Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020.

In the 10 months since the first confirmed case of coronavirus disease 2019 (COVID-19) was reported in the United States on January 20, 2020 (1), approximately 13.8 million cases and 272,525 deaths have been reported in the United States. On October 30, the number of new cases reported in the United States in a single day exceeded 100,000 for the first time, and by December 2 had reached a daily high of 196,227.* With colder weather, more time spent indoors, the ongoing U.S. holiday season, and silent spread of disease, with approximately 50% of transmission from asymptomatic persons (2), the United States has entered a phase of high-level transmission where a multipronged approach to implementing all evidence-based public health strategies at both the individual and community levels is essential. This summary guidance highlights critical evidence-based CDC recommendations and sustainable strategies to reduce COVID-19 transmission. These strategies include 1) universal face mask use, 2) maintaining physical distance from other persons and limiting in-person contacts, 3) avoiding nonessential indoor spaces and crowded outdoor spaces, 4) increasing testing to rapidly identify and isolate infected persons, 5) promptly identifying, quarantining, and testing close contacts of persons with known COVID-19, 6) safeguarding persons most at risk for severe illness or death from infection with SARS-CoV-2, the virus that causes COVID-19, 7) protecting essential workers with provision of adequate personal protective equipment and safe work practices, 8) postponing travel, 9) increasing room air ventilation and enhancing hand hygiene and environmental disinfection, and 10) achieving widespread availability and high community coverage with effective COVID-19 vaccines. In combination, these strategies can reduce SARS-CoV-2 transmission, long-term sequelae or disability, and death, and mitigate the pandemic's economic impact. Consistent implementation of these strategies improves health equity, preserves health care capacity, maintains the function of essential businesses, and supports the availability of in-person instruction for kindergarten through grade 12 schools and preschool. Individual persons, households, and communities should take these actions now to reduce SARS-CoV-2 transmission from its current high level. These actions will provide a bridge to a future with wide availability and high community coverage of effective vaccines, when safe return to more everyday activities in a range of settings will be possible.

Potentially Excess Deaths from the Five Leading Causes of Death in Metropolitan and Nonmetropolitan Counties - United States, 2010-2017.

PROBLEM/CONDITION: A 2017 report quantified the higher percentage of potentially excess (or preventable) deaths in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas. In that report, CDC compared national, regional, and state estimates of potentially excess deaths among the five leading causes of death in nonmetropolitan and metropolitan counties for 2010 and 2014. This report enhances the geographic detail by using the six levels of the 2013 National Center for Health Statistics (NCHS) urban-rural classification scheme for counties and extending estimates of potentially excess deaths by annual percent change (APC) and for additional years (2010-2017). Trends were tested both with linear and quadratic terms. PERIOD COVERED: 2010-2017. DESCRIPTION OF SYSTEM: Mortality data for U.S. residents from the National Vital Statistics System were used to calculate potentially excess deaths from the five leading causes of death among persons aged <80 years. CDC's NCHS urban-rural classification scheme for counties was used to categorize the deaths according to the urban-rural county classification level of the decedent's county of residence (1: large central metropolitan [most urban], 2: large fringe metropolitan, 3: medium metropolitan, 4: small metropolitan, 5: micropolitan, and 6: noncore [most rural]). Potentially excess deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). Potentially excess deaths were calculated separately for the six urban-rural county categories nationally, the 10 U.S. Department of Health and Human Services public health regions, and the 50 states and District of Columbia. RESULTS: The number of potentially excess deaths among persons aged <80 years in the United States increased during 2010-2017 for unintentional injuries (APC: 11.2%), decreased for cancer (APC: -9.1%), and remained stable for heart disease (APC: 1.1%), chronic lower respiratory disease (CLRD) (APC: 1.7%), and stroke (APC: 0.3). Across the United States, percentages of potentially excess deaths from the five leading causes were higher in nonmetropolitan counties in all years during 2010-2017. When assessed by the six urban-rural county classifications, percentages of potentially excess deaths in the most rural counties (noncore) were consistently higher than in the most urban counties (large central metropolitan) for the study period. Potentially excess deaths from heart disease increased most in micropolitan counties (APC: 2.5%) and decreased most in large fringe metropolitan counties (APC: -1.1%). Potentially excess deaths from cancer decreased in all county categories, with the largest decreases in large central metropolitan (APC: -16.1%) and large fringe metropolitan (APC: -15.1%) counties. In all county categories, potentially excess deaths from the five leading causes increased, with the largest increases occurring in large central metropolitan (APC: 18.3%), large fringe metropolitan (APC: 17.1%), and medium metropolitan (APC: 11.1%) counties. Potentially excess deaths from CLRD decreased most in large central metropolitan counties (APC: -5.6%) and increased most in micropolitan (APC: 3.7%) and noncore (APC: 3.6%) counties. In all county categories, potentially excess deaths from stroke exhibited a quadratic trend (i.e., decreased then increased), except in micropolitan counties, where no change occurred. Percentages of potentially excess deaths also differed among and within public health regions and across states by urban-rural county classification during 2010-2017. INTERPRETATION: Nonmetropolitan counties had higher percentages of potentially excess deaths from the five leading causes than metropolitan counties during 2010-2017 nationwide, across public health regions, and in the majority of states. The gap between the most rural and most urban counties for potentially excess deaths increased during 2010-2017 for three causes of death (cancer, heart disease, and CLRD), decreased for unintentional injury, and remained relatively stable for stroke. Urban and suburban counties (large central metropolitan and large fringe metropolitan, medium metropolitan, and small metropolitan) experienced increases in potentially excess deaths from unintentional injury during 2010-2017, leading to a narrower gap between the already high (approximately 55%) percentage of excess deaths in noncore and micropolitan counties. PUBLIC HEALTH ACTION: Routine tracking of potentially excess deaths by urban-rural county classification might help public health departments and decision-makers identify and monitor public health problems and focus interventions to reduce potentially excess deaths in these areas.

Evaluation of Syndromic Surveillance Systems in 6 US State and Local Health Departments.

OBJECTIVE: Evaluating public health surveillance systems is critical to ensuring that conditions of public health importance are appropriately monitored. Our objectives were to qualitatively evaluate 6 state and local health departments that were early adopters of syndromic surveillance in order to (1) understand the characteristics and current uses, (2) identify the most and least useful syndromes to monitor, (3) gauge the utility for early warning and outbreak detection, and (4) assess how syndromic surveillance impacted their daily decision making. DESIGN: We adapted evaluation guidelines from the Centers for Disease Control and Prevention and gathered input from the Centers for Disease Control and Prevention subject matter experts in public health surveillance to develop a questionnaire. PARTICIPANTS: We interviewed staff members from a convenience sample of 6 local and state health departments with syndromic surveillance programs that had been in operation for more than 10 years. RESULTS: Three of the 6 interviewees provided an example of using syndromic surveillance to identify an outbreak (ie, cluster of foodborne illness in 1 jurisdiction) or detect a surge in cases for seasonal conditions (eg, influenza in 2 jurisdictions) prior to traditional, disease-specific systems. Although all interviewees noted that syndromic surveillance has not been routinely useful or efficient for early outbreak detection or case finding in their jurisdictions, all agreed that the information can be used to improve their understanding of dynamic disease control environments and conditions (eg, situational awareness) in their communities. CONCLUSION: In the jurisdictions studied, syndromic surveillance may be useful for monitoring the spread and intensity of large outbreaks of disease, especially influenza; enhancing public health awareness of mass gatherings and natural disasters; and assessing new, otherwise unmonitored conditions when real-time alternatives are unavailable. Future studies should explore opportunities to strengthen syndromic surveillance by including broader access to and enhanced analysis of text-related data from electronic health records. Health departments may accelerate the development and use of syndromic surveillance systems, including the improvement of the predictive value and strengthening the early outbreak detection capability of these systems. These efforts support getting the right information to the right people at the right time, which is the overarching goal of CDC's Surveillance Strategy.

The Evolution of BioSense: Lessons Learned and Future Directions.

The BioSense program was launched in 2003 with the aim of establishing a nationwide integrated public health surveillance system for early detection and assessment of potential bioterrorism-related illness. The program has matured over the years from an initial Centers for Disease Control and Prevention-centric program to one focused on building syndromic surveillance capacity at the state and local level. The uses of syndromic surveillance have also evolved from an early focus on alerts for bioterrorism-related illness to situational awareness and response, to various hazardous events and disease outbreaks. Future development of BioSense (now the National Syndromic Surveillance Program) includes, in the short term, a focus on data quality with an emphasis on stability, consistency, and reliability and, in the long term, increased capacity and innovation, new data sources and system functionality, and exploration of emerging technologies and analytics.

Leading Causes of Death in Nonmetropolitan and Metropolitan Areas- United States, 1999-2014.

PROBLEM/CONDITION: Higher rates of death in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas have been described but not systematically assessed. PERIOD COVERED: 1999-2014 DESCRIPTION OF SYSTEM: Mortality data for U.S. residents from the National Vital Statistics System were used to calculate age-adjusted death rates and potentially excess deaths for nonmetropolitan and metropolitan areas for the five leading causes of death. Age-adjusted death rates included all ages and were adjusted to the 2000 U.S. standard population by the direct method. Potentially excess deaths are defined as deaths among persons aged <80 years that exceed the numbers that would be expected if the death rates of states with the lowest rates (i.e., benchmark states) occurred across all states. (Benchmark states were the three states with the lowest rates for each cause during 2008-2010.) Potentially excess deaths were calculated separately for nonmetropolitan and metropolitan areas. Data are presented for the United States and the 10 U.S. Department of Health and Human Services public health regions. RESULTS: Across the United States, nonmetropolitan areas experienced higher age-adjusted death rates than metropolitan areas. The percentages of potentially excess deaths among persons aged <80 years from the five leading causes were higher in nonmetropolitan areas than in metropolitan areas. For example, approximately half of deaths from unintentional injury and chronic lower respiratory disease in nonmetropolitan areas were potentially excess deaths, compared with 39.2% and 30.9%, respectively, in metropolitan areas. Potentially excess deaths also differed among and within public health regions; within regions, nonmetropolitan areas tended to have higher percentages of potentially excess deaths than metropolitan areas. INTERPRETATION: Compared with metropolitan areas, nonmetropolitan areas have higher age-adjusted death rates and greater percentages of potentially excess deaths from the five leading causes of death, nationally and across public health regions. PUBLIC HEALTH ACTION: Routine tracking of potentially excess deaths in nonmetropolitan areas might help public health departments identify emerging health problems, monitor known problems, and focus interventions to reduce preventable deaths in these areas.

Potentially Preventable Deaths Among the Five Leading Causes of Death - United States, 2010 and 2014.

Death rates by specific causes vary across the 50 states and the District of Columbia.* Information on differences in rates for the leading causes of death among states might help state health officials determine prevention goals, priorities, and strategies. CDC analyzed National Vital Statistics System data to provide national and state-specific estimates of potentially preventable deaths among the five leading causes of death in 2014 and compared these estimates with estimates previously published for 2010. Compared with 2010, the estimated number of potentially preventable deaths changed (supplemental material at https://stacks.cdc.gov/view/cdc/42472); cancer deaths decreased 25% (from 84,443 to 63,209), stroke deaths decreased 11% (from 16,973 to 15,175), heart disease deaths decreased 4% (from 91,757 to 87,950), chronic lower respiratory disease (CLRD) (e.g., asthma, bronchitis, and emphysema) deaths increased 1% (from 28,831 to 29,232), and deaths from unintentional injuries increased 23% (from 36,836 to 45,331). A better understanding of progress made in reducing potentially preventable deaths in the United States might inform state and regional efforts targeting the prevention of premature deaths from the five leading causes in the United States.

Differences in healthy life expectancy for the US population by sex, race/ethnicity and geographic region: 2008.

BACKGROUND: Healthy life expectancy (HLE) varies among demographic segments of the US population and by geography. To quantify that variation, we estimated the national and regional HLE for the US population by sex, race/ethnicity and geographic region in 2008. METHODS: National HLEs were calculated using the published 2008 life table and the self-reported health status data from the National Health Interview Survey (NHIS). Regional HLEs were calculated using the combined 2007-09 mortality, population and NHIS health status data. RESULTS: In 2008, HLE in the USA varied significantly by sex, race/ethnicity and geographical regions. At 25 years of age, HLE for females was 47.3 years and ∼2.9 years greater than that for males at 44.4 years. HLE for non-Hispanic white adults was 2.6 years greater than that for Hispanic adults and 7.8 years greater than that for non-Hispanic black adults. By region, the Northeast had the longest HLE and the South had the shortest. CONCLUSIONS: The HLE estimates in this report can be used to monitor trends in the health of populations, compare estimates across populations and identify health inequalities that require attention.

Potentially preventable deaths from the five leading causes of death--United States, 2008-2010.

In 2010, the top five causes of death in the United States were 1) diseases of the heart, 2) cancer, 3) chronic lower respiratory diseases, 4) cerebrovascular diseases (stroke), and 5) unintentional injuries. The rates of death from each cause vary greatly across the 50 states and the District of Columbia (2). An understanding of state differences in death rates for the leading causes might help state health officials establish disease prevention goals, priorities, and strategies. States with lower death rates can be used as benchmarks for setting achievable goals and calculating the number of deaths that might be prevented in states with higher rates. To determine the number of premature annual deaths for the five leading causes of death that potentially could be prevented ("potentially preventable deaths"), CDC analyzed National Vital Statistics System mortality data from 2008-2010. The number of annual potentially preventable deaths per state before age 80 years was determined by comparing the number of expected deaths (based on average death rates for the three states with the lowest rates for each cause) with the number of observed deaths. The results of this analysis indicate that, when considered separately, 91,757 deaths from diseases of the heart, 84,443 from cancer, 28,831 from chronic lower respiratory diseases, 16,973 from cerebrovascular diseases (stroke), and 36,836 from unintentional injuries potentially could be prevented each year. In addition, states in the Southeast had the highest number of potentially preventable deaths for each of the five leading causes. The findings provide disease-specific targets that states can use to measure their progress in preventing the leading causes of deaths in their populations.

Conclusion and future directions: CDC Health Disparities and Inequalities Report - United States, 2013.

The reports in this supplement document persistent disparities between some population groups in health outcomes, access to health care, adoption of health promoting behaviors, and exposure to health-promoting environments. Some improvements in overall rates and even reductions in some health disparities are noted; however, many gaps persist. These finding highlight the importance of monitoring health status, outcomes, behaviors, and exposures by population groups to assess trends and target interventions. In this report, disparities were found between race and ethnic groups across all of the health topics examined. Differences also were observed by other population characteristics. For example, persons with low socioeconomic status were more likely to be affected by diabetes, hypertension, and human immunodeficiency virus (HIV) infection and were less likely to be screened for colorectal cancer and vaccinated against influenza.

Introduction: CDC Health Disparities and Inequalities Report - United States, 2013.

This supplement is the second CDC Health Disparities and Inequalities Report (CHDIR). The 2011 CHDIR was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access (CDC. CDC Health Disparities and Inequalities Report-United States, 2011. MMWR 2011;60[Suppl; January 14, 2011]). The 2013 CHDIR provides new data for 19 of the topics published in 2011 and 10 new topics. When data were available and suitable analyses were possible for the topic area, disparities were examined for population characteristics that included race and ethnicity, sex, sexual orientation, age, disability, socioeconomic status, and geographic location. The purpose of this supplement is to raise awareness of differences among groups regarding selected health outcomes and health determinants and to prompt actions to reduce disparities. The findings in this supplement can be used by practitioners in public health, academia and clinical medicine; the media; the general public; policymakers; program managers; and researchers to address disparities and help all persons in the United States live longer, healthier, and more productive lives.

Preventable hospitalizations and emergency department visits for angina, United States, 1995-2010.

INTRODUCTION: Preventable hospitalizations for angina have been decreasing since the late 1980s - most likely because of changes in guidance, physician coding practices, and reimbursement. We asked whether this national decline has continued and whether preventable emergency department visits for angina show a similar decline. METHODS: We used National Hospital Discharge Survey data from 1995 through 2010 and National Hospital Ambulatory Medical Care Survey data from 1995 through 2009 to study preventable hospitalizations and emergency department visits, respectively. We calculated both crude and standardized rates for these visits according to technical specifications published by the Agency for Healthcare Research and Quality, which uses population estimates from the US Census Bureau as the denominator for the rates. RESULTS: Crude hospitalization rates for angina declined from 1995-1998 to 2007-2010 for men and women in all 3 age groups (18-44, 45-64, and ≥65) and age- and sex-standardized rates declined in a linear fashion (P = .02). Crude rates for preventable emergency department visits for angina declined for men and women aged 65 or older from 1995-1998 to 2007-2009. Age- and sex-standardized rates for these visits showed a linear decline (P = .05). CONCLUSION: We extend previous research by showing that preventable hospitalization rates for angina have continued to decline beyond the time studied previously. We also show that emergency department visits for the same condition have also declined during the past 15 years. Although these declines are probably due to changes in diagnostic practices in the hospitals and emergency departments, more studies are needed to fully understand the reasons behind this phenomenon.

Preventable hospitalizations for hypertension: establishing a baseline for monitoring racial differences in rates.

INTRODUCTION: Preventable hospitalization for hypertension is an ambulatory care-sensitive condition believed to indicate the failure of outpatient and public health systems to prevent and control hypertension. Blacks have higher rates of such hospitalizations than whites. The 2010 Patient Protection and Affordable Care Act (PPACA) seeks to implement higher quality health care, which may help close the racial gap in these rates. The objective of this study was to analyze pre-PPACA baseline rates of preventable hypertension hospitalizations in the United States and racial differences over time. METHODS: We used data from the 1995-2010 National Hospital Discharge Survey, a stratified, probability-designed survey representing approximately 1% of hospitalizations in the United States. Rates were calculated using specifications published by the Agency for Healthcare Research and Quality requiring census data as denominators for the rates. We combined at least 3 years of data to obtain more precise estimates and conducted a trend analysis by using rates calculated for each of the resulting 5 periods. RESULTS: For both sexes, all age groups, and each period, blacks had higher crude rates than whites. Age- and sex-standardized rates confirmed this finding (eg, 2007-2010: blacks, 334 per 100,000; whites, 97.4 per 100,000). Rates were generally flat over time; however, white women aged 65 or older showed increasing rates. CONCLUSION: Using national data, we confirmed higher rates of preventable hypertension hospitalizations for blacks, showing little improvement in disparities over time. This pre-PPACA baseline for blacks and whites allows for ongoing monitoring of preventable hospitalizations for hypertension.

Prevalence, management, and control of hypertension among US workers: does occupation matter?

OBJECTIVE: The role of occupation in the management of cardiovascular risk factors including hypertension is not well known. METHODS: We analyzed the 1999-2004 National Health and Nutrition Examination Survey data of 6928 workers aged 20 years or older from 40 occupational groups. Hypertension was defined as measured blood pressure of 140/90 mm Hg or greater or self-reported use of antihypertensive medication, treatment as use of antihypertensive medication, awareness as ever being told by a doctor about having hypertension, and control as having blood pressure of less than 140/90 mm Hg among treated participants. RESULTS: Protective service workers ranked among the lowest in awareness (50.6%), treatment (79.3%), and control (47.7%) and had lower odds of hypertension control and treatment compared with executive/administrative/managerial workers, adjusting for sociodemographic, body-weight, smoking, and alcohol. CONCLUSIONS: Protective service workers may benefit the most from worksite hypertension management programs.

Lexicon, definitions, and conceptual framework for public health surveillance.

Public health surveillance is essential to the practice of public health and to guide prevention and control activities and evaluate outcomes of such activities. With advances in information sciences and technology, changes in methodology, data availability and data synthesis, and expanded health information needs, the question arises whether redefining public health surveillance is needed for the 21st century. The current definition is "Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know and linked to prevention and control."

Rationale for periodic reporting on the use of adult clinical preventive services of public health priority--United States.

This supplement introduces a CDC initiative to monitor and report periodically on the use of a set of selected clinical preventive services in the U.S. adult population in the context of recent national initiatives to improve access to and use of such services. Increasing the use of these services has the potential to lead to substantial reductions in the burden of illness, death, and disability and to lower treatment costs. The majority of clinical preventive services are provided by the health-care sector, and public health agencies play important roles in helping to support increases in the use of these services (e.g., by identifying and implementing policies that are effective in increasing use of the services and by collaborating with stakeholders to conduct programs to improve use). Recent health reform initiatives, including efforts to increase the accessibility and affordability of preventive services, fund community prevention programs, and improve the use of health information technologies, offer opportunities to enhance use of preventive services. This supplement provides baseline information on a set of selected clinical preventive services before implementation of these recent reforms and discusses opportunities to increase the use of such services. This information can help public health practitioners collaborate with other stakeholders that have key roles to play in improving public health (e.g., employers, health plans, health professionals, and voluntary associations), understand the potential benefits of the recommended services, address the problem of underuse, and identify opportunities to apply effective strategies to improve use and foster accountability among stakeholders.

Control of hypertension among adults--National Health and Nutrition Examination Survey, United States, 2005-2008.

Cardiovascular disease (CVD) is the leading cause of preventable death in the United States, and approximately 1 million heart attacks and 700,000 strokes occur annually. Hypertension is a major risk factor for cardiovascular disease and stroke; the unadjusted prevalence of hypertension among U.S. adults aged ≥18 years is approximately 31% (representing 68 million adults), and hypertension increases with age to approximately 70% among persons aged ≥65 years. Hypertension contributes to one out of every seven deaths in the United States, and approximately 70% of persons who have a first heart attack or stroke or who have heart failure have hypertension. In clinical trials, treatment of hypertension was associated with substantial reductions in stroke incidence (35%-40%), myocardial infarction (20%-25%), and heart failure (>50%). The estimated annual direct costs of hypertension are approximately $69.9 billion, and the estimated annual indirect costs are $23.6 billion.

Conclusions and future directions for periodic reporting on the use of adult clinical preventive services of public health priority--United States.

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence population health, including employers, health plans, health professionals, and voluntary associations, to increase the use of a set of clinical preventive services that, with improved use, can substantially reduce morbidity and mortality in the U.S. adult population. This supplement highlighted that the use of the clinical preventive services in the U.S. adult population is not optimal and is quite variable, ranging from approximately 10% to 85%, depending on the particular service. Use was particularly low for tobacco cessation, aspirin use to reduce risk of cardiovascular disease, and influenza vaccination; however, ample opportunity exists to improve use of all of these services. Among the specific populations least likely to have used the recommended services, persons with no insurance, no usual source of care, or no recent use of the health-care system (if included in the analysis) were the groups least likely to have used the services. Use among the uninsured was generally 10 to 30 percentage points below the general population averages, suggesting that improvements in insurance coverage are likely to increase use of these clinical preventive services. A randomized, controlled trial of an expansion of Medicaid coverage by Oregon in 2008 supports this hypothesis by demonstrating improved use of clinical services with increased health insurance coverage. A recent survey among the uninsured found a low level of awareness of the provisions of the Patient Protection and Affordable Care Act of 2010 as amended by the Healthcare and Education Reconciliation Act of 2010 (referred to collectively as the Affordable Care Act [ACA]). Therefore, improving opportunities for coverage might be insufficient, and focused efforts by governmental health agencies and other stakeholders are likely to be needed to enroll uninsured persons in health plans. In addition, although use of the preventive services in insured populations was greater than among the uninsured, use among the insured was generally <75%, and often much less. Therefore, having health insurance coverage might not itself be sufficient to optimize use of clinical preventive services, and additional measures to improve use are likely to be necessary.

Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008.

OBJECTIVE: Overweight and obesity during adolescence are associated with an increased risk for cardiovascular disease (CVD) risk factors. The objective of this study was to examine the recent trends in the prevalence of selected biological CVD risk factors and the prevalence of these risk factors by overweight/obesity status among US adolescents. METHODS: The NHANES is a cross-sectional, stratified, multistage probability sample survey of the US civilian, noninstitutionalized population. The study sample included 3383 participants aged 12 to 19 years from the 1999 through 2008 NHANES. RESULTS: Among the US adolescents aged 12 to 19 years, the overall prevalence was 14% for prehypertension/hypertension, 22% for borderline-high/high low-density lipoprotein cholesterol, 6% for low high-density lipoprotein cholesterol (<35 mg/dL), and 15% for prediabetes/diabetes during the survey period from 1999 to 2008. No significant change in the prevalence of prehypertension/hypertension (17% and 13%) and borderline-high/high low-density lipoprotein cholesterol (23% and 19%) was observed from 1999-2000 to 2007-2008, but the prevalence of prediabetes/diabetes increased from 9% to 23%. A consistent dose-response increase in the prevalence of each of these CVD risk factors was observed by weight categories: the estimated 37%, 49%, and 61% of the overweight, obese, and normal-weight adolescents, respectively, had at least 1 of these CVD risk factors during the 1999 through 2008 study period. CONCLUSIONS: The results of this national study indicate that US adolescents carry a substantial burden of CVD risk factors, especially those youth who are overweight or obese.