Wake County
Human Services
Public Health
Quarterly Report
July-September 2014
Wake County
Human Services
Public Health Division
10 Sunnybrook Road
P.O. Box 14049
Raleigh, NC 27620-4049
www.wakegov.com
Regina Petteway, Interim, Human Services Director
Sue Lynn Ledford, Public Health Division Director
Editor-in chief: Edie Alfano–Sobsey, Public Health Epidemiologist
Content : Roxanne Deter, Nurse Informatics
Design and Layout: Yolanda McMillan, Public Health Educator
Editor: Carla Piedrahita, Public Health Educator
Public Health Quarterly
Table of contents ............................................................................................................. 2
Introduction..................................................................................................................... 3
Cancer of the Respiratory System and Digestive Track ..................................................... 4
Smoking………………………………………………………………………………………………………………………...5
Prostate Cancer ............................................................................................................... 7
Breast Cancer .................................................................................................................. 8
Heart Disease .................................................................................................................. 9
Diabetes ........................................................................................................................ 11
Asthma .......................................................................................................................... 13
Obesity .......................................................................................................................... 14
Club Choice .................................................................................................................... 15
Obesity in Youth…………………………………………………………………………………………………………...16
Physical Activity ............................................................................................................. 17
Community Physical Activity Programs .......................................................................... 20
References……………………………………………………………………………………………………………………22
2
Introduction
Persons with chronic diseases tend to have premature deaths. Nationally, according to the Center
For Disease Control and Prevention, 75% of our health care dollars go to treatment of chronic diseases. These persistent conditions are the leading causes of death and disability in the US. Many of
the deaths, lifelong disability, compromised quality of life, and burgeoning health care costs related
to these conditions could be prevented (1).
Leading Causes of Death
The leading cause of death in Wake County, Mecklenburg County, and North Carolina is cancer, in
contrast with heart disease, that is the leading cause of death in the US. In Wake County, cancer
caused 5,435 deaths at a rate of (156.4/100,000 population) from 2008-2012 (FIGURE 1) (2).
FIGURE 1
Causes of Death in Wake County
(Age-Adjusted Death Rate per 100,000 from 2008-2012)
180
160
156.4
134
140
120
Rate per
100,000
100
80
60
43.3
32.3
40
17
20
13.5
5.3
0
Cancer
Diseases of Cerebrovascular Chronic Lower
Heart
Disease
Respiratory
Diseases
Diabetes
Mellitus
Nephritis,
Chronic Liver
Nephrotic
Disease and
Syndrome, and
Cirrhosis
Nephrosis
Source: North Carolina Center for State Statistics
Compared to North Carolina overall, Wake County has lower mortality rates for each of the causes
of death in Figure 1 (3).
3
African American, non-Hispanic males had the highest age-adjusted overall death rate per
100,000 from all reported cancers (colon, rectum, anus, pancreas, trachea, bronchus, lung,
breast, prostate) (FIGURE 2):
 One and a half times more than white, non-Hispanics males
 Three times more than other non-Hispanic males
 Over two times more than Hispanic males
 Almost two times more than African American, non-Hispanic females
FIGURE 2
Cancer Death Rates in Wake County
Age-adjusted rate per 100,000
From 2008-2012: Racial Disparities
Source: North Carolina Center for State Statistics, 2014 County Health Data Book, 2008-2012
Cancers of the Respiratory System and Digestive Tract
From 2008-2012 in Wake County, cancer of the respiratory system accounted for the highest
death rate of all cancers (3) accounting for:

1,376 deaths

An overall death rate of 40.4 per 100,000 people
Disparity:

African American, non-Hispanic males also have the highest death rate for all of the cancers
in FIGURE 3 compared to African American, non-Hispanic females and white non-Hispanic
males and females.
4
FIGURE 3
Dates Rates for Colon, Rectum, Anus, Pancreas, Trachea, Bronchus and Lung Cancer among
Wake County African –American, Non-Hispanic and White, Non-Hispanic Residents from
2008-2012
Source: NC State Center for Health Statistics, 2014 County Health Data Book, Mortality, 2008-2012
County Health Ranking for Adult Smoking
One of the risk factors for developing chronic disease, including cancer, cardiovascular and respiratory conditions, is smoking. The County Health Rankings and Roadmaps estimates the percent
of the adults that currently smokes every day or “most days” and has smoked at least 100 cigarettes in their lifetime. In Wake County, the percent of adults smoking on most days decreased
from 16% during 2002-2008 to 13% during 2006-2012 (FIGURE 4).
FIGURE 4
Prevelance of Adult Smoking
County Health Rankings
25%
20%
23%
20%
15%
16%
10%
20%
-Overall in North
Carolina:
14%
13%
Adult SmokingWake
Top U.S.
Performers:
5%
0%
2002-2008 2003-2009 2004-2010 2005-2011 2006-2012
Source: County Health Rankings
5
Smoking and Wake County Public School System: Middle and High School Students
Just over 4% (4.4) of WCPSS middle school students and 11.8% of high school students reported
smoking at least one cigarette on at least one day during the past month. White high school
students were significantly more likely to have smoked cigarettes during the past 30 days than
Black students (4).
Wake County Human Services Project ASSIST/Tobacco Prevention and Control
Project ASSIST/Tobacco Prevention and Control Program was successful in helping to change policy
in the following organizations.

Three organizations adopted smoke free policies: impacting over one hundred and
sixty-five people.

Town of Apex increased health insurance premiums on smokers (effective 7/1/14)
Project ASSIST provides Tobacco Prevention Outreach Programs and makes referrals to the NC
Quitline which is a phone based counseling service that helps clients quit smoking.
Partnering and collaborating with community partners enables tobacco prevention efforts to reach
many citizens in Wake County. For the 2013 Great American Smoke-Out (GASO), Project ASSIST
coalition targeted multi-housing properties, municipalities, local organization/businesses and
health clinics. This annual event encourages tobacco users to quit for the day and in the future.
Seventeen organizations and healthcare clinics in Wake County agreed to participate in GASO
2013. They were provided tool kits that included: a sample tobacco free policy, cessation materials, posters and an educational display to use to market GASO to their employees and patrons.
ASSIST partnered with the County Parks and provided yard signs that were displayed in all eight
parks. There were approximately 19,635 Wake County residents that were reached by the 2013
GASO.
6
Prostate Cancer
The overall Mortality Rate from prostate cancer in Wake County was 26.2 per 100,000 from 2008
-2012 (3). The mortality rate for all minority males and Black non-Hispanic males has been more
than twice that of white males for over a decade ( FIGURE 5).
FIGURE 5
Source: NC State Center for Health Statistics, 2014 County Health Data Book, Mortality, 2008-2012
* These data include Blacks and other Non-White minority males compared to White males.
** These data include Black non-Hispanic males only compared to White males.
Source: http://www.schs.state.nc.us/schs/data/databook/, accessed 12/5/14.
7
Breast Cancer
From 2008-2012, 486 Wake County women died of breast cancer, with a death rate of 22.7 per
100,000 population (3). The death rate for African American, non-Hispanic females (32.3/100,000) is
one and a half times higher than for white, non-Hispanic females (21.2/100,000) (FIGURE 6).
FIGURE 6
Breast Cancer Death Rates for African American and White Non-Hispanic Females
from 2008-2012
Source: NC State Center for Health Statistics, 2014 County Health Data Book, Mortality, 2008-2012
Mammogram and Cervical Cancer Screening through Wake County Human Services (WCHS)
Early detection and treatment of breast cancer through mammography screening can reduce deaths.
WCHS facilitates screenings through the North Carolina Breast and Cervical Cancer Screenings
Programs (BCCCP) and the Susan G. Komen grant program. The NC Breast and Cervical Cancer Control
Program (NC BCCCP) provides free or low-cost breast and cervical cancer screenings and follow-up
to eligible women in North Carolina. NC BCCCP provides services to women who are uninsured or underinsured; are between ages 40 - 64 for breast screening services and 21-64 for cervical screening services; and have a household income at or below 250% of the federal poverty level.
During fiscal year 2013-2014, WCHS Health Promotion Chronic Disease Prevention (HPCDP) provided a
total of 449 mammography services (including mammograms, diagnostics and surgical evaluations). From
these screenings, 17 breast cancers were detected for a total potential medical cost savings of $255,000
to $442,000. This is based on 17 times the estimated cost range of $15,000 - $26,000 per year of life expectancy saved for women age 40-69 (5). Through the BCCCP Program HPCDP staff performed 58 cervical
screenings and one case of cervical cancer was detected in FY 2013-2014.
8
Heart Disease
From 2008-2012 in Wake County, heart disease was the second leading cause of death and
cerebro-vascular disease was the third leading cause of death.
 4,356 deaths occurred from heart disease (3).
 The age-adjusted death rate (134/100,000) for heart disease in Wake County from 2008-2012 is
lower than that of North Carolina (174.4/100,000) (3).
 The age-adjusted death rate declined 41% in Wake County from 233.4/100,000 during 19972001 to 137.5/100,000 during 2007-2011. Compared to earlier years, there has been only a
slight decrease from 2007-2011 to 2008-2012. (FIGURE 7).
FIGURE 7
Death Rates from Heart Disease in Wake County from 1997-2012
Source: North Carolina Center For State Statistics
Disparity :
African American, non-Hispanic males had a higher age-adjusted death rate from heart attacks (47.4
per 100,000) compared to white, non-Hispanic males (28.9/100,000) (FIGURE 8).
Age-adjusted rate per 100,000
FIGURE 8
Death Rate from Heart Attacks for African Americans
and Whites from 2008-2012
Source: North Carolina Center For State Statistics, 2014 County Health Data Book, Mortality, 2008-2012
9
Heart Disease and Wake County Human Services (WCHS) Health Promotion Chronic
Disease Prevention Program (HPCDP)
Cardiovascular Screenings
WCHS HPCDP staff provide cardiovascular health screenings in the community with particular focus
on low-income, low-resource populations. During FY 2013-2014 this program screened 672 people
and found 286 (43%) with pre-hypertension and 228 (34%) with hypertension (stage 1 and stage 2).
Fifty-nine of those with hypertension, were found with blood pressures at the hypertension stage 2
(HTN2) level. The HPCDP nurse follows up with these clients to make sure they secure care from a
medical provider. At follow up, 63% (37) of the patients with HTN2 had secured care, potentially preventing strokes. This is a potential medical cost savings of $3,832,312 based on 37 x $103,576 per
average lifetime cost of a stroke event 6).
Wisewoman
WCHS HPCDP staff have been facilitating the WiseWoman Program for the past five years.
The purpose of the WiseWoman Program is to provide expanded cardiovascular disease screenings,
intervention, counseling and referral services to BCCCP eligible women aged 40-64 years who are at
or below 250% of the federal poverty level and are uninsured or underinsured. Women who have
abnormal cardiovascular screening results are provided with nutrition, physical activity, other healthy
lifestyle interventions as well as referrals for medical evaluation.
During FY 2013-2014, 77 women were seen through the WISEWOMAN program. Sixty five (84%) of
the WISEWOMAN participants were overweight, obese, or morbidly obese, 9 (12%) WISEWOMAN
participants had hypertension and 13 (17%) WISEWOMAN participants had high cholesterol.
Red Dress
During February 2014, Heart Health Month, WCHS HPCDP staff sponsored a Red Dress campaign
that included several activities. A healthy cooking demonstration program called Simple Cooking
with Heart was sponsored by HPCDP in partnership with the American Heart Association and a local
faith based organization (Church of God of Prophecy) and included 40 participants, 6 staff assistants
and 4 church volunteers. Another program called Pretty Party in Red, sponsored by Duke Health
Center in partnership with WCHS included a health fair with screenings, heart healthy cooking
demonstrations, massages, exercise demonstrations, including line dancing and a heart healthy
dinner. Twenty three people visited the educational booth and over 40 people participated in the
line dance fitness session.
10
Cerebrovascular Disease (Stroke)
Stroke was the third leading cause of death from 2008-2012 . People surviving a stroke are likely to have
impairments or permanent disability, which is costly.
From 2008-2012 in Wake County:
 1,340 people died (3)
 The death rate per 100,000 population was 43.4 (3).
 African American, non-Hispanics were more likely to die of a stroke than white, non-Hispanics.
 African American, non-Hispanic males were one and a half times more likely to die of stroke than
white, non-Hispanics males. (FIGURE 9).
FIGURE 9
Cerebrovascular (Stroke) Age-Adjusted Death Rate Wake County 2008-2012
Source: North Carolina Center For State Statistics, 2014 County Health data Book Mortality, 2008-2012
Diabetes
In Wake County from 2008-2012, there were 570 deaths due to diabetes with a death rate of 17
per 100,000 population (3). The death rate for African American, non-Hispanic males (50.4/100,000)
was almost three times that of White, non-Hispanic males (17.7/100,000). African American, nonHispanic females death rate (35.9/100,000) was almost four times that of white, non-Hispanic females (9.4/100,000) (FIGURE 10) .
11
FIGURE 10
Age-adjusted Death Rate for Diabetes in Wake County 2008-2012
Rate per
100,000
Source: North Carolina Center For State Statistics, 2014 County Health Data Book, Mortality, 2008-2012
Diabetic Screening
Managing diabetes through screening and early detection of complications may prevent progression of
the disease and other health conditions related to diabetes such as hypoglycemia and hyperglycemic
crisis, high blood pressure, high blood cholesterol, heart disease, stroke, blindness, eye problems, kidney
disease, and amputations (7).
In 2014, 90% of Medicare enrollees aged 65-75 in Wake County had HbA1c screening compared to 88% in
North Carolina (County Health Rankings and Roadmap, 2014). Beginning in 2012, Wake County became
one of the top performing counties in the US for this indicator (FIGURE 11).
FIGURE 11
12
Asthma
Asthma continues to be a challenge in Wake County and is a major cause of chronic disease in school-age children . Hospital discharge data show a 12.6% increase in children ages 0-14 hospitalized due to asthma (TABLE
1). A higher percentage of black high school students (31.9%) have been diagnosed with asthma compared to
White and Hispanic/Latino students (20%) in the Wake County Public School System (FIGURE 12) .
TABLE 1
ASTHMA HOSPITAL DISCHARGES (AGES 0-14)
RATE PER 100,000 WAKE COUNTY
Asthma hospital
discharges per 100,000
children ages 0-14
(2007, 2012)
Wake
County,
Base
2007
Wake
County,
2012
Percent
Change
Trend
North
Carolina,
2007
Base
North
Carolina,
2012
140.8
158.5
12.6%
Worse
166.2
163.7
Source: Wake, 2013 Health County Data Card, http://www.ncchild.org/wp-content/uploads/2014/05/
Wake.pdf, Data Source: NC Department of Health and Human Services, State Center for Health
Statistics. "Asthma Hospital Discharges (Total and Ages 0-14) per 100,000 Population."
FIGURE 12
Percent of High School Students Who Have Been Told by
a Doctor or Nurse that They Have Asthma
Source: North Carolina Youth Risk Behavior Survey, Wake County Public Schools, Data Trends
13
Obesity
County Health Ranking Trend Data for Adult Obesity
The County Health Rankings measures adult obesity as an indicator. Adult obesity is defined as
the percent of the adult population that has a body mass index greater than or equal to 30.
North Carolina has maintained a 29% obesity level from 2008 through 2010. However, in Wake
County, the percent of adults with obesity has declined slightly from 27% in 2008 to 25% in 2010.
(FIGURE 13).
FIGURE 13
14
Club CHOICE Plus Is a Program Offered by Wake County Human Services
As an eight-week series of nutrition education and exercise classes for English and Spanish speaking
women and their children, the goal of Club CHOICE plus is to facilitate wellness, self-sufficiency and
personal empowerment for Choosing Healthy Options In a Challenging Economy. Through the
collaborative effort among WCHS, the University of North Carolina and Wake County 4-H Cooperative Extension, the nutrition education curriculum and Zumba classes promote weight loss and
healthy lifestyles for families.
During the spring 2014 session, 76 women and children participated in the program. The women lost
an average of 2.6 pounds during the eight week program.
Pre and post behavioral questionnaires indicated these women made the following statistically
significant (p <0.5) changes:
 Decreased intake of sweetened beverages
 Changed to low-fat or skim milk
 Increased intake of healthier snacks
 Decreased intake of home baked cookies, cakes or pies
 Increased use of artificial sweeteners (versus sugar)
They demonstrated positive transformations in their eating and exercise behaviors, weight loss and
excitement, expressing their desire for additional classes beyond the current eight.
15
Obesity in Youth
Obesity, overweight, healthy weight and underweight are classifications based on Body Mass Index
(BMI). BMI is calculated from the child’s height and weight and is an indicator of body fatness.
Obesity in Children Ages 2-4
The majority of the children ages 2 through 4 included in the 2012 NC-NPASS data are from the
Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the
WIC Program. The prevalence of obesity in children ages two to four decreased in Wake County
from 17.4% in 2009 to 14.5% in 2012 as compared to North Carolina overall, where rates have been
slowly, but steadily increasing (FIGURE 14).
FIGURE 14
North Carolina Youth Risk Behavior Survey
The North Carolina Youth Risk Behavior Survey was administered to a sample of Wake County Public
School System (WCPSS) high school and middle school students in the spring of 2013 to measure a
variety of behaviors including nutrition and physical health.
Overall in 2013:



46% of WCPSS high school students and 41% of middle school students reported trying to lose
weight
41% of WCPSS high school students and 45% of middle school students reported eating less
food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight during the
last 30 days
6% of WCPSS of high school students and 5% of middle school students reported vomiting or
taking laxatives to lose weight or to keep form gaining weight
16
Gender Disparities:
Female high school and middle school students compared to males were more likely to:
 Try to lose weight
 Eat less food, fewer calories or foods low in fat to lost weight or to keep form gaining weight
 Have vomited or taken laxatives to lose weight or to keep from gaining weight
Ethnic/Racial disparities:
 White or Hispanic/ Latino compared to African American high school students were more likely
to eat less food, fewer calories or foods low in fat to lost weight or to keep form gaining weight.
 Hispanic/ Latino or African American middle school students compared to whites were more
likely to have gone without eating for 24 hours or more to lose weight or to keep from gaining
weight
Physical Activity
County Health Rankings for Physical Inactivity
Lack of exercise and poor diet are factors that contribute to obesity. Nineteen percent of adults over
age 20 in Wake County reported spending no leisure time on physical activity in 2008 and again in
2010 (FIGURE 15).
FIGURE 15
Physical Inactivity
Adults aged 20 and over reporting no leisure time physical activity 2008- 2010
30%
Wake
County
25%
20%
15%
10%
5%
0%
2008
2009
2010
Source: County Health Rankings and Roadmap. (2014). Retrieved August 2014, from County Health http://
www.countyhealthrankings.org/app/north-carolina/2014/rankings/wake/county/outcomes/overall/
snapshot
Time spent commuting to work in the Triangle may decrease the amount of time that could otherwise be spent for leisure activity . A 2012 study in the American Journal of Preventive Medicine
found that the farther people commute by vehicle, the higher their blood pressure and body mass
index (8). The percentage of individuals in Wake County who drive for longer than thirty minutes
each day is twice (31%) the percentile of those in other US counties (15%) (9).
17
Physical Activity and WCPSS Middle School Students
According to the Youth Risk Behavioral Survey, over one third of WCPSS middle school students
(37.5%) were physically active for a total of 60 minutes per day on fewer than 5 of the past 7 days,
which is slightly less than what is seen in North Carolina overall (43%) (FIGURE 16).
Disparities within WCPSS (FIGURE 16). :
 Female students (41.4% ) were significantly less likely to have been physically active for a total of
at least 60 minutes per day on fewer than 5 of the past 7 days compared to male students
(33.3%).
 Black (45.0% ) and Hispanic/Latino (42.2%) students were significantly less likely to have been
physically active for a total of at least 60 minutes per day on fewer than five of the past seven
days compared to White students(29.6%) .
FIGURE 16
Percent of Middle School Students Who Were Physically Active for a Total of at Least
60 Minutes per Day on Fewer than 5 of the Past 7 Days - 2013
Source: North Carolina Youth Risk Behavior Survey, Wake County Public Schools, Data Trends,
Data and Accountability Department: 2014
18
Physical Activity and WCPSS High School Students
According to the Youth Risk Behavioral Survey, over half (59%) of WCPSS high school students
reported being physically active for at least 60 minutes a day on fewer than five of the last seven
days, which is slightly more than for North Carolina as a whole (53.5%) (FIGURE 17).
Within WCPSS: (FIGURE 17)


Female students (68%) were significantly less likely to be physically active on fewer than 5 of the
past 7 days a week than male (50%), students.
Students in 10th, 11th, and 12th grade (60.3%, 67%, 62.7% , respectively ) were significantly less
likely to be physically active on fewer than 5 of the past 7 days a week than students in 9th grade
(48.2%).
.
FIGURE 17
Percent of High School Students Who Were Physically Active for a Total of at Least
60 Minutes per Day on Fewer than 5 of the Past 7 days—2013
Source: North Carolina Youth Risk Behavior Survey, Wake County Public Schools, Data Trends, Data and
Accountability Department: 2014
19
Physical Activity
WCHS HPCDP works to increase access to physical activity in the community by partnering with
other organizations to host physical activity programs.
Community Physical Activity Programs
Movin' & Groovin'
During the Spring of 2011, Health Promotion and 4H Youth Development Staff specifically planned
the Movin’ & Groovin’ series to encourage families living in the North Central and Eastern regions
of Wake County to increase their physical activity in a free, fun and safe way. Designed to help
fight the overweight/obesity epidemic, mini physical activity sessions as well as organized walking
are facilitated weekly by Health Promotion Staff. 4-H Youth Development engages children by
implementing an evidenced based physical activity module, Operation Fit Kids. The program was
the recipient of a NCPHA Award in 2013. In the fall and spring of FY 13/14 there were 4 walking
programs, 2 in Zebulon and 2 in Raleigh (Spring Forest Road) with a total of 161 participants.
Results of a survey completed by 46 participants of Movin’ and Groovin’ demonstrated that:
 89% increased other physical activity habits
 96% improved nutrition habits
 48% improved their weight
 54% maintained their weight
 39% improved their blood pressure
 13% improved their blood cholesterol levels
 7% improved their blood sugar levels
This program partners with the
Grocers on Wheels to bring fresh fruits
and vegetables to Movin’ and Groovin’
Participants. Over $350 worth of
“Healthy Bucks” were distributed to
participants (adults and children)
to purchase produce at a mobile
market. More than 30 individuals
participated and 320 pounds of
food were purchased with the
“Healthy Bucks”. Participants earned
"Healthy Bucks" throughout the Movin’
and Groovin’ series by attending weekly
sessions and submitting weekly activity
and healthy behavior logs.
20
Couch to 5K program "Couch to 5k" is a free 9 week fitness and wellness program designed for
inexperienced runners interested in working towards running a 5k or a 30 minute run. Participants
receive a step by step plan preparing them to walk, jog and then run. Weekly running meetings allow
for continued motivation, support and inspiration. An added bonus to this program is family involvement. Wake County 4-H and Raleigh Parks Recreation and Cultural Resources engage
children, ages 7+, in physical activities preparing them to complete a 5K with their parent(s). At the
end of the 9 weeks, families and participants can sign up for a local 5K to show off newly developed
running ability. In Spring 2014 there were 27 participants.
The Poe Center PlayWELL Park program
included activities encouraging children
and their parents to be more physically
active and eat a healthy diet. From October
2012 - September 2013, 177 adults and 331
children participated in this program.
The Dancing in the Park program is hosted by
Southeast Raleigh Assembly and WCHS HPCDP
is a corporate sponsor. HPCDP staff provide
nutrition and health information materials and
displays for all 9 summer sessions during
which over 1000 people participated .
The Exercise as Medicine Prescription Pad Project
is a project that encourages pediatricians to ask
about physical activity during visits. To date, 7
physicians practices in Eastern Wake County have
distributed 90 prescriptions and maps of facilities
that promote or support physical activities,
including parks and greenways.
21
References
1. Center for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion,
http://www.cdc.gov/chronicdisease/index.htm, Retrieved November 17, 2014.
2. North Carolina Center For State Statistics. 2012 Cancer Mortality Rates Statistics, http://
www.schs.state.nc.us/schs/CCR/mortality.html, retrieved November 4, 2014
3. North Carolina Center For State Statistics. 2014 County Health Data Book North Carolina Community Health Assessment Process, 2008-2012 Race-Sex-Specific Age Adjusted Death Rates by County http://www.schs.state.nc.us/schs/data/databook/, retrieved November 4, 2014
4. Townsend, M. (September, 2014) North Carolina Youth Risk Behavior Survey: 2013 WCPSS
Middle School and High School Results; Data Trends, D&A Report No. 14.06 ad 14.07, http://
www.wcpss.net/results/reports/2014/hs_nc_yrbs.pdf and http://www.wcpss.net/results/
reports/2014/ms_nc_yrbs.pdf, Retrieved November 17, 2014
5. Screening Mammography Beginning at Age 40 Years: A Reappraisal of Cost Effectiveness",
Rosenquist, et.al., 1998.
6. Source: The Burden of CVD in NC-July 2010 update. http://digital.ncdcr.gov/cdm/ref/collection/
p249901coll22/id/132976, retrieved 11/6/14
7. National Diabetes Statistics Report, 2014. (2014, June 2). Center for Disease Control and Prevention: http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf, retrieved 11/6/14
8. Christine M. Hoehner, P. M., Carolyn E. Barlow, M. A., & Mario Schootman, P. (2012, June). American Journal of Preventive Medicine. from Commuting Distance, Cardiorespiratory Fitness, and
Metabolic Risk: http://www.ajpmonline.org/article/S0749-3797(12)00167-5/fulltext, Retrieved
November, 17,2014
9. County Health Rankings and Roadmap. (2014). Long Commute - Driving Alone. From County
Health Rankings: http://www.countyhealthrankings.org/app/northcarolina/2014/rankings/wake/
county/outcomes/overall/snapshot, Retrieved November 17, 2014
22