-Based Information System for Public Health, Foodborne Illness – E. Coli Infections. Available online at http://ibis.health.utah.gov/indicator/view_numbers/FooPoiEcoli.Year.html. Accessed March 17, 2010.
3 Utah Division of Administrative Rules, UT Admin Code R386-702, Communicable Disease Rule. Available online at http://www.rules.utah.gov/publicat/
code/r386/r386-702.htm#T5. Accessed March 17, 2010.
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
135
2010 Utah’s Health: An Annual Review
Gonorrhea
Compiled by JB Flinders, MPH, MBA
Utah ranked 43rd in the 50 states in gonorrhea infections in 2007.
Neisseria gonorrhoeae, the bacteria that causes gonorrhea infections, is considered a major public health concern throughout
the United States. This bacterium is especially dangerous as it
can easily multiply in warm, moist areas of the reproductive
tract in men and women as well as the eyes, mouth, throat, and
anus. Gonorrhea, like chlamydia, is also considered a “silent”
infection, due to symptoms generally remaining unnoticed by
the individual. The CDC estimates over 700,000 new gonorrhea infections are detected each year, with a reported rate of
120.9 cases per 100,000 people.1 The State of Utah ranks 43rd
among the 50 states in gonorrheal infections with 32.2 cases
per 100,000 people.2
In women, gonorrhea often causes pelvic inflammatory disease (PID) which, in women, can lead to internal abscesses,
damage the fallopian tubes and uterus, and increase the risk of
infertility, ectopic pregnancy, and chronic pelvic pain. In men,
gonorrhea can cause epididymitis and infertility if untreated.1,3
These infections can also cause serious problems for infants,
including eye infections, blindness, pneumonia, or death if
infection occurs during birth.3 Gonorrhea can also spread into
the joints where it can become systemic and life-threatening.
Individuals with untreated gonorrhea are also more likely to
contract a serious sexually transmitted infection such as HIV.
4
Both women and men often show no symptoms even when
an infection is present, but even noticeable symptoms can mirror other health problems like bladder or vaginal infections in
women or painful or swollen testicles in men.1
During the 2003-2007 time period, 64% of gonorrhea cases
reported in females were in the 15-24 age range. Detected
gonorrhea cases in females increased 125% across all age
groups. 54% of detected cases in males were in the 20-29 age
group, and 24% in males aged 35 and above. Gonorrhea cases
increased by 130% from 2003 through 2006 in the 20-29 age
group, and a 133% increase was observed in males ages 35 and
older from 2003-2007.2 However, in 2008, gonorrhea rates in
Utah dropped substantially from 30.6 cases per 100,000 to 17.3
cases per 100,000. Figure 1 shows gonorrhea infection rates
by age and sex.4 Males aged 20-24 and 25-29 still account for
the majority of gonorrhea infections, at 83.7 and 60.0 cases
per 100,000 respectively. Figure 2 shows gonorrhea infection
rates by race and ethnicity.5 Higher rates of infection from
2003-2008 appear in Black, African-American and Hispanic,
Figure 1: Cases per 100,000 Population for Gonorrhea by Age and
Sex, Utah, 2008
90
80
Cases per 100,000
70
60
50
40
Males
30
Females
20
10
0
15-19
20-24
25-29
30-34
35+
Age Group
136
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Latino populations. However, as the number of reported cases
for most minority populations in Utah is low, results should be
interpreted with caution.
The Utah State Health Department, with funding from the
CDC, runs a Comprehensive STD Prevention System (CSPS)
grant program which helps prevent STD’s through behavioral
interventions, medical and laboratory services, outbreak response, surveillance of disease, professional development, and
awareness and education campaigns, including the Catch the
Answer campaign aimed at young adults.6
Figure 2: Cases per 100,000 Population for Gonorrhea by Race and
Ethnicity, Utah, 2008
Hispanic, Latino
White
Native Hawaiian, Pacific Islander
Black, African American
Asian
American Indian, Alaskan Native
0
20
40
60
80
100
120
140
160
180
Cases Per 100,000
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, Gonorrhea – Fact Sheet. Available online at http://www.cdc.gov/std/gonorrhea/STDFact-gonorrhea.htm. Accessed March 16, 2010.
2 Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Utah Profile. Available online at http://www.cdc.gov/
nchhstp/stateprofiles/pdf/Utah_profile.pdf. Accessed March 16, 2010.
3 Utah Department of Health, Bureau of Communicable Disease Control, STD Epi Profile. Available online at http://health.utah.gov/cdc/hivsurveillance/
std%20docs/STD%20Epi%20Profile.pdf. Accessed March 16, 2010.
4 Utah’s Indicator-Based Information System for Public Health, Gonorrhea Cases. Available online at http://ibis.health.utah.gov/indicator/view/GonCas.
AgeSex.html. Accessed March 16, 2010.
5 Utah’s Indicator-Based Information System for Public Health, Gonorrhea Cases. Available online at http://ibis.health.utah.gov/indicator/view/GonCas.Race.
html. Accessed March 16, 2010.
6 Utah Department of Health, Utah Health News Item, Report Shows Chlamydia and Gonorrhea Cases are Skyrocketing in Utah. Available online at http://
health.utah.gov/uthealthnews/2009/20090430-ChlamydiaGonorrhea.html. Accessed March 16, 2010.
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
137
2010 Utah’s Health: An Annual Review
Hepatitis
Compiled by Cici Zhou
Hepatitis rates in Utah mirror the national average
60
50
40
30
20
10
0
appetite, dark urine, fever, jaundice, and malaise.1
HAV can be transmitted through personal contact or consumption of contaminated materials. This acute form of hepatitis
and can be treated with rest and hydration. HAV will run its
course in roughly a month. Prevention includes adherence to
strict personal hygiene and avoidance of
uncooked foods. HBV can be both acute
Figure 1: Number of Reported Hepatitis A Infections per 100,000
and chronic. This form can be transmitPopulation by Year, Utah, 1990-2008
ted through contamination of bodily fluids, such as through sexual contact and
contact with contaminated needles, and/
or of blood, such as through blood transfusions, illegal drug use, and tattoos.
Untreated cases can cause complex immune diseases. HCV is a predominantly
Utah
chronic form of hepatitis, and is generUS
ally transmitted through blood. Although
HCV may be asymptomatic for up to 20
years, symptoms may include cirrhosis.
No vaccine is available and most cases
result in death, although it can be treated
with interferon and antiviral drugs.1
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Infections per 100,000 population
Hepatitis, characterized by inflammation of the liver, is a gastroenterological disease. Hepatitis is most commonly known
by its viral forms A (HAV), B (HBV), and C (HCV). Hepatitis
is most often caused by alcohol, certain medicines, various viral and autoimmune diseases, and severe bacterial infections.
Symptoms can include joint aches, frequent vomiting, loss of
60
50
40
30
HAV
20
HBV
10
HCV
Year
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
1995
Rate per 100,000 Population
Figure 2: Hepatitis A, B, and C rates per 100,000
population, Utah, 1995-2008
Figure 1 shows that Utah HAV rates
decreased considerably in the 1990’s. In
1994 the rate was 38.7 cases per 100,000
population, while in 2000 the rate was
3.2 cases per 100,000 population. In 2007
the rate reached its low point of 0.3 cases
per 100,000 population, but rose again in
2008 the 0.5 cases per 100,000 population. HAV rates in the U.S. decreased
from 11.7 per 100,000 population in 1996
to 1.0 per 100,000 population in 2007.1,2
Utah and U.S. rates were similar from
1998 to 2007. The HAV vaccine was introduced in 1995 and experts believe this
vaccination has dramatically affected
rates of the disease in the United States.2
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Surveillance Summaries. Available online at http://www.cdc.gov/
mmwr/PDF/ss/ss5803.pdf. Accessed April 6, 2010.
2 Utah’s Indicator-Based Information System for Public Health, Hepatitis A Infections. Available online at http://ibis.health.utah.gov/indicator/complete_profile/HepACas.html. Accessed April 6, 2010.
138
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Herpes Simplex Virus and Trichomoniasis
Compiled by JB Flinders, MPH, MBA
Visits to Physicians Offices’ for Herpes Infections have doubled since 2001
Herpes simplex is a viral infection affecting the mouth or
genital area. There are two strains of herpes simplex viruses,
herpes simplex virus type 1 (HSV-1), associated with infections of the face, especially the lips and mouth, and herpes
simplex virus 2 (HSV-2) which causes genital ulcers or sores.1
HSV-1 is most often transmitted by saliva causing cold sores
on the lips or around the mouth. These symptoms may last a
few weeks and go away but may return in weeks, months, or
years. They are usually harmless in children and adults but
can be very harmful to newborns.2 By adulthood, up to 90% of
people will have antibodies to HSV-1.1 Individuals with HSV2 often exhibit either no symptoms, mild symptoms that go
unnoticed, or symptoms that they do not recognize as a sign
of herpes infection. The most common of these symptoms is
a cluster of blistery sores on the genital area. As with HSV-1,
these symptoms may last several weeks and go away but may
return in weeks, months, or years.2
Figure 1 shows the number of physician visits from 2000-2007
due to herpes or trichomoniasis infection.6 Visits for herpes
infections have doubled, from 157,000 in 2001 to 317,000 in
2007. Visits for trichomoniasis have fluctuated from a low of
150,000 visits in 2002 to 222,000 in 2000, with 205,000 visits in 2007. There is currently no cure for herpes, but certain
medications help manage the infection, speeding up the healing of sores, and prevent frequent outbreaks.7
Figure 1. Physician Visits For Herpes and Trichomoniasis,
U.S., 2000-2007
400
Number of Visits, Thousands
The National Health and Nutrition Examination Survey (NHANES) compiles
statistics on the health of the U.S. resident through multistage probability sampling. The CDC analyzed NHANES test
results from 2005-2008 in persons aged
14-49. The results of NHANES indicated
the prevalence of HSV-2 was 16.2% and
highest among women (20.9%) and nonHispanic blacks (39.2%). Of those individuals infected with HSV-2, 81.1% had
never received a diagnosis from a health
care professional.3
mon sites of infection are the vagina and urethra.4 Most men
with trichomoniasis do not have signs or symptoms, but can
have penile irritation, discharge, or burning after urination or
ejaculation. Infection in women can cause a frothy, yellowgreen vaginal discharge with a strong odor, genital irritation
and itching, and discomfort during intercourse and urination.5
These symptoms often appear between 5 and 28 days from
time of exposure. Trichomoniasis can usually be cured with
antibiotics such as metronidazole or tinidazole.4
Trichomoniasis is caused by the parasite,
Trichomonas vaginalis. The parasite is
sexually transmitted, and the most com-
350
300
250
200
Herpes
150
Trichomoniasis
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007
Year
Information on this page was gathered from:
1 Medline Plus Medical Encyclopedia, Herpes Simplex Virus. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/001324.htm. Accessed
April 25, 2010.
2 Planned Parenthood, Herpes. Available online at http://www.plannedparenthood.org/health-topics/stds-hiv-safer-sex/herpes-4271.htm. Accessed April 25, 2010.
3 Centers for Disease Control and Prevention, Seroprevalence of Herpes Simplex Virus Type 2 Among Persons Aged 14-49, United States 2005-2008. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5915a3.htm. Accessed April 25, 2010.
4 Centers for Disease Control and Prevention, Trichomoniasis. Available online at http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm. Accessed
April 25, 2010.
5 Medline Plus Medical Encyclopedia, Trichomoniasis. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/001331.htm. Accessed April 25, 2010.
6 Centers for Disease Control and Prevention, STD Surveillance, 2007. Available online at http://www.cdc.gov/std/stats07/tables/42.htm. Accessed April 25, 2010.
7 Planned Parenthood, Herpes. Available online at http://www.plannedparenthood.org/health-topics/stds-hiv-safer-sex/herpes-4271.htm. Accessed April 25, 2010.
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
139
2010 Utah’s Health: An Annual Review
Human Papillomavirus
Compiled by Charlene Hill
Since 2000, Utah reported a 7.7% decrease of women having a Pap test within 3 years
Human Papillomavirus (HPV) is the name of a family of viruses that consists of over 100 various strains. Genital Human
Papillomavirus is the most commonly sexually transmitted
infection and there are more than 40 HPV types that can infect
the genital areas of both males and females.1 HPV can cause
normal cells on infected skin to turn abnormal. In most cases
the immune system fights off HPV naturally. When HPV is
not eradicated from the body it can cause visible changes in
the cells resulting in genital warts or cervical cancer. Genital
warts can take weeks or months to become evident, and cancer
typically takes years.
HPV is typically passed through genital contact during sexual
intercourse. Spreading of the disease can also occur through
oral and anal sex. Straight and same-sex partners are at risk
even if the infected partners show no signs or symptoms at the
time.
Approximately 20 million Americans (about 6%) are currently
infected with HPV.1 Another 6 million become infected each
year. At least 50% of sexually active men and women will get
HPV at some point in their lives.
Cervical cancer and genital warts are the most common diseases that develop as a result of contracting HPV. At any one
time 1% of sexually active adults in the U.S. have genital warts
and each year about 12,000 women get cervical cancer in the
U.S.1 As shown by Figure 1 from 1980 to 2007 the number of
Utah deaths due to cervical cancer have been less than those
in the U.S. overall. HPV is responsible for 70% of all types of
cervical cancer.2 However, cancers such as vulvar cancer, anal
cancer, vaginal cancer, and penile cancers are also results of
HPV, though less common. Each year approximately 10,100
U.S. citizens develop these other cancers as a result of HPV.1
There are several ways that people can lower the risk of getting
HPV and cervical cancer. People can lower their number of
sexual partners, having protected sexual intercourse, receiving
Figure 1: Cervical Cancer Deaths, U.S. and Utah, 1980-2007
4
3.5
3
2.5
2
Utah
1.5
U.S.
1
0.5
0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Number of deaths per 100,000 females
5
4.5
Year
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Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Utah
U.S.
1991
88.2
88.6
1992
81.1
82.1
regular Pap smear tests, and receiving available preventative
1993
79.4
83 cell
vaccines. A Pap smear test is used to detect abnormal
1994
82.5
82.8
growth on the cervix, which may then be removed to prevent
80
82.8 two
the development of 1995
cervical cancer. There
are currently
1996
80.1
vaccines (Gardasil and Cervarix) available to prevent83.3
certain
78.2vaccine for men
83.6 and
types of HPV. The1997
most widely used
77.9
women is Gardasil. 1998
Gardasil is able to
protect women83.5
against
1999
80.4
HPV viruses that cause cervical cancer and both 84.6
genders
2000
81.8
against genital warts
caused by HPV.
The vaccine is85.2
recom2002
80.7
85.6years.
mended for women aged 12-26 years and men aged 9-26
79
A complete course 2004
of the vaccine consists
of three 84.8
different
2006
75.1
83.5
injections separated over a six-month period.
2008
74.1
82.2
Figure 2 illustrates, for each year between 1991 and 2008, the
percentage of women over the age of 18 in the U.S. and Utah
that have received a Pap smear test within the last three years.
In 2008, 74.1% of women in Utah reported receiving a Pap
smear test within the last three years and 82.2% of U.S. women
reported the same.4 Since approximately the year 2000 both the
U.S. and Utah has seen a decline in the percentage of women
reporting having received a Pap test. Utah has seen a 7.7% decrease since 2000 and the U.S. has seen only a 3.4% decrease
since 2002.4 Overall, this figure shows a general decline in the
number of women over the age of 18 who have received a Pap
smear test within the last three years between the years of 1991
and 2008.
Figure 2: Percentage of Women Who Reported Having Pap. Test Within Past
Three Years, U.S. and Utah
90
Percentage of Women
85
80
Utah
75
U.S.
70
65
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008
Year
Information on this page was gathered from:
1 Centers for Disease Control and Prevention. Department of Health and Human Services. HPV. Available online at http://www.cdc.gov/std/HPV/STDFactHPV.htm#howget. Accessed on December 23, 2009.
2 Utah Department of Health. Utah Health Status Update. Available online at http://health.utah.gov/opha/publications/hsu/07Jul_AdolSexualHealth.pdf. Accessed on December 24, 2009.
3 Utah Department of Health. Complete Indicator Profile of Cervical Cancer Death. Available online at http://utah.ptfs.com/awweb/main.
jsp?flag=browse&smd=1&awdid=2. Accessed on December 24, 2009.
4 Utah Department of Health. Complete Indicator of Cervical Cancer Screening. Available online at http://utah.ptfs.com/awweb/main.
jsp?flag=browse&smd=1&awdid=4. Accessed on December 24, 2009.
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
141
2010 Utah’s Health: An Annual Review
Immunizations
Compiled by Blake R. Wilde
In 2008 Utah exceeded the national average of the 4:3:1:3:3:1 immunization recommendation
Immunizations are an effective and inexpensive way of ensuring the health of children as well as adults. Immunizations
fortify the immune system through injection or digestion of
vaccines. Vaccines, which are typically weakened forms of
the targeted disease, stimulate the body to produce antibodies
against the selected disease. Immunizations effectively prevent
diseases that once plagued the world such as polio and measles.
Some diseases, such as smallpox, have even been eradicated by
immunizations.1
Recent research has suggested that new vaccines have potential
ability to either prevent or inhibit the effects of Alzheimer’s
disease, parasitic diseases, substance abuse, and malaria.4 In
1999, the New Vaccine Surveillance Network (NVSN) began
with 3 sites across the country to monitor and research the
impact of new vaccines. In 2009, 3 more sites were added to
the network, which is now the NVSN-Extended Network.2
Ongoing surveillance ensures new varieties of vaccines and
improved methods of immunization.
Many diseases that vaccines prevent may be very harmful to
children. Suggested immunizations for children is 4 doses of
diptheria-tetanus-pertussis (DTaP), 3 doses of polio, 1 dose of
measles-mumps-rubella (MMR), 3 doses of hepatitis B, 3 doses
of haemophilus influenza type b (HiB), 1 dose of varicella, and
4 doses pneumococcal conjugate vaccine. This recommendation is nationally known as “4:3:1:3:3:1:4”.2 According to state
law for Utah, children must receive these vaccinations before
attending any public schools.3
As seen in Figure 1, immunizations in Utah prior to 2005 had
been historically below the national average. In 2006 and 2008,
Utah exceeded the national average in 4:3:1:3:3:1 immunization
coverage; however, in both 2007 and 2008 Utah’s 4:3:1:3:3:1:4
immunization coverage was below the national average.2 In
1993 Utah Every Child By Two Immunization Coalition was
formed to promote 4:3:1:3:3:1 and other national immunization
goals. The organization aims to achieve 90% vaccination levels for children under two in Utah.3
Number of immunizations per 100,000
Firgure 1: Immunization Rates, U.S. and Utah, 2002-2008
90
80
70
60
50
40
Utah
30
U.S.
20
10
0
2002
2003
2004
2005
2006
2007
2008
Year
Information on this page was gathered from:
1 World Health Organization. Available online at http://www.who.int/immunization/en/ Accessed March 28, 2010.
2 Department of Health and Human Services: Center For Disease Control and Prevention. Available online at http://www.cdc.gov/vaccines/stats-surv/ Accessed March 28, 2010.
3 Utah Department of Health: Immunization Program. Available online at http://health.utah.gov/immu/public/pub_imm_sched.htm Accessed March 28,
2010.
4 Immunization Action Coalition. Available online at http://www.immunize.org/journalarticles/toi_poten.asp Accessed March 28, 2010.
142
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Mumps, Polio, and Rubella
Compiled by Anthony Tran
Utah has a significantly lower mumps rate than the national average of 17.1 per 100,0003
Mumps is a virus that presents as a painful swelling of the
salivary glands. Mumps will usually run its course through
the body without treatment other than rest, fluids, and pain
management using painkillers. Mumps can also cause fever,
headache, testicular swelling (orchitis), and a rash.1 There have
only been 16 cases of Mumps in Utah since 2004.2 Mumps is
also known as a vaccine-preventable disease, and is prevented
by receiving the Mumps vaccination early in childhood as
two separate doses. Figure 1 shows the prevalence of Mumps
from 2000 to 2008 in the United States.3 Mumps cases are significantly lower in Utah than the rest of the United States. For
example, in 2006, there were 6,339 reported cases in the U.S.
and only 2 cases reported in Utah.3
Polio, also known as Poliomyelitis, is also a viral infection. The
symptoms are often mild and most commonly affect the spinal
neurons causing weakness, sudden paralysis, and asymmetric
paralysis of the legs. The paralytic symptoms usually begin
1-10 days after the prodromal symptoms and will progress for
2-3 days. However, the muscle weakness and paralysis can be
present as far as 12 months after onset, if not permanently.2
The incidence rate in both the U.S. and Utah has decreased
because of the vaccine introduced in 1955 and, as of 2008; Polio is essentially eliminated in both in the state and nationally.
There have been no reported cases of Polio in the state of Utah
since 1996 and prior to that the last case occurred in 1959.2
Rubella, also known as German measles, is caused by the
rubella virus. The symptoms of Rubella are maculopapular
rash, swollen lymph nodes, and a slight fever. Rubella is most
serious in pregnant women as it can cause birth defects in some
newborns.4 These defects are most often physical abnormalities, and can be referred to as Congenital Rubella Syndrome or
CRS. These include a multitude of signs and symptoms such
as deafness, blindness, heart defects, behavioral disorders,
mental retardation, growth retardation, bone disease, enlarged
liver and spleen, thrombocytopenia, and purple skin lesions.
These symptoms may not develop for 2-4 years. The last case
of Rubella occurred in 2004 and since 2001 there have only
been 2 reported cases.5
Figure 1: Mumps Cases in the U.S., 2000-2008
7000
Mumps Cases
6000
5000
4000
3000
2000
1000
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Information on this page was gathered from:
1 FreeMD, Mumps Definition. Available online at http://www.freemd.com/mumps/. Accessed on April 22, 2010.
2 Utah Department of Health, Utah Reported cases of selected Vaccine-preventable Disease from 1999-2008. Available online at http://www.immunize-utah.
org/provider/state/morbidity.htm. Accessed on April 1, 2010
World Health Organization, available online at http://www.who.int/immunization_monitoring/en/globalsummary/timeseries/TSincidenceByCountry.
cfm?C=USA accessed on April 20, 2010.
3 Utah department of Health, Poliomyelitis. Available online at http://health.utah.gov/epi/anrpt/anrpt07/VPD_Summary_2007_012609.pdf. Accessed on
April 1, 2010
4 CDC, Outbreak of mumps. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d518a1.htm. Accessed on April 1, 2010
5 Wikipedia, the free encyclopedia, Rubella. Available online at http://en.wikipedia.org/wiki/Rubella. Accessed on April 1, 2010
6 Utah Department of Health, Rubella. Available online at http://health.utah.gov/epi/anrpt/anrpt07/VPD_Summary_2007_012609.pdf. Accessed on April 1, 2010
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
143
2010 Utah’s Health: An Annual Review
Seasonal and H1N1 Influenza
Compiled by Kyley Joell Cox
48.9% of all influenza-associated hospitalizations in Utah occurred in children under the age of 4
Influenza is a highly contagious viral infection of both the
upper and lower respiratory tracts. Influenza primarily affects the nose, throat, bronchi, and lungs. On average, 5% to
20% of the population in the United States contracts influenza
per year. Additionally, an average of 36,000 people die from
flu-related complications, with approximately 200,000 hospitalizations annually.1 Influenza is mainly transmitted via
respiratory droplets in coughing and sneezing. Influenza may
also be spread when a person touches these droplets on other
persons or objects and then touches their own mouth or nose
without first washing their hands.2 Infection results in symptoms which include: fever, cough, sore throat, runny or stuffy
nose, body aches, headache, chills, and sometimes diarrhea
and vomiting. Anyone is at risk for developing influenza; however, the elderly, pregnant women, people with chronic medical
conditions, and young children demonstrate increased rates of
serious complications from influenza.3
In April of 2009, a new influenza virus was detected in the
United States, the novel 2009 H1N1 virus. The H1N1 virus, colloquially referred to as “swine flu”, has been the predominant
strain of influenza in circulation throughout the 2009 flu season.4 The H1N1 virus is spread from person to person through
the same mechanisms as seasonal influenza. The H1N1 strain
contains a combination of swine, avian, and seasonal human
influenza viruses, causing identical clinical symptoms in infected persons, making additional laboratory testing necessary
to diagnose the appropriate flu strain.5
According to data from 2008-2009, the highest number of Influenza-Associated Hospitalizations (IAH’s) in Utah occurred
in children age 1 to 4, closely followed by children <1 year of
age. Fifty-five hospitalizations occurred in the <1 age group,
and 56 hospitalizations occurred in the 1-4 year age group.6
As shown by Figure 1, 48.9% of the total influenza-associated
hospitalizations occurred in those two age groups combined.
Additionally, 13.7% of the IAH’s occurred in the 5-14 year old
age group with 31 total hospitalizations. The least number of
hospitalizations occurred in the 85+ category with only 4 hospitalizations, representing 1.8% of the total IAH’s.5
As illustrated in Figure 2, current data from 2009-2010 indicates women outnumber men in IAH’s with a reported 487
visits for women and 409 visits for men to date. Racially, the
highest number of IAH’s occurred in Caucasians, with 605 hospitalizations. Caucasians accounted for 67.5% of total IAH’s
followed by Hispanics with149 reported IAH’s, accounting for
16.6% of the total IAH’s.4
Figure 1. Cumulative Influenza-Associated Hospitalizations by Age Group, 2008-2009
60
50
40
Number of
Hospitalizations
30
Percentage of
Hospitalizations
20
10
0
< 1 1-4 5-14 25-34 35-44 45-54 55-64 65-74 75-84 85+
year years years years years years years years years years
144
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2. Summary Data for Influenza-associated Hospitalizations, 2009-2010 Season to Date
% of Influenza-AssociatVariable
Number of cases
ed Hospitalizations
Sex
Male
409
45.60%
Female
487
54.40%
Unknown
0
0%
Race
White, Not Hispanic
605
67.50%
Hispanic
149
16.60%
Native Hawaiian/Pacific Islander
25
2.80%
Black/African American
15
1.70%
American Indian
25
2.80%
Asian
18
2.00%
Unknown
59
6.60%
% in Utah Pop
50.30%
49.70%
NA
82.00%
11.60%
0.70%
0.90%
1.10%
1.90%
NA
Information on this page was gathered from:
1
2
3
4
5
Centers for Disease Control, Seasonal Influenza. Available at http://www.cdc.gov/flu/about/disease/index.htm. Accessed March 26, 2010
Centers for Disease Control, Seasonal Influenza. Available at http://www.cdc.gov/flu/about/disease/spread.htm. Accessed March 26, 2010
Centers for Disease Control, Seasonal Influenza. Available at http://www.cdc.gov/flu/about/disease/symptoms.htm. Accessed March 26, 2010
Centers for Disease Control, 2009 H1N1 Flu and You. Available at http://www.cdc.gov/h1n1flu/qa.htm. Accessed March 26, 2010.
Helium Health and Fitness, Diagnosis of Novel H1N1 Flu Versus Seasonal Influenza. Available online at http://www.helium.com/items/1603130-h1n1-flu.
Accessed April 22, 2010.
6 Utah Department of Health. Utah Bureau of Epidemiology. Available at http://health.utah.gov/epi/h1n1flu/UT_update.html. Accessed March 26, 2010.
©2010 The University of Utah. All Rights Reserved.
Infectious Diseases and STDs
145
2010 Utah’s Health: An Annual Review
Syphilis
Compiled by JB Flinders, MPH, MBA
Utah’s 0.9 cases per 100,000 is significantly less than the national average of 3.8 cases per 100,000.
Syphilis is caused by the bacterium Treponema pallidum, and
is often referred to as “the great imitator” due to its signs and
symptoms being indistinguishable from other diseases. The
primary stage of syphilis is denoted by a chancre, a highly
infectious and painless open sore. These chancres are most
often found on external genitalia, the vagina, anus, rectum,
lips, or mouth. These are the sites where, via direct contact,
syphilis is passed from person to person.1 Open syphilis sores
also increases the risk of acquiring HIV, if exposed.2 Without
proper treatment, the infection can progress to a secondary
stage, where development of a rash (oftentimes not noticeable), fever, swollen lymph nodes, muscle aches, fatigue, and
other symptoms occur. Again, without proper treatment, the
infection can progress into the latent stage, which develops
15% of people, up to 10-20 years after initial infection. At this
point, the infection may damage internal organs, including
the brain, nerves, eyes, heart, blood vessels, liver, bones, and
joints, and may cause paralysis, numbness, gradual blindness,
dementia, and even death. Pregnant women with syphilis have
an increased risk of stillbirth or having a baby who dies shortly
after birth. Should the infection be passed to the baby, it may
be born without signs or symptoms of disease; however, if not
treated immediately, serious problems can occur including
developmental delays, seizures, or death.1
Figure 1 shows the rate of reported Syphilis occurrences in
Utah as compared to the United States.2 Utah had 0.9 cases of
Syphilis reported per 100,000 cases in 2008, up from 0.8 in
2007 but still substantially less than the 3.8 cases per 100,000
nationwide in 2007. Overall, Utah has seen a small increased
prevalence of syphilis since 2000, but still ranks 41st among
the 50 states.3
One of the major syphilis prevention campaigns is the Syphilis
Elimination Effort (SEE); a national initiative that joins health
care providers, policy makers, community leaders, and state
and local public health agencies to create evidence-based action plans to reduce and control syphilis rates, reduce the transmission of HIV, and protect unborn infants from the disease.4
Figure 1: Primary and Secondary Syphilis, Utah and U.S., 1992-2008
14
Cases per 100,000
12
10
8
6
Utah
U.S.
4
2
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Information on this page was gathered from:
1 Centers for Disease Control and Prevention, STD Facts- Syphilis. Available online at http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm. Accessed
March 17, 2010
2 Utah’s Indicator-Based Information System for Public Health, Syphilis Cases – Primary and Secondary. Available online at http://ibis.health.utah.gov/
indicator/view/SyphCas.UT_US.html. Accessed March 17, 2010.
3 Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Utah Profile. Available online at
http://www.cdc.gov/nchhstp/stateprofiles/pdf/Utah_profile.pdf. Accessed March 16, 2010.
4 Centers for Disease Control and Prevention, Syphilis Elimination Effort. Available online at http://www.cdc.gov/stopsyphilis. Accessed March 17, 2010.
146
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Tuberculosis
Complied by Priti D. Shah
Twenty-seven cases of tuberculosis were reported in Utah in 2008
Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis. The bacteria usually infect
the lungs but may attack any part of the body. TB can infect
anyone at any age and is contracted by inhaling air that contains TB germs. The general symptoms of TB disease include
feeling sick or weak, weight loss, fever, and night sweats.
Symptoms of TB of the lungs include coughing, chest pain,
and coughing up blood. Other symptoms depend on the part of
the body that is affected.
People with TB infection, but not TB disease, have the germs
that cause TB in their bodies. They are not sick because the
germs are inactive or dormant, and they cannot spread the
germs to others. However, people with TB disease are sick
from germs that are active in their body, have symptoms of TB,
and those with the bacteria in the lungs or throat are capable of
spreading the disease to others when they expel tiny airborne
particles when exhaling.1,2 Most people who are exposed to TB
germs develop a positive tuberculin skin test approximately
2-10 weeks after exposure, although 90% of these people will
never develop the disease.1 People who are at high risk of developing TB disease include persons with HIV, chronic illnesses
that weaken the immune system such as silicosis, gastrectomy,
or body weight below 10 % of ideal. In addition, babies and
young children, those infected with TB germs within the last
two years, those with improper TB treatment in the past, and
substance abusers, especially IV-drug users, are also at risk.1,2
Figure 1 shows that twenty-seven cases of TB were reported in
Utah in 2008, the lowest case count ever reported.2 For the five-
©2010 The University of Utah. All Rights Reserved.
year period from 2004-2008, Utah had an average of 33 cases
reported per year. The 2008 TB case range in Utah was 1.0 per
100,000 persons as compared to 1.4 per 100,000 persons in
2007. For the five-year period from 2004 to 2008, Utah had an
average of 1.3 cases of TB per 100,000 persons. Figure 2 shows
that the case rate of TB in Utah has consistently been about
30% lower than that found in the U.S. overall.2
It is very important that patients with active TB adhere to their
treatment regimen not only for effective therapy, but also to
prevent an increase in cases of drug-resistant germs. In 2008,
9% of persons with TB in Utah on whom drug sensitivity
testing was performed had organisms that were resistant to
one or more of the anti-tuberculosis medications.2 When TB
isolates are resistant to the two most effective drugs, isoniazid
and rifampin, treatment is more difficult, costly, and can be
prolonged up to 24 months. Utah had one case of multidrugresistant TB in both 2007 and 2008, and already one case
reported in 2009.2
The Tuberculosis Control and Refugee Health Program at the
Utah Department of Health is responsible for reducing the
incidence of active TB through timely reporting and treatment. The program provides screening and preventive therapy
for those with TB infections with the 12 local health districts
throughout Utah at the forefront who diagnose and treat latent
TB infections and active TB disease, ensure patient compliance, screen high-risk populations, coordinate/refer persons,
and provide culturally-appropriate client education.2
Infectious Diseases and STDs
147
2010 Utah’s Health: An Annual Review
Figure 1. Number of Tuberculosis Cases by Year, Utah, 1992-2008
90
80
Number of Cases
70
60
50
40
30
20
10
0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Figure 2. Tuberculosis Rates, Utah and U.S., 1990-2008
Cases per 100,000 Population
12
10
8
Utah
6
U.S.
4
2
0
Year
Information on this page was gathered from:
1 Utah Department of Health, available online at http://health.utah.gov/cdc/tbrefugee/resources/tb_factsheet.html. Accessed October 23, 2008.
2 Utah Department of Health, available online http://ibis.health.utah.gov/indicator/complete_profile/TubCas.html. Accessed October 23, 2008.
148
Infectious Diseases and STDs
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Breast Cancer
Compiled by Michelle Everill-Flinders
Despite Lower Breast Cancer Incidence, Mammography Rates are Lower and Death Rates are Higher in Utah than the
National Average
Breast cancer, also termed breast carcinoma, is a form of cancer
found in the breast of both males and females; more commonly
in females. Tumors, lumps, or growths appear where there is an
abundance of cells due to the overproduction of new cells and/
or old damaged cells that are not disposed of naturally. Breast
tumors can be benign (non-cancerous) or malignant (cancerous). Malignant cells are cancerous cells that have a pathologic
susceptibility to reoccurrence. This is manifested through the
spread of cancerous cells to other organs and tissues, and can
be a threat to life. Malignant breast cancer cells infiltrate other
organs by entering the blood stream or lymph nodes. The cardiovascular and lymphatic systems transport cancerous cells
throughout the body, where the malignant cells attach to other
tissues or organs, usually the lungs, liver, or bones.1
ranges from self-breast exams, physical exam by a medical
professional, mammography, magnetic resonance imaging
(MRI), ultrasound, biopsy, computerized tomography (CT)
scan, or positron emission tomography (PET) scan. Mammography is the most common and preferred method of breast
cancer screening as it is the most effective way of detecting
breast cancer early.2 As mammographic screening for breast
cancer has been controversial due to mixed recommendations
from the US Preventive Services Task Force (USPSTF), it is
important for women to have an informed discussion with their
physicians to determine if mammography is preferred. The National Cancer Institute recommends women age 40 and older
should have mammograms every one to two years. Women
with higher risk of breast cancer should consult their doctor.3
Utah Cancer Control Program offers free breast cancer screening for women who meet age, income and insurance eligibility
requirements.4
Published risk factors for breast cancer include: increasing
age, genetics, family history, early or late menstrual cycle,
alcohol use, late or no childbirth, long term use of hormone
therapy, breast density, and obesity. Breast cancer screening
In 2009, the five year survival rate for women diagnosed with
Figure 1. Breast Cancer Incidence by Year, Utah and U.S., 1980-2006
160
Incidence per 100,000 women
140
120
100
Utah
80
U.S.
60
40
20
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
0
Years
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
149
2010 Utah’s Health: An Annual Review
Figure 2. Breast Cancer Deaths by Year, Utah and U.S., 1980-2008
35
Deaths per 100,000 women
30
25
20
Utah
U.S.
15
10
5
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
0
Years
breast cancer is approximately 90%. This rate has been successfully increasing mostly due to advances in treatment and
early detection. Breast cancer treatments include: surgical intervention, radiation therapy, chemotherapy, hormone therapy,
and targeted therapy. Pathological criteria must be met for hormone and targeted therapy, termed as ER-positive and HER-2
positive; which can be more aggressive forms of breast cancer.
Standard of care treatment decisions are widely accepted in
breast cancer and are determined by the stage of cancer. An
early diagnosed and treated cancer will generally respond
better to necessary treatments and result in better outcomes.
Breast cancer is often curable if found early.5
In the National Cancer Institute annual report to the nation,
new cancer diagnoses and death rates had declined overall.
Specifically, breast cancer new diagnoses have decreased by
2.0% and deaths related to breast cancer have declined by 1.9%
nationally.6 Breast cancer remains the most commonly occurring cancer in U.S. women and is the leading cause of cancer
related deaths in Utah. Figure 1 represents the incidence of
breast cancer per 100,000 females in Utah and in the U.S. col-
150
Chronic Diseases
lectively. The breast cancer incidence rate in Utah in 2006 was
105.5 per 100,000 women. Utah continues to maintain a lower
rate of new breast cancer diagnoses compared to the U.S.7
Figure 2 shows the death rates of breast cancer related deaths
per year in Utah compared to the U.S. Utah data is reported
up to 2008; however U.S. data for 2007 and 2008 is not yet
available. The 2006 values show an increased mortality rate in
Utah which exceeds the U.S. values. The Utah values in 2007
and 2008 are fewer than the 2006 rate, showing a temporary
increase in mortality rates within the state. Despite the decrease in incidence in Utah, the statistics reported over the last
ten years show that the U.S. mortality rate overall is decreasing at a greater rate than that of Utah death rates.8 This trend
can be explained by the number of breast cancer cases being
smaller in Utah than the U.S. and by Figure 3’s representation of the Utah mammography rates being nine percentage
points lower than the U.S. average. Breast cancer deaths can
be substantially reduced (between 20-30% in women aged 5069) by early detection; emphasizing a greater need for regular
screening within Utah.9
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 3. Mammogram Within the Past Two Years, Utah and U.S.,
1989-2000, 2002, 2004, 2006-2008
90.00%
Percentage of Women
80.00%
70.00%
60.00%
50.00%
Utah
40.00%
U.S.
30.00%
20.00%
10.00%
2008
2006
2002
1999
1997
1995
1993
1991
1989
0.00%
Years
Information on this page was gathered from:
1 National Cancer Institute, What You Need To Know About Breast Cancer. Available online at http://www.cancer.gov/cancertopics/wyntk/breast. Accessed
April 4, 2010.
2 National Institutes of Health Medline Plus, Breast Cancer. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/000913.htm. Accessed
April 4, 2010.
3 National Cancer Institute: Fact Sheet, Breast Cancer. Available online at http://www.cancer.gov/cancertopics/factsheet/Detection/mammograms. Accessed
April 4, 2010.
4 The Huntsman Online Patient Education (HOPE) Guide, Utah Cancer Control Program: Breast and Cervical Cancer Screening. Available online at http://
www.hopeguide.org. Accessed April 4, 2010.
5 National Cancer Institute, Cancer Advances In Focus. Available online at http://www.cancer.gov/cancertopics/cancer-advances-in-focus/breast. Accessed
April 4, 2010.
6 National Cancer Institute, Annual Report to the Nation Finds Continued Declines in Overall Cancer Rates; Special Feature Highlights Current and Projected Trends in Colorectal Cancer. Available online at http://www.cancer.gov/newscenter/pressreleases/ReportNation2009Release. Accessed April 4, 2010.
7 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view_
numbers/BreCAInc.UT_US.html. Accessed April 4, 2010.
8 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view_
numbers/BreCADth.UT_USYear.html. Accessed April 4, 2010.
9 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view_
numbers/BreCAMam.UT_US.html. Accessed April 4, 2010.
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
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2010 Utah’s Health: An Annual Review
Cerebrovascular Disease (Stroke)
Compiled by Trevor Wright
Stroke remains the third leading cause of death in Utah
When arteries to, or in, the brain become blocked or burst
this is known as a stroke.1 There are two main types of stroke,
hemorrhagic and ischemic. When a blood vessel ruptures
in the brain due to weakening it is known as a hemorrhage.
Due to the rupture cerebral pressure increases. Hemorrhagic
strokes are the most serious and dangerous type resulting in
13 percent of stroke cases. There are two types of hemorrhagic
strokes, intracerebral, or subarachnoid. Ischemic strokes account for roughly 87 percent of all stroke cases. Blood vessels
can become blocked by fatty deposits which may cause one of
two types of ischemic strokes. A cerebral thrombosis is when
a blood clot blocks part of the vessel within the brain. Cerebral
embolisms are caused by portions of a blood clot that formed
in alternate regions of the circulatory system, generally in the
large arteries of the neck and upper chest. The clot continues
to flow through the vessels until it becomes lodged within a
narrow vessel.2
Several risk factors have been associated with increased incidence of stroke; the primary risk factor being high blood pressure. Risk factors which are conducive to behavioral change
or treatment include: high blood pressure, cigarette smoking,
diabetes mellitus, artery diseases, arterial fibrillation, sickle
cell disease, high blood cholesterol, poor diet, physical inactivity and obesity. Resistant risk factors include: heredity, race,
sex, prior stroke, transient ischemic attacks, or heart attack.3
A transient ischemic attack occurs when the blood clot only
occludes the blood vessel for a short duration of time. Normal
cardiovascular functions of the body will generally resolve
these clots.
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Chronic Diseases
The U.S. and Utah met their Healthy People 2010 goals to
decrease the incidence of stroke deaths in 2004 and 2006 respectively.2 Utah’s Goal for 2010 was 46.6 deaths per 100,000
people, and the U.S. had a goal of 50 deaths per 100,000 people.4
As of the year 2008, Utah achieved an incidence rate of 40.3
deaths per 100,0004. Stroke continues to be the third leading
cause of death in Utah following heart disease and cancer and
is still a major cause in long-term disability.1
The risk of a stroke increases with age. For those aged 55 and
older the prevalence of stroke more than doubles with each
passing decade, and those 65 or older at the highest risk for
stroke.4 Along with age, race tends to affect the level of risk as
well. As an example, Black persons were noted to be at twice
the risk for experience an initial stroke compared to White
persons.3
In an attempt to continue to decrease the amount of deaths
caused by stroke the following preventative measures are being
utilized by the State of Utah: 1) To increase public awareness
of the signs of stroke, an awareness plan has been implemented
in both English and Spanish, 2) Hospitals are being encouraged
to participate in the American Heart Association’s “Get with
the Guidelines for Stroke” Program, 3) To help with the selfmanagement of high blood pressure, health care facilities have
been given tools to improve patient control of their hypertension.4
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Deaths per 100,000 Population
Figure 1: Stroke Deaths, Utah and U.S., 1980-2008
110
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
Utah
U.S.
Year
Information on this page was gathered from:
1 American Stroke Association: Learn About Stroke, Available on line at http://www.strokeassociation.org/presenter.jhtml?identifier=3030066. Accessed on
4/3/2010.
2 American Stroke Association, Types of Stroke. Available online at http://www.strokeassociation.org/presenter.jhtml?identifier=1014. Accessed 4/3/2010.
3 American Stroke Association, Stroke Risk Factors. Available online at http://www.strokeassociation.org/presenter.jhtml?identifier=4716. Accessed
4/3/2010.
4 Utah’s Indicator-Based Information System for Public Health: Complete Indicator Profile of Stroke deaths, available on line at http://ibis.health.utah.gov/
indicator/complete_profile/StrDth.html. Accessed on 4/3/2010.
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
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2010 Utah’s Health: An Annual Review
Colorectal Cancer
Compiled by Michelle Everill-Flinders
Utah is Ranked Lowest in the Nation for Colorectal Cancer Incidence and Mortality
Colorectal cancer is a cancer that affects the colon (the longest
part of the large intestine) or rectum and is often referred to as
colon cancer. Most colon cancers are termed adenocarcinomas,
meaning cancers that form in cells that produce and release fluids, such as mucus. Rectal cancers generally form in the tissues
of the rectum, closest to the anus.1 Tumors, lumps, or growths
appear where there is an abundance of cells due to the overproduction of new cells and/or buildup of old damaged cells that
do not dispose of naturally. Colorectal cancer cells infiltrate
other organs by entering nearby lymph nodes. The lymphatic
systems transport cancerous cells throughout the body, where
the diseased cells attach to other tissues or organs; usually
the liver. When the cancer cells spread outside the colon or
rectum a new tumor is formed and has the same pathology of
the primary tumor, despite the location, this disease is termed
metastatic colorectal cancer.1
Risk for colon or rectal cancer increases with age, family history of cancer, genetic alterations, diets high in fat and low
in calcium, folate, and fiber, personal history of ulcerative
colitis, Crohn’s disease, colorectal polyps, or cigarette smoking. Screening is most commonly done by colonoscopy or
sigmoidoscopy, but also done by fecal occult blood test, virtual
colonoscopy, double contrast barium enema, or digital rectal
exam. During a colonoscopy or sigmoidoscopy, pre-cancerous
polyps can be removed and prevent further growth of abnormal
cells that can develop into cancerous lesions. When colorectal
cancer is diagnosed early, the five year survival rate is approximately 90%. The National Cancer Institute recommends
regular screening for people 50 years of age or older for those
at high risk for colorectal cancer.2 The Utah Cancer Control
Program offers free fecal occult blood tests which can be done
at home, for people who meet age, income, and health criteria.3
The most recent 2006 data from the Center for Disease Control and Prevention shows Utah as the state with the lowest
colorectal cancer incidence rate at 35.6 per 100,000 people, significantly lower than the national average of 46.8 per 100,000
people.4 Utah also ranks the lowest for colorectal death rates at
12.6 per 100,000 people versus the national average of 17.1 per
100,000 people.4 Utah has maintained a significant lower mortality rate than that of the national average since the beginning
of data collection in 1980.5 Colorectal cancer is the third most
common cancer and the third leading cause of cancer-related
deaths in the U.S. of both men and women. Overall, colorectal
incidence and mortality rates have been declining over the
past decade and continue to decline with the most recent data.
Figure 1 illustrates the decline in death rates due to colorectal
cancer in both Utah and the U.S.
Figure 1. Colorectal Cancer Deaths by Year, Utah and U.S., 1980-2008
Deaths per 100,000 Population
30
25
20
Utah
15
U.S.
10
5
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
0
Year
154
Chronic Diseases
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2 shows the difference in mortality rates in Utah males
is statistically significant compared to Utah females. This data
also shows the increased risk of colorectal related death with
age in both the male and female populations. Both males and
females had significantly higher death rates over age 85 as
compared to the lower age groups.6 The Utah Department of
Health and Utah Cancer Action Network (UCAN) continue to
incorporate public health services for colorectal cancer screening and prevention.3
Deaths per 100,000 Population
Figure 2. Colorectal Cancer Deaths by Age and Sex, Utah, 2004-2008
250
200
150
Male
100
Female
50
0
0-44
45-64
65-84
85+
Age Group
Information on this page was gathered from:
1 National Cancer Institute, Colon and Rectal Cancer. Available online at http://www.cancer.gov/cancertopics/types/colon-and-rectal. Accessed April 4, 2010.
2 National Cancer Institute, What You Need to Know About Cancer of the Colon and Rectum. Available online at http://www.cancer.gov/cancertopics/wyntk/
colon-and-rectal. Accessed April 4, 2010.
3 Utah Department of Health, Utah Cancer Action Network. Available online at http://www.ucan.cc. Accessed April 4, 2010.
4 Department of Health and Human Services, Center for Disease Control and Prevention, National Program of Cancer Registries (NPCR), United States
Cancer Statistics (USCS). Available online at http://apps.nccd.cdc.gov/uscs/cancersrankedbystate.aspx. Accessed April 4, 2010.
5 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view/
ColCADth.html. Accessed April 4, 2010.
6 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://www.ibis.health.utah.gov/indicator/
view/ColoCADth.AgeSex.html. Accessed April 4, 2010.
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
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2010 Utah’s Health: An Annual Review
Coronary Heart Disease (CHD) Mortality Rates
Compiled by Trevor Wright
Utah continues with its trend of staying below the national mortality rate for Coronary Heart Disease
Coronary heart disease (CHD) is a condition in which blood
flow to the heart is reduced. This reduction of blood flow can
be caused by a narrowing or clogging of the coronary arteries.
The decreased flow of blood causes an inadequate amount of
oxygen to reach the heart’s tissues. This decrease or lack of
oxygen being transported may cause the surrounding muscle
and tissue to become permanently damaged or even die.
Coronary Heart Disease continues to be the most common
type of heart disease. Those suffering from CHD may experience angina (chest pain), myocardial infarction (heart attack),
and sudden cardiac death. Risk factors for CHD include high
blood cholesterol, high blood pressure, physical inactivity,
obesity, diabetes, and tobacco smoke. Coronary heart disease
is the number one cause of death for both men and women in
the U.S.1
The figure below shows the continuing decline of deaths attributed to CHD- both in Utah and the United States from 1980 to
2008. Utah has continued to stay below the national mortality
rate since 1980. In 2005 the national mortality rate was 153.1
deaths per 100,000 versus Utah’s 88.9 deaths per 100,000.
Utah’s mortality rate has continued to decrease yearly. In 2008,
the mortality rate for Utah was 80.5 deaths per 100,000 which
is down from 83.8 deaths per 100,000 in 2007.
Utah’s Healthy People 2010 goal has been set at 109.4 deaths
per 100,000 people. This goal was reached in the year 2003
with only 102.8 deaths per 100,000 people. A five year plan
(2007 to 2012) to prevent or delay onset of heart disease and
stroke, and promote heart health, has been implemented by
The Alliance for Cardiovascular Health in Utah. Other preventative measures being taken include patient education, and
self-management tools; and many community health centers
are participating in the Department of Health and Human
Services- Health Disparities Collaborative for Cardiovascular
Disease.1
Deaths per 100,000 Population
CHD Deaths, Utah and U.S., 1980-2008
380
360
340
320
300
280
260
240
220
200
180
160
140
120
100
80
60
Utah
U.S.
Year
Information on this page was gathered from:
1 Utah’s Indicator-Based Information System for Public Health: Complete Indicator Profile of Coronary Heart Disease Deaths, Available at http://ibis.health.
utah.gov/indicator/complete_profile/HrtDisDth.html Accessed on 10/1/2009.
156
Chronic Diseases
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Diabetes Mellitus
Compiled by Blake R. Wilde
It is estimated that 45,000 Utahns have diabetes mellitus but remain undiagnosed
Insulin is a hormone linked with cellular uptake of glucose
from the blood. Diabetes Mellitus is the dysfunction of insulin
production resulting in improper blood glucose levels. Diabetes
Mellitus can be classified as Type 1 Diabetes, Type 2 Diabetes,
or Gestational Diabetes. Complex genetics play a role in the
development of Diabetes Mellitus. Symptoms include glucosuria (high glucose concentrations in urine), high urine output,
unexplained weight changes, dehydration, reduced healing of
cuts and bruises, and blurred vision; however, sometimes no
symptoms occur.1
Type 1 Diabetes is often referred to as “juvenile onset”
diabetes because it is commonly diagnosed in children. It
is characterized by the autoimmune destruction of insulinproducing β cells. Type 2 Diabetes or “adult onset” diabetes
is characterized by insulin resistance that usually results from
high levels of insulin. Research has suggested that this type of
diabetes may have correlations with unhealthy and excessive
eating.1 Gestational Diabetes is diagnosed in pregnant women
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1989
0
1998
1
1997
2
1996
3
1995
4
1994
5
1993
6
1992
Percentage of Adults
7
1991
8
For all Diabetes Mellitus types, exogenous insulin usually
will help to maintain suitable levels of blood-glucose. Further
treatment includes regular exercise, healthy meal plans, and
medications.1
Over 24 million individuals, or over 8% of the U.S. population,
have Diabetes Mellitus (both diagnosed and undiagnosed),
with 1.6 million new cases diagnosed each year.4 Utah has
historically had a lower percentage of adults with Diabetes
Mellitus than the national percentage. Approximately 124,000
Utahns have been diagnosed with Diabetes
2
Figure 1: Percent of Adults with Diabetes, Age Adjusted, Utah and U.S., 1989-2008
Mellitus, almost 7% of
Utahans; however, it is
estimated that another
45,000 Utahans have
undiagnosed Diabetes
Mellitus.2 The ADA
estimates that Diabetes
Mellitus places a masUtah
sive burden on health
care resources, with
U.S.
nearly $116 billion in
direct medical costs and
$58 billion in indirect
costs such as disability,
work loss, and premature mortality each
Year
year.3
1990
9
with high blood glucose. This type of Diabetes Mellitus occurs
when placental hormones inhibit the mother’s insulin function
resulting in high blood-glucose levels in the mother. The glucose may enter the blood of the baby through diffusion across
the placenta. As the body of the baby converts the glucose to
fat, developmental errors may occur. Normally gestational
diabetes goes away after the pregnancy; however, the chance
of having gestational diabetes in later pregnancies is greatly
increased.1
Information on this page was gathered from:
1 American Diabetes Association. Available online at http://www.diabetes.org. Accessed March 10, 2010.
2 Utah’s Indicator Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view/DiabPrev.UT_US.html. Accessed March 10, 2010.
3 Utah’s Indicator Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/view/DiabPrev.Edu.html. Accessed
March 31, 2010.
4 CDC Newsroom Press Release, Diabetes Increases to 24 Million. Available online at http://www.cdc.gov/media/pressrel/2008/r080624.htm. Accessed April
4, 2010.
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
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2010 Utah’s Health: An Annual Review
Lung Cancer
Compiled by Blake R. Wilde
Utah has historically been below the national average of both adults who report cigarette smoking as well as deaths
related to lung cancer.
Lung cancer leads to death more frequently than any other type of cancer.2
Symptoms of lung cancer include
shortness of breath, frequent coughing,
voice changes, and coughing up blood1.
Because these symptoms often do not
appear until the disease is advanced,
early detection of this cancer is difficult. Smoking accounts for 87% of lung
cancer deaths. In 2006, the lung cancer
mortality rate in Utah was less than half
the U.S. rate, at 53.0 per 100,000 for the
U.S. and 23.6 per 100,000 for Utah.3
50
40
30
Utah
20
U.S.
10
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
Year
Figure 2: Percentage of Adults Who Reported Current Cigarette
Smoking, Adults Aged 18 and Older, Utah and U.S., 1989-20083
30
25
20
15
Utah
10
U.S.
5
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Most cases of lung cancer are NSCLC
(8-9 out of 10). NSCLC includes cancer
cells located in the middle of the lungs
(squamous cell carcinoma), the outer part
of the lungs (adenocarcinoma), and any
other part of the lung consisting of large
cells (undifferentiated carcinoma). Treatment includes surgery, chemotherapy,
radiation, and targeted therapy.2
Percentage of Adults
SCLC starts in smaller cells located in
the bronchi. Treatment includes the use
of chemotherapy. Due to rapid division
and spread to other organs, surgery is
rarely used to treat the cancer.2
Deaths per 100,000 population
Mutations in DNA from lung cells can lead to lung cancer. The Utah’s statewide Tobacco Prevention and Control Program is
mutations cause malfunction in the regulation of cell division. seeking to prevent underage use of tobacco, help tobacco users
Unregulated division causes a tumor. The cells often become quit, eliminate unwanted exposure to secondhand smoke, and
metastatic, losing their ability to anchor to tissues resulting in reduce tobacco-related disparities.3
the spread of cancer throughout the body. Primary lung cancer
begins in the lungs whereas secondary
lung cancer begins elsewhere in the body
Figure 1: Lung Cancer Deaths by Year, Utah and U.S., 1980-20083
and is spread to the lungs.1 The two types
70
of lung cancer are non-small cell lung
cancer (NSCLC) and small cell lung
60
cancer (SCLC).
Year
Information on this page was gathered from:
1 Lungcancer.org A Program of Cancer Care, Inc. Available online at http://www.lungcancer.org/reading/about.php. Accessed March 10, 2010.
2 Available online at http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=15. Accessed March 10, 2010.
3 Utah’s Indicator Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/complete_profile/LungCADth.html.
Accessed March 10, 2010.
158
Chronic Diseases
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Prostate Cancer
Compiled by Michelle Everill-Flinders
Prostate Cancer Incidence and Death Rates in Utah are Higher than the National Average
Prostate cancer is a cancer of the prostate, a male reproductive
organ between the bladder and rectum, which surrounds the
urethra. Tumors, also called lesions, form where there is an
abundance of cells due to the overproduction of new cells and/
or buildup of old damaged cells that do not dispose of naturally.
These tumors can be malignant (cancerous) or benign. Prostate
cancer cells infiltrate other organs by entering nearby blood
or lymph vessels. The circulatory and/or lymphatic systems
transport cancerous cells throughout the body, where the diseased cells attach to other tissues or organs; most commonly
the bones. Risk factors for prostate cancer include family history, age, genome changes, prostate changes, and race.1
Screening for prostate cancer is recommended for men over
40 years of age. Screening consists of two tests: a Digital
Rectal Exam (DRE), also called a finger wave, and a blood
test that measures the Prostate Specific Antigen (PSA). Most
health care providers will suggest being screened annually, or
every two to four years if risk is limited.2 Based on 2004-2006
incident rates, 15.9% of men born today (or 1 in 6 men) will
be diagnosed with prostate cancer at some point during their
lifetime. Early prostate cancer diagnoses result in a 100% fiveyear survival rate. Men diagnosed with distant metastasis (the
spread of cancer to distant areas away from the prostate) are
given a 30.6% five-year survival rate.3 Prostate cancer is currently the second leading cancer-related cause of death in men.4
As treatment options for prostate cancer vary from surgical
treatment, radiation, watchful waiting, hormone therapy, and
chemotherapy, decision making for men diagnosed with prostate cancer can be very difficult. More research is needed in
these areas; however, funding for Prostate Cancer research in
the United States is limited due to the controversy regarding a
standard treatment after diagnosis.
Prostate cancer incidence in Utah is ranked the seventh highest
in the nation and death rates from Prostate Cancer eleventh
based on 2006 data.5 Figure 1 illustrates the fluctuation of
mortality rates in Utah versus the United States average. Overall, Utah death rates are consistently higher than that of the
national average. In 2008, the state prostate cancer death rate
was 26.0 per 100,000 men, exceeding the national rate of 23.6
per 100,000 men. The Healthy People 2010 goal of reducing
prostate cancer to 20.0 per 100,000 men appears to be a challenging number to meet.6 Figure 2 shows that PSA screening
rates of men aged 40 or higher in Utah was below the national
average by 3.3% as of 2008 data. This data does not account
for regular screening values. PSA screening rates do increase
with age, as 88.2% of men aged 65 and higher have had a PSA
50
45
40
35
30
25
20
15
10
5
0
Utah
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
U.S.
1980
Deaths per 100,000 Men
Figure 1. Prostate Cancer Deaths per 100,000 Men by Year,
Utah and U.S., 1980-2008
Year
©2010 The University of Utah. All Rights Reserved.
Chronic Diseases
159
2010 Utah’s Health: An Annual Review
test at some point in their lives.7 As prostate cancer is a slow
forming cancer, and oftentimes does not show physical symptoms until after the cancer has progressed to a higher stage, it
is important for men to be screened for this disease regularly
prior to symptoms being present. Prostate screening is generally performed by a family care physician, urologist, or on-
cologist and can be performed during a routine physical exam.
Various organizations within Utah perform free screening at
certain times throughout the year. More information regarding
free screening can be found through the Utah Cancer Action
Network (UCAN).8
Percentage of Men Aged 40+
Figure 2. Percentage of Men Aged 40+ Who Reported Ever Having a PSA
Test by Year, Utah and U.S., 2001-2004, 2006, 2008
66.00%
64.00%
62.00%
Utah
60.00%
U.S.
58.00%
56.00%
54.00%
2001
2002
2003
2004
2006
2008
Year
Information on this page was gathered from:
1 Department of Health and Human Services, National Cancer Institute, What You Need to Know About Prostate Cancer. Available online at http://www.
cancer.gov/cancertopics/wyntk/prostate. Accessed April 6, 2010.
2 American Cancer Society, Detailed Guide to Prostate Cancer, Can Prostate Cancer be Found Early?. Available online at http://www.cancer.org/docroot/CRI/
content/CRI_2_4_3X_Can_prostate_cancer_be_found_early_36.asp. Accessed April 7, 2010.
3 Surveillance Epidemiology End Results, Cancer Statistics review 1975-2006. Available online at http://seer.cancer.gov/csr/1975_2006/browse_csr.php. Accessed April 6, 2010.
4 Centers For Disease Control and Prevention, Features, Prostate Cancer. Available online at http://www.cdc.gov/Features/ProstateCancer. Accessed April 7,
2010.
5 Centers For Disease Control and Prevention, United States Cancer Statistics. Available online at http://apps.nccd.cdc.gov/uscs/cancersrankedbystate.aspx.
Accessed April 6, 2010.
6 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/complete_profile/ProsCAScr.html. Accessed April 7, 2010.
7 Utah Department of Health, Utah Cancer Action Network, Prostate Cancer. Available online at http://health.utah.gov/ucan/cancer/Sitespecific/prostate.htm.
Accessed April 7, 2010.
8 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/indicator/complete_profile/ProsCADth.html. Accessed April 7, 2010.
160
Chronic Diseases
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Bear River Health Department
Compiled by Shannon Talbott, MS
Counties: Box Elder, Cache, and Rich
Population: 167,331
Area: 7,915 square miles
Figure 1: Percent Reporting Binge Drinking by
Local Health District, 2008
Weber-Morgan HD
Wasatch County HD
TriCounty HD
Utah County HD
Tooele County HD
Summit County HD
Southwest Utah HD
Salt Lake Valley HD
Southeastern Utah HD
Davis County HD
Binge Drinking
Figure 2: General Health Status by Local Health District, 2008
Figure 2 shows BRHD has the second
highest general health status with 92.62%
report having excellent/very good/good
health in response to the question “Would
you say that in general your health is Excellent, Very Good, Good, Fair or Poor?”
This response rate could be indicative
of individuals not participating in risky
behaviors such as smoking and binge
drinking.4
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Excellent / Very Good /
Good
Bear River HD
Central Utah HD
Davis County HD
Salt Lake Valley HD
Southeastern Utah HD
Southwest Utah HD
Summit County HD
Tooele County HD
TriCounty HD
Utah County HD
Wasatch County HD
Weber-Morgan HD
Percent Reported
Figure 1 shows that from 2007-2009
BRHD had the second lowest percentage of Binge Drinking in the state with
only 5% of the individuals in the district
reporting that they are binge drinkers.
Binge drinking is reported as having 5
or more drinks for a male and 4 or more
drinks for a female in one sitting.3
Not Binge Drinking
Bear River HD
BRHD has one of the lowest smoking
rates in the State of Utah, which is one
of the leading preventable health issues
in the state. There was a slight increase
in the percentage of individuals reporting being current smokers, from 5% in
2007 to 8% in 2009. These percentages
are well below the national average.2
120.00%
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Central Utah HD
Percent Reporting
The Bear River Health Department
(BRHD) consists of three counties: Box
Elder, Cache, and Rich. The total population for these three counties are 167, 331,
with Cache having the largest population
at 115,269 followed by Box Elder with 49,
902 individuals, and Rich with a population of 2,160.1
Fair / Poor
Information on this page was gathered from:
1 U.S. Census Bureau. State and County Quick Facts. Available online at http://quickfacts.census.gov/qfd/states/49/49005.html Accessed May 19, 2010.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/SmokeCurCig.html. Accessed May 19, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/BingeDrink2.html . Accessed May 19, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/GeneralHlthStat.html. Accessed May 19, 2010.
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
161
2010 Utah’s Health: An Annual Review
Central Utah Health District
Compiled by JB Flinders, MPH, MBA
Counties: Juab, Millard, Piute, Sanpete, Sevier, Wayne
Population (2008): 75,252
Area: 16,897 square miles
Figure 1: Leading Causes of Death by Crude Rate, CUHD, 2008
Parkinson's Disease
Nephritis & Nephrotic Syndrome
Chronic Liver Disease
Suicide
Influenza & Pneumonia
Alzheimer's Disease
Diabetes
Chronic Lower Respiratory Diseases
Cerebrovascular Diseases
Unintentional Injuries
Malignant Neoplasms
Diseases of the Heart
89.34% state average.4 13.65% of individuals in the
CUHD reported that they had seven or more days
in the past 30 days when their physical health was
not good. This is near the state average of 13.16%
who reported seven or more days in the past 30 days
when their health was not good.5
As shown in Figure 1, the CUHD had a crude death
rate from cerebrovascular disease (CVD) at 45.18
suicides per 100,000 people in 2008, the highest
rate of CVD deaths in the entire state. It is almost
ten points above the state’s rate of 15.2 deaths per
0 20 40 60 80 100 120 140 160 180 200
100,000 people that same year. The CUHD also has
Crude Death Rate
the second highest rate of deaths from nephritis and
other nephritic diseases behind Bear River Health
The Central Utah Health District (CUHD) includes six counties
District, and the second highest rate of heart disease
and is the third largest health district in Utah. The birth rate behind Southeastern Health District.6
of the CUHD in 2008 was 17.02 per 1,000 persons, lower than
the state of Utah rate of 20.16 per 1,000.1 The crude mortality The CUHD reported a smoking rate of 14.67% of its adults 18
rate of adults in the CUHD was 721.58 per 100,000 people in years and older in 2008, an increase from 11.84% in 2006, and
2008, a substantial decrease from 845.37 per 100,000 people 12.73% in 2007. This rate of 14.67% is above the state smoking
in 2007.2 This rate is still higher than the state’s 2008 rate of rate of 12.82%.7 In response to the question “During the past
504.75 deaths per 100,000 people that same year. In 2008, indi- month, did you participate in any physical activities or exercises
viduals aged 15 to 24 were the largest population in the CUHD, such as running, calisthenics, golf, gardening, or walking for
comprising 19.67%of the population. The CUHD has a higher exercise”, 23.18% of individuals in the CUHD reported engagpercentage of persons in the 15 to 24 age group than any other ing in no such activity. This is higher than the state average
of 19.8%.8 62.43% of individuals in the CUHD are considered
health district in the State of Utah.3
overweight or obese, also higher than the state average of
In 2008, 86.46% of individuals in the CUHD reported hav- 58.18%.9
ing excellent/very good/good health, which is lower than the
Information on this page was gathered from:
1 Utah’s Indicator-Based Information System for Public Health, Query Module for
builder/birth/BirthPopCnty/BirthRate.html. Accessed May 24, 2010.
2 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/pop/PopMain/Count.html. Accessed May 24, 2010.
3 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/mort/MortCntyICD10/CrudeRate.html. Accessed May 24, 2010.
4 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/brfss/BRFSSCrude/GeneralHlthStat.html. Accessed May 24, 2010.
5 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/brfss/BRFSSCrude/PhysicalHlthPast30Day.html. Accessed May 24, 2010.
6 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/mort/MortCntyICD10/Top10CrudeRate.html. Accessed May 24, 2010.
7 Utah’s Indicator-Based Information System for Public Health, Query Module for
builder/brfss/BRFSSCrude/SmokeCurCig.html. Accessed May 24, 2010.
8 Utah’s Indicator-Based Information System for Public Health, Query Module for
builder/brfss/BRFSSCrude/PhysicalInact.html. Accessed May 24, 2010.
9 Utah’s Indicator-Based Information System for Public Health, Query Module for
result/brfss/BRFSSCrude/OverWtObese.html. Accessed May 24, 2010.
162
Local Health Districts
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
Health Districts. Available online at http://ibis.health.utah.gov/query/
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Davis County Health District
Compiled by Shannon Talbott, MS
County: Davis
Population (2009): 300, 827
Area: 634 square miles
The Davis County Health Department (DCHD) serves Davis
County, which is located in the Northern Utah. The 2009 census estimated that the population of Davis County is 300,827,
in the last 9 years the population has increased 25.9%. The
county is predominately Caucasian, comprising 94.1% of the
population. The median household income for the DCHD is
$67,004 which is higher than the state average of $56,820.1
DCHD is one of the healthier districts in the state of Utah.
Since 2005, data indicated that the general health status of
DCHD has increased from 87.64% of individuals reporting
they were in excellent, very good, or good health, to 90.56%
in 2008 (see Figure 1). 2008 did decline significantly from the
2007 rate of 94.24% with no explanation for the decline.2 This
was indicated by residents’ answers to the question, “Now
thinking about your physical health, which includes physical
illness and injury, for how many days during the past 30 days
was your physical health not good?”
DCHD also has one of the highest vigorous physical activity
rates in the state of Utah. In a 2009 survey of 772 participants,
DCHD reported that 66.6% of participants indicate that they
performed vigorous physical activity at least three times in the
last week, with a minimum of 20 minutes at a time.3 The Davis County Health Department, the oldest local public health
department in Utah, collects data and implements programs to
ensure the population is serves is healthy.1
Percent Reported
Figure 1: General Health Status, Davis County
Health District, 2005-2008
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Excellent / Very Good / Good
Fair / Poor
2005
2006
2007
2008
Year
Information on this page was gathered from:
1 U.S. Census Bureau. State and County Quick Facts. Available online at http://quickfacts.census.gov/qfd/states/49/49011.html. Accessed May 8, 2010.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/GeneralHlthStat.html. Accessed May 8, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/PhysicalActVig.html. Accessed May 8, 2010.
1 Davis County Government, Official Website of Davis County Utah. Available online at http://www.co.davis.ut.us/health/default.cfm. Accessed May 23,
2010.
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
163
2010 Utah’s Health: An Annual Review
Salt Lake Valley Health District
Compiled by Allison Stuart, MS, CHES
County: Salt Lake
Population (2009): 1,042,1251
Area: 808 square miles
The Salt Lake Valley Health Department (SLVHD) is located
in Northern Utah. The population is predominantly white
(90.8%). This is more diverse than Utah overall, which is
92.9% white.2 The death rate in 2008 was 521 per 100,000;
heart disease was the leading cause of death.3 According to
US Census data for 2008, the median household in Salt Lake
County is $56,378.
since 1990. Figure 1 shows the percentage of adults residing in
Salt Lake County who reported having diabetes in 2000-2008.4
Diabetes is classified as either Type 1 or Type 2. Type 1 diabetes, previously known as juvenile diabetes, occurs when the
body does not produce insulin. Type 2 diabetes is more common, and occurs when the body either does not make enough
insulin, or the body is resistant to insulin.5
In 2008, SLVHD had the fourth highest rate of diabetes among
adult citizens, as compared to other local health districts in
Utah. With 6.81% of SLVHD’s population stating that a doctor
told them they have diabetes (not including those with diabetes
due to pregnancy), this is SLVHD’s highest rate of diabetes
Lack of physical activity is related to insulin resistance, and
is a risk factor for developing diabetes.6 Currently, almost half
of SLVHD’s adult residents are not meeting the recommended
level of physical activity.7 Figure 2 shows the physical activity
levels in SLVHD for odd-numbered years, 2001-2007.
Figure 1: Percentage of Adults in Salt Lake Valley Health District
with Diabetes, 2000-2008
8.00%
Percentage with Diabetes
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
164
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Percentage Not Meeting Physical Activity
Recommendation
Figure 2: Percentage of Adults in Salt Lake Valley Health District
Not Meeting Physical Activity Recommendation, 2001-2007
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2001
2003
2005
2007
Year
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/pop/
PopMain/Count.html. Accessed May 23, 2010.
2 US Census Bureau, USA Counties. Available online at http://censtats.census.gov/cgi-bin/usac/usatable.pl. Accessed May 16, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/mort/
MortCntyICD10/ CrudeRate.html. Accessed May 16, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/
brfss/BRFSSCrude/Diab.html. Accessed April 27, 2010.
5 American Diabetes Association, Diabetes Basics. Available online at http://www.diabetes.org/diabetes-basics. Accessed May 2, 2010.
6 National Diabetes Information Clearinghouse, Insulin Resistance and Pre-Diabetes. Available online at http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance. Accessed May 2, 2010.
7 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/
brfss/BRFSSCrude/PhysicalActRec.html.
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
165
2010 Utah’s Health: An Annual Review
Southeastern Utah Health District
Compiled by Michelle Everill-Flinders
Counties: Carbon, Emery, Grand, San Juan
Population (2009): 55,752
Area: 17,574 square miles
The Southeastern Utah Health District (SUHD) covers four
rural counties in Utah. It is the second largest district in terms
of square mileage and has the fourth smallest population of
districts in Utah. Southeastern Utah’s population rose to 55,752
individuals in 2009, up from 54,522 in 2008; one of the lowest
growth rates in Utah at 2.25%.1 Figure 1 illustrates the rate
of child poverty in 2007, one of the most alarming economic
conditions within SUHD as compared to national and state
averages, as well as other Utah health districts. U.S. Poverty
Guidelines are set nationally each year. The poverty level for a
family of four in 2007 was $20,650 while the poverty level for
a family of four in 2009 was $22,050. In the Southeastern Utah
health district, 30.3% of children are considered to be living in
poverty. The national average is 18.0% and the Utah average
is significantly lower at 11.8%. This factor has been shown to
inhibit healthy development and well-being in children. Other
factors such as teen pregnancy, substance abuse, and education
are directly affected by childhood poverty.2
Persons 19-64 years of age living in the SUHD have the
highest uninsured rate compared to all other health districts
in Utah. The uninsured rate of the SUHD has consistently
remained above the uninsured rate of the state of Utah since
2001. The SUHD, as of 2008, has an uninsured rate at 24.0%
compared to the state uninsured rate of 13.9%.3 The high rate
of uninsured can be an indication of the area’s health status.
In a survey meant to locate disparities in health based on the
Health People 2010 goals, Utahns were asked “Now thinking
about your physical health, which includes physical illness and
injury, for how many days during the past 30 days was your
physical health NOT good?” As shown in Figure 2, individuals
in the SUHD reported the second highest percentage of adults
who reported seven or more days at poor health at 18.6% between 2006 and 2008.4 This information aids health program
planning to improve the quality and years of healthy life and
eliminating health disparities.
Figure 1. Child Poverty by Local Health District, Utah, 2007
U.S.
State
Weber-Morgan
Wasatch
Local Health District
Utah County
TriCounty
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Percentage of Children
166
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Figure 2. Seven or More Days of Poor Physical Health in the Past 30 Days
by Local Health District, Utah, 2006-2008
Weber-Morgan
Wasatch
Utah County
Local Health District
TriCounty
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
0.00%
5.00%
10.00%
15.00%
20.00%
Percentage of Adults
Another notable disparity in the SUHD is the rate of suicide
deaths. At 24.2 suicides per 100,000, based on 2004-2008 data,
the SUHD has the highest rate in the State. The Utah state
rate is 15.2 persons per 100,000 (Figure 3). Utah has one of
the highest age-adjusted suicide rates in the U.S. Suicide is
the leading cause of death for Utahns ages 35 to 44 years old
©2010 The University of Utah. All Rights Reserved.
and the second leading cause of death for Utahns ages 15 to
34 years old. This data does not account for non-fatal suicide
attempts. Treating this condition is very complex due to the
intricacies of the circumstance. A 24-hour national suicide
prevention lifeline can be accessed by calling (800) 273-TALK
(8255).5
Local Health Districts
167
2010 Utah’s Health: An Annual Review
Figure 3. Suicide by Local Health District, Utah, 2004-2008
State
Weber-Morgan
Wasatch
Local Health District
Utah County
TriCounty
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
0
5
10
15
20
25
30
Rate per 100,000 Population
Information on this page was gathered from:
1 Economic Development Corporation of Utah, Utah Demographics, Available online at http://www.edcutah.org/files/Section3_Demographics_09.pdf. Accessed on 25 Apr 2010.
2 Utah Department of Health, Complete Indicator Profile of Utah Population Characteristics: Poverty, Children Age 17 and Under, Available online at http://
ibis.health.utah.gov/indicator/complete_profile/ChldPov.html. Accessed on 15 Apr 2010.
3 Utah Department of Health, Complete Indicator Profile of Health Insurance Coverage, Available online at http://ibis.health.utah.gov/indicator/complete_
profile/HlthIns.html. Accessed on 11 May 2010.
4 Utah Department of Health, Complete Indicator Profile of Health Status: Physical Health Past 30 Days, Available online at http://ibis.health.utah.gov/indicator/complete_profile/HlthStatPhys.html. Accessed on 15 Apr 2010.
5 Utah Department of Health, Complete Indicator Profile of Suicide Deaths, Available online at http://ibis.health.utah.gov/indicator/complete_profile/SuicDth.
html. Accessed on 15 Apr 2010.
168
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Southwest Utah Health District
Compiled by Michelle Everill-Flinders
Counties: Beaver, Garfield, Iron, Kane, Washington
Population (2009): 200,246
Area: 17,640 square miles
The Southwest Utah Health District (SUHD) is the largest
health district by area and the fifth largest by population size.
The population of this district was 200,246 in 2009 compared
to 215,140 in 2008.1 The 2008 uninsured rate of 9.8% has dramatically improved from the 2007 rate. The SUHD now ranks
as the 6th lowest uninsured district as compared to the other
twelve Utah Health Districts.
The fetal mortality rate in the SUHD is the lowest rate in the
state at 4.2 per 1,000 live births tied with the Bear River Health
District. Figure 1 illustrates the comparison of fetal mortality
rate among health districts within Utah.2 All other health indicators for this region are generally positive in that the district
is, by comparison to other health districts within Utah, healthy
with emphasis on preventative care. For instance, Figure 2 represents the percentage of adults who could correctly identify
major symptoms of a stroke. The SUHD ranks the highest in
Utah.3
Figure 1. Fetal Mortality Rate by Local Health District, Utah, 2003-2007
State
Weber-Morgan
Wasatch
Local Health District
Utah County
TriCounty
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
0
1
2
3
4
5
6
Number per 1,000 Live Births Plus Fetal Deaths
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
169
2010 Utah’s Health: An Annual Review
Figure 2. Data and Confidence Limits for Adults Who Could Correctly
Identify the Major Symptoms of Stroke by Local Health
District, Utah, 2008
State
Weber-Morgan
Wasatch
Local Health District
Utah County
TriCounty
Tooele
Summit
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
0%
10%
20%
30%
40%
50%
60%
Percent Correctly Identifying
Information on this page was gathered from:
1 U.S. Census Bureau, State and County QuickFacts. Available online at http://quickfacts.census.gov/qfd/states/49/49001.html. Accessed 23 May 2010.
2 Utah Department of Health, Complete Indicator Profile of Fetal Mortality. Available online at http://ibis.health.utah.gov/indicator/complete_profile/FetMort.html. Accessed 17 May 2010.
3 Utah Department of Health, Complete Indicator Profile of Stroke Awareness and Willingness to Call 911. Available online at http://ibis.health.utah.gov/
indicator/complete_profile/StrSignSymp.html. Accessed 24 May 2010.
170
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Summit County Health District
Compiled by Allison Stuart, MS, CHES
County: Summit
Population (2009): 40,4511
Area: 1,882 square miles
The Summit County Health Department is located in Northern
Utah. Similar to the state of Utah, the most frequently occurring age category in Summit County is 15 to 44 years old
(43.7%), and its population is predominantly white (96.5%).2
The death rate in 2008 was 327.9 per 100,000; heart disease
was the leading cause of death.3 According to US Census data
for 2008, the median household in Summit County is $80,431;
this is well above Utah’s average of $55,220.
be related to their relatively high physical activity levels. According to BRFSS data, approximately two-thirds of adults in
Summit County have been meeting the recommended level of
physical activity over the past decade. This health district consistently outranks the other health districts in Utah regarding
the percentage of people who meet the physical activity level
recommendation. Figure 2 shows Summit County’s physical
activity data for odd-numbered years, 2001-2007.5
Summit County currently boasts one of the healthier health
districts in Utah. In 2008, BRFSS data indicated that citizens
18 years and older had the best reported physical health among
Utah’s local health districts. This was indicated by residents’
answers to the question, “Now thinking about your physical
health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health
not good?” Figure 1 shows how other health districts in Utah
compared to Summit County.4
In addition to having high physical activity levels, Summit County Health District also had the highest percentage
of residents aged 18 years and older consuming at least five
servings of fruits and vegetables per day in 2007. This data
was gathered by asking, “How often do you drink fruit juices,
eat fruit, green salad, potatoes, carrots, or other vegetables?”
This measure was based on a group of questions about an individual’s eating habits. Figure 3 shows the percentage of adults
in Summit County who got at least five servings of fruits and
vegetables per day for odd-numbered years, 2003-2007.6
Summit County Health District’s good physical health may
Figure 1: Adults Reporting Poor Physical Health on Less Than 7 Days
in the Past 30 Days, by Local Health District, Utah, 2008
Percentage of Adults with
Mostly Good Physical Health
95.00%
90.00%
85.00%
80.00%
75.00%
©2010 The University of Utah. All Rights Reserved.
Weber-Morgan
Wasatch
Utah County
TriCounty
Tooele County
Summit County
Southwest
Southeastern
Salt Lake Valley
Davis County
Central
Bear River
70.00%
Local Health Districts
171
2010 Utah’s Health: An Annual Review
Percentage Not Meeting Physical Activity
Recommendation
Figure 2: Percentage of Adults in Summit County Health District
Not Meeting Physical Activity Recommendation, 2001-2007
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
2001
2003
2005
2007
Year
Figure 3: Percentage of Adults in Summit County Health District
Consuming 5+ Servings/Day of Fruits and Vegetables, 2003-2007
Percentage Getting 5+ Servings/Day
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
2003
2005
2007
Year
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/pop/
PopMain/Count.html. Accessed May 23, 2010.
2 US Census Bureau, USA Counties. Available online at http://censtats.census.gov/cgi-bin/usac/usatable.pl. Accessed May 16, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/mort/
MortCntyICD10/ CrudeRate.html. Accessed May 16, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/ PhysicalHlthPast30Day.html. Accessed April 27, 2010.
5 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/
brfss/BRFSSCrude/PhysicalActRec.html. Accessed April 27, 2010.
6 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/5aDay.html. Accessed April 27, 2010.
172
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Tooele County Health Department
Compiled by Shannon Talbott, MS
County: Tooele County
Population: 58,335
Area: 6,930 square miles
Weber-Morgan HD
Wasatch County HD
TriCounty HD
Utah County HD
Tooele County HD
Southwest Utah HD
Summit County HD
Salt Lake Valley HD
Southeastern Utah HD
Central Utah HD
BMI less than 25 (normal)
Davis County HD
Percent BMI
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Bear River HD
2008 data indicated that Tooele County
Health Department (TCHD) members 18
years and older had the third highest rate
of individuals classified as overweight or
obese in the state. This was indicated
by residents’ answers to the questions,
“About how much do you weigh without shoes?” and “About how tall are
you without shoes?” A normal BMI is
defined as less than 25; overweight, but
not obese, is defined as having a BMI of
25-29; and obese is defined as having a
BMI of 30 or more” Figure 1 shows how
other health districts in Utah compared
to TCHD.2
Figure 1: BMI Rates by Local Health District, 2008
BMI 25+ (Overweight or
obese)
Figure 2: Recommended Physical Activity by Local Health
Department, 2008
Percent Meeting Recommendation
Although Tooele County contains the
second largest land area in the state of
Utah, it has one of the smallest populations. The population has increased in
the last year, with an estimated population of 58,335 individuals. Almost 94%
of the population is white, non-hispanic,
with the median income of $61,867.1
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Meeting recommendation
Bear River HD
Central Utah HD
Davis County HD
Salt Lake Valley HD
Southeastern Utah HD
Southwest Utah HD
Summit County HD
Tooele County HD
TriCounty HD
Utah County HD
Wasatch County HD
Weber-Morgan HD
Figure 2 shows the percentage of individuals reporting that they do not meet
the recommended physical activity requirements by Health District. TCHD
has the largest percentage not meeting
the requirements at 48.48%. The recommended daily physical activity is defined
as the “Percentage of adults aged 18 years
and older who report light or moderate
physical activity for at least 30 minutes five or more times per
week or who report vigorous physical activity for at least 20
minutes three or more times per week.”3
Not meeting
recommendation
Information on this page was gathered from:
1 U.S. Census Bureau. State and County Quick Facts. Available online at http://quickfacts.census.gov/qfd/states/49/49045.html Accessed May 8, 2010.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/OverWtObese.html. Accessed April 27, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/PhysicalActRec.html. Accessed May 19, 2010.
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
173
2010 Utah’s Health: An Annual Review
Tri-County Health District
Compiled by Shannon Talbott, M.S.
County: Daggett, Duchesne, Uintah
Population: 47,684
Area: 8,478 square miles
2009 showed an increase in the number
of individuals in TCHD who received the
influenza shot in the previous12 months;
from 35% in 2008 to 39% in 2009 (see
Figure 2).2 The low rates of influenza
shots in TCHD are presumed to be related to an increased rate of individuals
without health insurance.3
In the last year, TCHD reported a decrease in the number of individuals who
have been diagnosed as diabetic; from
10.18% in 2008 to 9.5% in 2009. This is
the lowest reported diabetic rate in the
TCHD in the past few years, and could
be caused from either an actual decrease
in diabetes rates or due to fewer population members being seen or screened by
a doctor.4
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Weber-Morgan LHD
Utah County LHD
Wasatch County LHD
TriCounty LHD
Tooele County LHD
Southwest Utah LHD
Summit County LHD
Salt Lake Valley LHD
Southeastern Utah LHD
Central Utah LHD
Davis County LHD
Always, nearly always
Bear River LHD
Percent Sunscreen Usage
TCHD has very low rates of sunscreen
use in the last couple of years with nearly
65.91% of individuals reported at risk
for not using sunscreen appropriately.
TCHD ranks as one of the highest at-risk
counties in the State (see Figure 1).1
Figure 1: Sunscreen Use by Local Health District, 2008
At risk
Figure 2: Influenza Vaccination, Tri-County Health District, 2007-2009
70.00%
60.00%
Percent Vaccinated
The Tri-County Health District (TCHD)
represents individuals in Daggett, Duchesne, and Uintah Counties. These counties are located in the Northern portion
of Utah. 89.72% of the population is Caucasian, and 50.34% are male. The 25-29
year old age group is the most prevalent
in the TCHD at 10.2% followed by the
0-4 year old age group at 9.86%.2
50.00%
40.00%
30.00%
Within past 12 months
20.00%
Outside past 12 months
10.00%
0.00%
2007
2008
2009
Year
Information on this page was gathered from:
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/pop/
PopRaceAlone/Count.html. Accessed April 8, 2010.
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/Sunscreen.html. Accessed April 8, 2010.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/InflVac.html. Accessed May 8, 2010
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/HlthCareCov.html. Accessed May 10, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/Diab.html. Accessed May 10, 2010.
174
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Utah County Health District
Compiled by JB Flinders, MPH, MBA
Counties: Utah
Population (2009): 531,442
Area: 2,141 square miles
The Utah County Health District (UCHD) provides services
to all of Utah County, including the metropolitan areas of
Provo/Orem. UCHD has consistently experienced substantial
population growth, from 423,286 residents in 2003 to 519,632
residents in 2008, and currently houses 18.8% of Utah’s population. The 3.6% growth rate is 1.4% higher than the State
average, making UCHD the second fastest growing area in the
state1. Its birth rate of 24.07 births per 1,000 residents in 2007
ranked as the highest rate of any local health district in Utah 2.
UCHD remains a relatively healthy area despite the rapidly
growing population, and in 2008 had the second lowest percentage of overweight or obese residents in Utah at 54.99%, trailing only Summit County3. However, UCHD has experienced
an 8.7% increase in individuals being classified as overweight
or obese from 1998 to 20081. UCHD also had the lowest rate
of adult smoking in Utah, with only 5.1% of residents above 18
years of age smoking cigarettes in 2008; which is well below
the national average of 20.8%4.
In terms of communicable disease control, 2008 data shows
UCHD was close to, or below, the 2003-2007 average for most
of the reportable communicable diseases. The exceptions were
varicella (or chickenpox) and Chlamydia1. Most notably, UCHD
did not see a return of the outbreak of cryptosporidiosis, a parasitic disease which causes short-term infection and diarrhea,
which caused over 500 reported cases. Cryptosporidiosis tends
to linger for an additional season after the original outbreak,
but in 2008 only a few cases were reported, which is attributed
to new ultraviolet-light filters at many public swimming pools5.
UCHD has much lower rates of preventive care screenings
than both the State and national averages. Figure 1 shows that
UCHD has lower rates of cholesterol screenings, Pap smear
screenings, and mammograms than both the State of Utah and
the U.S., and has lower rates of PSA tests and colonoscopies
than the State average. UCHD has a higher rate of diabetes
than the national average (9.4% to 8.2%) but lower rates of high
cholesterol (19.3% versus 24.8%) and hypertension (16% to
27.8%). The Utah County Health Department provides health
education programs, classes, workshops and technical training
designed to prevent and reduce these leading causes of death
and disability in the UCHD, along with cardiovascular disease
prevention, injury prevention, and tobacco cessation and control1.
Figure 1: Leading Causes of Death per 100,000 population, 2008, Utah
County Health District
Suicide
Motor Vehicle Injuries
Pneumonia and Influenza
Lung Disease
Alzheimer's
Diabetes
Unintentional Injuries
Stroke
Cancers
Heart Disease
0
10
20
30
40
50
60
70
80
Deaths per 100,000 Population
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
175
2010 Utah’s Health: An Annual Review
90
80
70
60
50
40
30
20
10
0
UCHD
HIV
Colonoscopies
PSA
Clinical Breast Exam
Mammograms
Pap smear
Utah
Cholesterol
Screening Rate Percentage
Figure 2: Screening Rates in Utah County Health District and Utah,
2008, and U.S., 2006
U.S.
Information on this page was gathered from:
1
2
3
4
5
http://www.utahcountyonline.org/Dept2/documents/2008_Annual_Report.pdf
http://ibis.health.utah.gov/query/result/birth/BirthPopCnty/BirthRate.html
http://ibis.health.utah.gov/query/result/brfss/BRFSSCrude/OverWtObese.html
http://ibis.health.utah.gov/indicator/view_numbers/CigSmokAdlt.LHD.html
Allbusiness.com, Chlamydia is present. Available online at http://www.allbusiness.com/medicine-health/diseases-disorders-infectious/12079871-1.html.
Accessed April 12, 2010.
176
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Wasatch County Health District
Compiled by Allison Stuart, MS, CHES
County: Wasatch
Population (2009): 23,4281
Area: 1,209 square miles
The Wasatch County Health Department (WCHD) is located
in Northern Utah. Like the rest of Utah, the most frequently
occurring age category in WCHD is 15 to 44 years old (45.3%),
and its population is predominantly white (95.7%).2 The death
rate in 2008 was 437.73 per 100,000; heart disease was the
leading cause of death.3 According to US Census data for 2008,
the median household in Wasatch County is $60,888.2
In 2008, BRFSS data indicated that citizens 18 years and older
had the second best reported physical health among Utah’s
local health districts behind Summit County Health District.
This was indicated by residents’ answers to the question, “Now
thinking about your physical health, which includes physical
illness and injury, for how many days during the past 30 days
was your physical health not good?”4
WCHD citizens boasted the best mental health in Utah in 2008.
When asked, “Now thinking about your mental health, which
includes stress, depression, and problems with emotions, for
how many days during the past 30 days was your mental health
not good,” 89.92% reported fewer than 7 days of poor mental
health.5
WCHD’s efforts in 2009 included combating the H1N1 pandemic. They organized a mass vaccination campaign to im-
munize high-risk individuals first, and ultimately were able to
offer the vaccine to all those who were interested (see Figure
1 for the total number of doses given). Wasatch County was
fortunate to have only five hospitalizations and zero deaths result from the H1N1 virus in 2009.6 The percentage of citizens
18 years and older in the Wasatch County Health District who
got vaccinated against influenza each year from 2004 through
2008 can be seen in Figure 2.7
The only communicable disease that resulted in a death in Wasatch County in 2009 was from Meningococcal Disease. The
total number of reportable disease cases diagnosed in Wasatch
County residents increased by 15 cases over 2008, totaling 82
cases during 2009. Cases of Chlamydia accounted for nearly
forty percent of these.8 For a summary of diseases reported see
Figure 3 below.8
It is also notable that the WCHD received a grant to be one
of only three local health departments to participate in the
OutbreakNet pilot project with the Utah Department of Health.
The goals of this project were “to create and train a statewide
Outbreak Investigation Team for food-borne and enteric disease outbreaks and develop methods for using volunteer public
health students to conduct interviews and collect products.”6
Figure 1:Total Doses of H1N1 Vaccine Given in Wasatch County
October 1 - December 31, 2009
3000
Total Doses
2500
2000
1500
1000
500
0
October
©2010 The University of Utah. All Rights Reserved.
November
December
Local Health Districts
177
2010 Utah’s Health: An Annual Review
Figure 2: Percentage of Adults Vaccinated Against Influenza in Wasatch County
2004-2008
50.00%
Percentage Vaccinated
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
2004
2005
2006
2007
2008
Year
Streptococcal (other)
Strep pneumo (IPD)
Salmonellosis
PID
Meningococcal Disease
Meningitis (viral & …
Lyme Disease
Influenza (hospitalized)
Hepatitis C (Past or …
Hepatitis B (Chronic)
Giardiasis
Coccidioidomycosis
Chlamydia
Chickenpox
40
35
30
25
20
15
10
5
0
Campylobacteriosis
Number of Cases
Figure 3: Communicable Diseases in Wasatch County
January 1 - December 31, 2009
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/pop/
PopMain/Count.html. Accessed May 23, 2010.
2 US Census Bureau, USA Counties. Available online at http://censtats.census.gov/cgi-bin/usac/usatable.pl. Accessed May 16, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/mort/
MortCntyICD10/ CrudeRate.html. Accessed May 16, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/ PhysicalHlthPast30Day.html. Accessed May 23, 2010.
5 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at h http://ibis.health.utah.gov/query/result/
brfss/BRFSSCrude/ MentHlthPast30Day.html . Accessed May 23, 2010.
6 Wasatch County Health Department, Annual Report 2009. Available online at http://www.wasatchcountyhd.org/LinkClick.aspx?fileticket=cOxDKTKBw
mU%3d&tabid=183. Accessed April 8, 2010.
7 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at ttp://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/InflVac.html. Accessed April 27, 2010.
8 Wasatch County Health Department, Disease Summary for 2009. Available online at http://www.wasatchcountyhd.org/LinkClick.aspx?fileticket=gcpo3Vg
Y5W8%3d&tabid=124. Accessed April 13, 2010.
178
Local Health Districts
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Weber-Morgan Health District
Compiled by Allison Stuart, MS, CHES
Counties: Weber and Morgan
Population (2009): 237,2061
Area: 1,270 square miles
Figure 1: Percentage of Adults Vaccinated Against Influenza in
Weber-Morgan Health District, 2004-2008
50.00%
45.00%
Percent Vaccinated
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
2004
2005
2006
2007
Year
The Weber-Morgan Health Department (WMHD) is located
in Northern Utah. Similar to the state of Utah, the most frequently occurring age category in WMHD is 15 to 44 years old
(43.4%).1 The death rate in 2008 was 621.74 per 100,000, which
is higher than the state of Utah overall (504.75 per 100,000).
Heart disease was the leading cause of death.2
WMHD saw a steady improvement in its citizens’ reported
physical health between 2006 and 2008. In 2008, BRFSS data
indicated that 89.39% of citizens 18 years and older reported
fewer than seven days of poor health (as compared to 80.24%
in 2006). This was indicated by residents’ answers to the question, “Now thinking about your physical health, which includes
physical illness and injury, for how many days during the past
30 days was your physical health not good?”3 During the same
time period, WMHD also saw a decrease in the percentage of
people stating that a doctor told them they have diabetes, falling from 6.75% in 2006, to 5.91% in 2008 (not including those
with diabetes due to pregnancy).4
When the H1N1 pandemic hit, the WMHD
experienced great success with their H1N1
Prevention Campaign. They were the first
local health department to offer vaccinations
by appointment, as well as the first to lift
eligibility restrictions and offer the vaccine
to all interested individuals.5 The WMHD
considers one of their best practices during
the H1N1 Prevention Campaign to be their
combined use of public education, messaging, a flu hotline, social networking sites,
and media relations to inform people about
2008
their H1N1 flu campaign activities. In particular, they recognized the value of social
networking via the Internet to inform the
public about mass vaccination clinics and
provide timely information updates. Among their best practices, the WMHD also recognized the importance of working
with volunteers in order to have a successful campaign.5
The WMHD also faced challenges during their H1N1 Prevention Campaign. For instance, communication could have been
more successful if better meeting minutes had been recorded
and distributed within 24 hours of their meetings. They also
learned the importance of giving information to the people
working the phone banks and frontline receptionists before
contacting the media or updating their website, and clarifying
people’s understanding of their roles within the campaign.5
The percentage of citizens 18 years and older in the WeberMorgan Health District who got vaccinated against influenza
each year from 2004 through 2008 can be seen in Figure 1.6
Information on this page was gathered from:
1 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/pop/
PopMain/Count.html. Accessed May 23, 2010.
2 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/mort/
MortCntyICD10/ CrudeRate.html. Accessed May 16, 2010.
3 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/ PhysicalHlthPast30Day.html. Accessed May 23, 2010.
4 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at http://ibis.health.utah.gov/query/builder/
brfss/BRFSSCrude/Diab.html.Accessed May 23, 2010.
5 Weber-Morgan Health Department, Weber-Morgan Health Department’s H1N1 Influenza Campaign (Retrospective Analysis and Review). Available online
at http://www.webermorganhealth.org/documents/GaryFinalReport.pdf. Accessed April 8, 2010.
6 Utah Department of Health, Utah’s Indicator-Based Information System for Public Health. Available online at ttp://ibis.health.utah.gov/query/result/brfss/
BRFSSCrude/InflVac.html. Accessed April 27, 2010.
©2010 The University of Utah. All Rights Reserved.
Local Health Districts
179
UH Review 2010
Utah’s Health: An Annual Review
Health Services Directory
Pages 183─191
Utah’s Health: An Annual Review
June 2010 | Volume 15
www.matheson.utah.edu
2010 Utah’s Health: An Annual Review
Hospital/Medical Centers
Contact
Telephone
Website
Nicole Mihalopoulos, MD
(801) 587-7574
www.uuhsc.utah.edu/coe/womenshealth/clinical/ adolescent.
html
Alta View Hospital
9660 South 1300 East
Sandy, Utah 84094-3793
(801) 501-2600
www.intermountainhealthcare.
org/xp/public/altaview
American Fork Hospital
170 North 1100 East
American Fork, Utah 84003-2096
(801) 855-3300
www.intermountainhealthcare.
org/xp/public/americanfork/
Bear River Valley Hospital
440 West 600 North
Tremonton, Utah 84337-1129
(435) 257-7441
www.intermountainhealthcare.
org/xp/public/bearriver/
Saundra Buys, MD
Ed Nelson, MD
(801) 587-4241
www.hci.utah.edu/group/
breastCancer/breastCancerIndex.jsp
Karen Segerson, MD
(801) 581-4182
1-866-850-886
healthcare.utah.edu
(208) 678-4444
www.intermountainhealthcare.
org/xp/public/cassia
Adolescent Health – University
Health Care – Clinic 6
Madsen Health Center
555 S Foothill Blvd
Salt Lake City, Utah
Breast Cancer Program
Huntsman Cancer Institute
2000 Circle of Hope
Salt Lake City, Utah 84112
Cardiology –Preventative Cardiology Program
University Health Care
50 North Medical Drive
Salt Lake City, Utah 84132
Cassia Regional Medical Center
1501 Hiland Avenue
Burley, Idaho 83318-2648
Delta Community Medical Center
126 South White Sage Avenue
Delta, Utah 84624-8928
James Beckstrand
(435) 864-5591
www.intermountainhealthcare.
org/xp/public/delta/
Dental Clinic at University Hospital
50 North Medical Drive
Clinic 7
Salt Lake City, Utah 84132
Craig Olson
(801) 581-2220
www.healthcare.utah.edu
Dixie Regional Medical Center
544 South 400 East
St. George, Utah 84770-3799
Terri Kane, CEO
(435) 688-4000
www.intermountainhealthcare.
org/xp/public/dixie/
Eye Health-John A. Moran Eye
Center
John A. Moran Eye Center
65 Medical Drive
Salt Lake City, Utah 84132
Randall Olson, MD
Telephone
801.581.2352
Fax 801.581.3357
www.uuhsc.utah.edu/moraneyecenter
Fatigue Consultation Clinic
1002 E South Temple, Suite 408
Salt Lake City, Utah, 84102
Lucinda Bateman, MD
(801) 359-7400
www.fcclinic.com
Fillmore Community Medical
Center
674 South Highway 99
Fillmore, Utah 84631
James Beckstrand
(435) 743-5591
www.intermountainhealthcare.
org/xp/public/fillmore/
Allan D. Ainsworth, CEO
(801) 364-0134
http://fourthstreetclinic.org
Fourth Street Clinic
404 South 400 West
Salt Lake City, Utah
©2010 The University of Utah. All Rights Reserved.
Health Services Directory
183
2010 Utah’s Health: An Annual Review
Hospital/Medical Centers
Contact
Telephone
Website
Alberto Vasquez
(435) 676-8811
www.intermountainhealthcare.
org/xp/public/garfield/
Kathleen Digre, MD
(801) 585-6387
www.healthcare.utah.edu
(435) 654-2500
www.intermountainhealthcare.
org/xp/public/hebervalley/
Ed Brisley
(801) 777-4681
www.hill.af.mil/family/
Mary C. Beckerle,
Executive Director
(877) 585-0303
www.huntsmancancer.org
Merrill Gappmayer,
Chairman, Board of
Trustees
(801) 442-2000
http://intermountainhealthcare.
org/xp/public/facilities/hospitals.xml
LDS Hospital
8th Avenue & C Street
Salt Lake City, Utah 84143-0001
(801) 408-1100
www.intermountainhealthcare.
org/xp/public/lds/
Logan Regional Hospital
1400 North 500 East
Logan, Utah 84341
(435) 716-1000
www.intermountainhealthcare.
org/xp/public/logan
McKay-Dee Hospital Center
3939 Harrison Boulevard
Ogden, Utah 84409-0370
(801) 387-2800
www.intermountainhealthcare.
org/xp/public/mckaydee
John Greenlee, MD
(801) 585-6387
www.healthcare.utah.edu
Amy Powell, MD
Timothy Beals, MD
Co-Directors
(801) 587-7109
1-866-850-886
healthcare.utah.edu
(801) 224-4080
www.intermountainhealthcare.
org/xp/public/orem/
Faculty:
1-866-850-8863
www.healthcare.utah.edu/
medicalServices/
(801) 662-1000
www.intermountainhealthcare.
org/xp/public/primary/
(435) 462-2441
www.intermountainhealthcare.
org/xp/public/sanpete
Garfield Memorial Hospital
200 North 400 East
Panguitch, Utah 84759-0389
Headache Clinic- University Health
Care
729 Arapeen Drive
Salt Lake City, Utah 84108
Heber Valley Medical Center
1485 South Highway 40
Heber City, Utah 84032
Hill Air Force Base Family Support
Center
7336 D Street
Building 150
Hill Air Force Base, Utah 84056
Huntsman Cancer Institute
2000 Circle of Hope
Salt Lake City, Utah 84112
Intermountain Healthcare Facilities
Neurology Department ─ University
Health Care
729 Arapeen Drive
Salt Lake City, Utah 84108
Osteoporosis/Bone Density Program – University Health Care
Department of Orthopaedics
590 Wakara Way
Salt Lake City, Utah 84108
Orem Community Hospital
331 North 400 West
Orem, Utah 84057-1999
Psychiatry – University Health Care
50 North Medical Drive
Salt Lake City, Utah 84132
Clara Michael, MD
Primary Children’s Medical Center
100 North Medical Drive
Salt Lake City, Utah 84113-1100
Sanpete Valley Hospital
1100 South Medical Drive
Mt. Pleasant, Utah 84647-2222
184
Health Services Directory
Brad Howell
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Hospital/Medical Centers
Contact
Telephone
Website
Gary Beck
(435) 896-8271
www.intermountainhealthcare.
org/xp/public/sevier
Elaine J. Skalabrin, MD
(801) 587-9935
www.healthcare.utah.edu
TOSH – The Orthopedic Specialty
Hospital
5848 South 300 East
Murray, Utah 84107
(801) 314-4100
www.intermountainhealthcare.
org/xp/public/tosh/
University Counseling Center
Student Services Building
201 South 1460 East
Room 426
Salt Lake City, Utah 84112-9061
Office:
(801) 581-6826
Fax:
(801) 585-6816
Sevier Valley Hospital
1100 North Main Street
Richfield, Utah 84701-1843
Stroke Center - University Health
Care
175 North Medical Drive
Room 3204
Salt Lake City, Utah 84132
University Health Care
50 North Medical Drive
Salt Lake City, Utah 84132
Lorris Betz, MD, PhD, CEO
(801) 581-2121
www.healthcare.utah.edu
University of Utah; Certified NurseMidwives and Nurse Practitioners;
BirthCare HealthCare
Madsen Clinic
555 South Foothill Blvd
Salt Lake City, Utah 84112
Leissa Roberts, MS, CNM
(801) 581-4014
www.nurs.utah.edu/practice/
practices.htm
University of Utah; Certified NurseMidwives and Nurse Practitioners;
BirthCare HealthCare
Clinic 4 – University Hospital
50 North Medical Drive
Salt Lake City, Utah 84132
Leissa Roberts, MS, CNM
(801) 581-4014
www.nurs.utah.edu/practice/
practices.htm
University of Utah; Certified NurseMidwives and Nurse Practitioners;
Birthcare HealthCare
Ellis R. Shipp Clinic
4535 South 5600 West
West Valley City, Utah 84120
Leissa Roberts, MS, CNM
(801) 963-7357
www.nurs.utah.edu/practice/
practices.htm
(801) 357-7850
www.intermountainhealthcare.
org/xp/public/uvrmc
Utah Valley Regional Medical
Center
1034 North 500 West
Provo, Utah 84604-3337
Valley Mental Health Crisis Hotline
5965 South 900 East
Salt Lake City, Utah 84121
Debra Falvo,
Executive Director
(801) 261-1442
www.vmh.com/
Valley Mental Health
5965 S 900 E
Suite 420
Salt Lake City, Utah 84121
Debra Falvo,
Executive Director
(801) 263-7100
www.vmh.com/
(435) 868-5000
www.intermountainhealthcare.
org/xp/public/valleyview
Valley View Medical Center
1303 North Main
Cedar City, Utah 84720-3462
©2010 The University of Utah. All Rights Reserved.
Health Services Directory
185
2010 Utah’s Health: An Annual Review
Hospital/Medical Centers
Women’s Health Clinic ─
UniversityHealth Care
Madsen Clinic
555 South Foothill Blvd
Salt Lake City, Utah 84112
Government Resources
Contact
Telephone
Website
Jennie VanHorn, MD
Medical Director
(801) 585-2111
www.uuhsc.utah.edu/coe/womenshealth/ clinical/
Contact
Telephone
Website
Phone: 2-1-1 or
1-888-826-9790
Fax: (801) 7462880
www.informationandreferal.org
211 Info Bank
(Health Resource List)
Adult Protective Services
120 North 200 West
Suite 325
Salt Lake City, Utah 84103
Nels Holmgren
Executive Director
(800) 371-7897
www.hsdaas.utah.gov/ap_purpose.htm
Aging and Adult Services
Utah State Department of Human
Services
120 North 200 West, Suite 325
Salt Lake City, Utah 84145
Nels Holmgren
Executive Director
(801) 538-3910
www.hsdaas.utah.gov/
Bear River Health Department
655 E. 1300 N.
Logan, Utah 84341
Lloyd C. Berentzen, MBA
Department Director
(435) 792-6500
www.brhd.org
Centers for Disease Control &
Prevention
1600 Clifton Rd.
Atlanta, GA 30333
Dr. Julie L Gerberding,
Director
(404) 639-3311
http://www.cdc.gov
Robert Resendes
Executive Director
(435) 896-5451
www.centralutahhealth.com
Mark L. Shurtleff
Utah Attorney General
(800) 244-4636
www.attygen.state.ut.us/childjuscntrloc.html
Children with Special Health Care
Needs Bureau
Utah Department of Health
44 North Medical Drive
Salt Lake City, Utah 84114
L. Harper Randall
Bureau Director
(800) 829-8200
www.health.utah.gov/cshcn/
Children’s Health Insurance
Program (CHIP) Utah Department
of Health
P.O. Box 144102
Salt Lake City, Utah 84114
Gaylene Henderson
Manager
1-877-KIDS-NOW
www.health.utah.gov/chip/
Central Utah Public Health
Department
70 Westview Dr.
Richfield, Utah 84701
Children Justice Centers – Office of
the Utah Attorney General
Utah State Capitol Complex
East Office Bldg, Suite 320
Salt Lake City, Utah 84114
186
Health Services Directory
©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Government Resources
Contact
Telephone
Website
Clinicas de Buena Salud
(See Website for all Community
Health Centers)
14 North 100 East
Suite 2
Brigham City, Utah 84302
Dexter Pierce
Executive Director, CHC Inc
(435) 723-8276
www.immunize-utah.org/public/
evchild_chc.htm
Community and Family Health
Services
Utah Department of Health
288 North 1460 West
2nd Floor
Salt Lake City, Utah 84116
George Delavan, MD
(801-538-6901
health.utah.gov/cfhs/
Jim Pugh
Executive Director
(801) 978-2452
www.csc-ut.org/
Lewis Garrett, APRN, MPH
Director of Health
(801) 451-3340
www.daviscountyutah.gov/
health
Division of Water Quality – State
Dept of Environmental Quality
288 North 1460 West, 3rd floor
Salt Lake City, Utah 84114
Walter L. Baker
(801) 538-6146
*24-hour emergency spill line:
(801) 536-4123
www.waterquality.utah.gov/
Health Education Association of
Utah
P.O. Box 2337
Salt Lake City, Utah 84110
Eric Edwards
President
(801) 851-7097
www.heau.org/
Indian Health Services
Phoenix Area Indian Health
Services
Two Renaissance Square
40 North Central Avenue
Don J. Davis, MPH
Director
(602) 364-5039
http://www.ihs.gov
Medicaid Program
Utah Department of Health
P.O. Box 144102
Salt Lake City, UT, 84114
Michael Hales
Director, Division of Health
Care Financing
(800) 662-9651
www.health.utah.gov/medicaid/
Oral Health Program
Utah Department of Health
288 North 1460 West
Salt Lake City, Utah 84116
Steven J. Steed
State Dental Director
(801) 538-9177
health.utah.gov/oralhealth/
Pregnancy Risk Line
Utah Department of Health
44 North Medical Drive
Salt Lake City, Utah 84114
Julia Robertson
Project Director
800-822-BABY
(in Salt Lake
City: 801-328BABY)
www.pregnancyriskline.org/
Iona Thraen
Director
(801) 538-6113
http://www.primarycareutah.org
Community Services Council (CSC)
1025 South 700 West
Salt Lake City, Utah 84104
Davis County Health Department
Courthouse Annex
50 E. State St.
P.O. Box 618
Farmington, Utah 84025
Primary Care, Rural and Ethnic
Health
Division of Health Systems
Improvement
UDOH, P.O. Box 142005
Salt Lake City, UT, 84114
©2010 The University of Utah. All Rights Reserved.
Health Services Directory
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2010 Utah’s Health: An Annual Review
Government Resources
Contact
Telephone
Website
Sicilia Richins
Program Manager
(866) 221-0265
www.health.utah.gov/rxconnectutah/
Lorri Lake
Coordinator
(801) 269-7500
www.slcoyouth.org/html/SafePlace.html
Salt Lake City Housing Authority
1776 South West Temple
Salt Lake City, Utah 84115
Rosemary Kappes
(801) 487-2161
www.hasaltlakecity.com/
Salt Lake Valley Health Department
(SLVHD) - Salt Lake County Human
Services Department
2001 South State Street
Suite S-2500 (South Building)
Salt Lake City, Utah 84190
Gary Edwards
Executive Director
(801) 468-2700
www.slvhealth.org/
Services for People with Disabilities
120 North 200 West, Suite 411
Salt Lake City, Utah 84103
George Kelner
Acting Director
(800) 837-6811
www.dspd.utah.gov/index.htm
David Cunningham, RN,
MSN
(435) 637-3671
http://www.southeastuthealth.
org/
Kristy Cottrell
(801) 483-5451
www.slvhealth.org/fh/html/
locfhs.html
Southwest Utah Health Department
620 South 400 East #400
St. George, Utah 84770
Gary L. Edwards, MS, CHES
Health Officer
(435) 673-3528
http://www.swuhealth.org/
Summit County Health Department
85 N. 50 E.
P.O. Box 128
Coalville, Utah 84017
Steve Jenkins EHS, MPH
Director
(435) 336-3222
www.co.summit.ut.us/services/
office/health.html
Tooele County Health Department
151 N. Main St
Tooele, Utah 84074
Myron Bateman, EHS, MPH
Director
(435) 843-2300
www.tooelehealth.org
Tri-County Health Department
147 E. Main St
Vernal, Utah 84078
Joseph B. Shaffer MA, MBA,
EHS
Director of Health
(866) 275-0246
www.tricountyhealth.com/main.
html
Rita Hieber
Assistant
(801) 377-1264
(801) 374-3076
RxConnect Utah
Utah Department of Health
288 North 1460 West
Salt Lake City, Utah 84114
Safe Place (shelter for youth)
Salt Lake County Division of Youth
Services
177 West Price Avenue (3610 Sth)
Salt Lake City, Utah 84115
Southeastern Utah Health
Department
28 S. 100 E.
Price, Utah 84501
South Main Public Health Center
(healthcare for low-income individuals)
3195 South Main Street
Salt Lake City, Utah 84115
Utah Association of Local Health
Officers and Local Boards of
Health
Kathy M. Froerer MHEd, Executive
Director, 726 North 1890 West
Provo, Utah 84601
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Government Resources
Contact
Utah Bureau of Childcare Licensing
288 North 1460 West
Salt Lake City, Utah 84116
Teresa Whiting
Bureau Director
Telephone
Website
Utah Cancer Control Program
Utah Department of Health
288 North 1460 West
Salt Lake City, Utah 84114
Katheryn Rowley
Program Director
(800) 717-1811
www.utahcancer.org/index.htm
Utah Commission for Women and
Families
140 East 300 South
Salt Lake City, Utah 84114
Carol Walker
Executive Director
(801) 468-0174
www.governor.state.ut.us/
women/
Joseph K. Miner, MD, MSPH
Executive Director
(801) 851-7000
www.co.utah.ut.us/Dept/Health/
index.asp
(801) 536-4200
http://www.deq.state.ut.us/
eqdw
(801) 521-5544
www.udvc.org
Utah County Health Department
151 S. University Ave.
Provo, Utah 84061
Utah Department of Health
288 North 1460 West
P.O. Box 141010
Salt Lake City, Utah 84114-1010
Utah Division of Drinking Water
Utah State Office Park ─ Building
One
150 North 1950 West
Salt Lake City, Utah 84116
Utah Division Substance Abuse
and Mental Health (DSAMH)
120 North 200 West, Room 209
Salt Lake City, Utah 84103
David Sundwall
Executive Director
Kevin Brown
Division Director
Mark Payne
Director
Utah Domestic Violence Council
205 North 400 West
Salt Lake City, Utah 84403
Utah Health Data Committee
UDOH Office of Health Care
Statistics
288 North 1460 West,
PO Box 144004
Salt Lake City, Utah 84114-4004
Wu Xu
Director
(801) 538-6152
http://www.health.utah.gov/
licensing
Utah Health Facility Licensing,
Certification and Resident
Assessment
288 North 1460 West
Salt Lake City, Utah 84116
Allan D. Elkins
Bureau Director
(801) 538-6158
http://www.health.utah.gov/
hflcra
Utah Heart Disease Stroke
Prevention Program
UDOH, P.O. Box 142107
Salt Lake City, Utah 84114-2107
Barbara Larsen, MPH, RD
Program Director
(801) 538-6142
http://www.hearthighway.org
Joseph M. Krella
President
(801) 486-9915
http://www.uha-utah.org
Utah Hospitals & Health Systems
Association
2180 South 1300 East
Suite 440
Salt Lake City,Utah 84106
©2010 The University of Utah. All Rights Reserved.
Health Services Directory
189
2010 Utah’s Health: An Annual Review
Government Resources
Utah Immunization Program
288 North 1460 West,
Salt Lake City, Utah 84116
Utah Medical Association
540 East 500 South
Salt Lake City, Utah 84102
Utah Medical Education Council
230 S. 500 E., Suite 550
Salt Lake City, Utah 84102
Contact
Telephone
Website
Linda Abel, BSN, MPA
Program Manager
(801) 538-9450
http://www.immunize-utah.org
Dr. Catherine J. Wheeler
President
(801) 355-7477
http://www.utahmed.org
Gar Elison
Executive Director
(801) 526-4554
http://www.utahmec.org
Utah Nurses Association
4505 South Wasatch Blvd. #290
Salt Lake City, Utah 84124
Donna Eliason, MS, RN
President
Utah Psychological Association
2757 E. South Temple #112
Salt Lake City, Utah 84111
Teresa Bruce
Executive Director
Utah Public Health Association
P.O. Box 16048
Salt Lake City, Utah 84116
Teresa Garrett
President
Utah State Division of Community
and Family Health Services
PO Box 142001
Salt Lake City, Utah 84114-2001
George Delavan, MD
Director
Utah State Division of
Epidemiology and Laboratory
Services
UDOH, PO 142104
Salt Lake City, Utah 84114-2104
Theresa Garrett
Division Director
(801) 538-6128
www.health.utah.gov/els
Utah State Division of Mental
Health and Substance Abuse
120 North 200 West, Room 209
Salt Lake City, Utah 84103
Dr. Michael Crookston
Chair
(801) 538-3939
www.hsmh.state.ut.us
D. Kent Michie
Commissioner
(801) 538-3800
www.insurance.utah.gov
Utah Tobacco Prevention and
Control Program
UDOH, PO Box 142106
Salt Lake City, Utah 84114-2106
Heather Borski
Program Manager
(801) 538-9998
Toll Free
Resource Line:
(877) 220-3466
www.tobaccofreeutah.org
Violence and Injury Prevention
Utah Department of Health
PO Box 142106
Salt Lake City, Utah 84114
Trisha Keller
Program Manager
(801) 538-6864
www.health.utah.gov/vipp/
Phil D. Wright, MS, EHS
Health Officer
(435) 654-2700
www.health.utah.gov/ihd/html/
wasatch city-country healthdep.
html
Gary House
Executive Director
(801) 399-7100
www.co.weber.ut.us/healthdept/index.asp
Utah State Insurance Department
3110 State Office Building
PO Box 146901
Salt Lake City, Utah 84114-6901
Wasatch City/County Health
Department
55 S. 500 E.
Heber City, Utah 84032
Weber-Morgan Health Department
477 23rd Street
Ogden, Utah 84401
190
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©2010 The University of Utah. All Rights Reserved.
2010 Utah’s Health: An Annual Review
Government Resources
Contact
Telephone
Website
Nan Streeter
Acting Director
877-WIC-KIDS
health.utah.gov/wic/
Youth Crisis Center, Iron County
(Shelter for abused children)
1692 West Harding Ave
Cedar City, Utah 84720
Paul Arnold
(435) 586-1704
www.jjs.utah.gov/shelter-care.
htm
Youth Crisis Center, Washington
County
(Shelter for abused children)
251 East 200 North
St. George, Utah 84770
Tammy Fullerton
(435) 656-6100
www.jjs.utah.gov/shelter-care.
htm
Contact
Telephone
Website
Women, Infants and Children
Program
Utah Department of Health
288 North 1460 West
Salt Lake City, Utah 84116
RESEARCH/EDUCATION FACILITIES
IHC Clinical Research Foundation
959 E. 400 S.
Salt Lake City, Utah 84102
(801) 272-7498
MidContinental Regional Medical
Library
National Network of Medical
Libraries
10 North 1900 East
Salt Lake City, Utah 84112
Claire Hamasu
Associate Director
(800) 338-7657
nnlm.gov/mcr/
National Center of Excellence in
Women’s Health
University of Utah
30 N 1900 East
School of Medicine,
Rm 2B-111
Salt Lake City, Utah 84132
Kathleen Digre, MD
(801) 585-9971
www.uuhsc.utah.edu/coe/womenshealth/
Spencer S. Eccles Health Sciences
Library
University of Utah
10 North 1900 East
Salt Lake City, Utah 84112
Wayne J. Peay
(866) 581-5534
library.med.utah.edu/
Utah State Library Division
250 North 1950 West, Suite A
Salt Lake City, Utah 84116
Donna Jones Morris
(801) 715-6777
www.library.utah.gov/
Utah State Library for the Blind and
Disabled
250 North 1950 West, Suite A
Salt Lake City, Utah 84116
Bessie Oakes
Program Manager
(800) 662-5540
www.blindlibrary.utah.gov/
©2010 The University of Utah. All Rights Reserved.
Health Services Directory
191
Utah’s Health: Manuscript Submission Guidelines
Utah’s Health invites original analyses on any aspect of health,
health care access and delivery, or health politics and policy
as it pertains to the state of Utah. Articles may be submitted
electronically to contact@uhreview.com. Attach the article and
any other pertinent documentation. Label all files with the primary
author’s last name and brief description of the document (e.g.
Franklin_Short Title of Article; Franklin_Table 1; Franklin_Figure 1).
Articles may also be mailed/hand delivered to:
Dr. Richard Sperry
Faculty Advisor
Utah’s Health: An Annual Review
University of Utah Health Sciences Center
175 North Medical Drive East
Salt Lake City, UT 84132-5901
If submitting an article in hardcopy, you must include four hard
copies along with a PC-formatted disk. The version on the disk must
match exactly the version on the hard copies. Label the disk with the
primary author’s last name and name of the file.
Articles and Brief Reports
Manuscripts may be submitted as Articles (approximately 5,000
words or less) or as Brief Reports (approximately 1,500 words or
less). Articles are definitive, comprehensive accounts of significant
studies, whereas Brief Reports are more limited in scope than
articles and may include preliminary findings. With your article
submission please include the names and contact information
(including phone and fax numbers, current mailing address, as well
as a current email) of two colleagues who you feel are qualified
to review your work. The editors will take this information into
account when selecting peer-reviewers.
General Formatting
Manuscripts should be prepared in Microsoft Word. Article text
should be in Arial font at 10 characters per inch (CPI). Text for
footnotes, graphs, and tables should be in Arial font, 8 cpi. Text
should be left justified, with no other page formatting included in
the text. The manuscript should be in the following order: title,
author or authors’ name(s), correspondence, key words, abstract,
text, references, tables and figures, and a short biography about the
author(s). Tables and figures should be sent separately in Microsoft
Excel (may also be included in text). Authors should write in clear,
concise English using grammar and standard nomenclature that
is unambiguous and consistent, conforming to current American
usage. Responsibility for all aspects of manuscript preparation rests
with the authors. The editors will not undertake extensive changes
or rewriting of the manuscript. However, the editorial board may
make formatting or small content changes to an article before final
publication.
Title and Authorship
The title should be concise and representative of the manuscript’s
purposes and findings in order to provide maximum information in
computerized title searches. Nonfunctional words should be deleted
from the title. The authors’ full first name(s), middle initial(s),
last name(s) should be followed by titles, and degree(s) earned.
Provide the phone number, address, and email of the primary and/or
corresponding author(s).
Key Words
A list of 3-5 descriptive key words (or phrases) should be included
directly below the abstract. These will be used for indexing
purposes and will allow for better searches of the online version
of the journal. Key words should express the precise content of the
manuscript.
Abstract
An abstract must accompany each article and should be between 100
and 150 words in length. It should summarize the most important
findings and conclusions of the article.
Text
The rationale and objectives of the article should be stated in the
introductory sentences of the manuscript. Background material
should be brief and relevant to the topic described. Authors should
state their conclusions or the significance of their article following
the discussion of findings. Conclusions should be summarized in
order to place the author’s observations in perspective.
Citations and References
Citations and references should be formatted in APA style.
References should be provided at the end of the manuscript in one
consecutive series in alphabetical order (not numbered). Accuracy of
the references is the responsibility of the author. For clarification on
other formatting issues, please refer to an APA Style Manual.
Tables and Figures
Tables and figures (i.e. original drawings or graphs) are encouraged
when they lead to a more effective presentation of findings. They
should be numbered consecutively as Table 1. Title and Figure 1.
Title, respectively. Headings and descriptions should be included
so that tables and figures are self-explanatory. Please submit all
tables and graphs as an Excel file along with the data spreadsheet.
While articles will be published in color online, they will be printed
in black and white in the hard copy edition. Please ensure that any
color charts or graphs are understandable in grayscale. Also, please
avoid the use of hatch marks and patterned fills in graphs.
For further instructions, please visit our website at www.matheson.
utah.edu. For comments and questions, please email us at contact@
uhreview.com.
www.matheson.utah.edu/UHReview
Utah’s Health: An Annual Review | The University of Utah
Governor Scott M. Matheson Center for Healthcare Studies
175 North Medical Drive East
Salt Lake City, UT 84108
© 2010 The University of Utah. All Rights Reserved