THE LIBRARY OF THE
UNIVERSITY OF
NORTH CAROLINA
AT CHAPEL HILL
THE COLLECTION OF
NORTH CAROLINIANA
C614.1
N87v5
1988
UNIVERSITY OF N C AT CHAPEL HILL
00034018777
FOR USE ONLY IN
THE NORTH CAROLINA COLLECTION
For.71 No, A-368
Digitized by the Internet Arcinive
in 2009 with funding from
Ensuring Democracy through Digital Access (NC-LSTA)
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LEADING CAUSES
OF MORTALITY
North Carolina
Vital Statistics
1988—Volume 2
LEADING CAUSES
OF MORTALITY
North Carolina
Vital Statistics
1988—Volume 2
Center for Health and Environmental Statistics
N.C. Department of Environment, Health, and Natural Resources
Division of Statistics and Information Services
STATE OF NORTH CAROLINA
James G. Martin, Governor
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
William W. Cobey, Jr., Secretary
DIVISION OF STATISTICS AND INFORMATION SERVICES
Delton Atkinson, M.S.P.H., M.P.H., Director
June 1990
800 copies of this public document were
printed at a cost of $3,310.44 or $4.14 per copy.
ins
TABLE OF CONTENTS
Page
PREFACE vii
I. INTRODUCTION 1-1
Purpose and Organization 1-3
Overview of Mortality in North Carolina 1-9
II. TECHNICAL NOTES 2-1
North Carolina Population Bases 2-3
Mortality Rates 2-4
Computation of Mortality Rates 2-4
Interpretation of Mortality Rates 2-6
Flagging Biased Rates 2-9
Procedure for Geographic Clustering of Counties . . .2-12
III. GENERAL MORTALITY IN NORTH CAROLINA 3-1
IV. MAJOR CARDIOVASCULAR DISEASE MORTALITY 4-1
Heart Disease 4-3
Cerebrovascular Disease 4-9
Atherosclerosis 4-15
Page
V. CANCER MORTALITY 5-1
Cancer 5-3
Cancer of the Colon, Rectum, and Anus 5-13
Cancer of the Trachea, Bronchus, and Lung 5-19
Cancer of the Female Breast 5-25
Cancer of the Prostate 5-31
Cancer in Special Populations 5-37
VI. OTHER LEADING CAUSES OF MORTALITY 6-1
Septicemia 6-3
Diabetes Mellitus 6-8
Pneumonia and Influenza 6-13
Chronic Obstructive Pulmonary Disease 6-19
Chronic Liver Disease and Cirrhosis 6-26
Nephritis, Nephrosis, and Nephrotic Syndrome . . . .6-31
VII. MAJOR EXTERNAL CAUSES OF MORTALITY 7-1
Injuries 7-3
- Unintended Motor Vehicle Injuries 7-5
Unintended Injuries Excluding Motor Vehicles . . .7-12
Suicide 7-20
Homicide 7-27
VIII. INFANT MORTALITY 8-1
IX. MULTIPLE CONDITIONS PRESENT AT DEATH 9-1
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PREFACE
The Center for Health and Environmental Statistics produces
a major publication annually, describing in tabular and map form
North Carolina's mortality experience over the most recent
five-year period. Periodically, an expanded volume is produced
that includes a narrative analysis for each cause of death. The
expanded format is resumed in this 1988 edition, which includes
statistical tables, maps, and graphs, as well as discussions of
cause-specific trends, geographic patterns, risk factors,
multiple conditions present at death, and pertinent research. An
overview of the mortality experience in North Carolina is also
presented.
The tables in this report provide selected 1988 mortality
statistics for counties. Department of Human Resources regions.
Health Service Areas, and the state (see maps on preceding
pages) . More than a dozen of the leading causes of mortality in
North Carolina are tabulated; in addition, various cancer sites
and total infant mortality are included. Comparisons with
national statistics are usually based on 1987 data, which is the
most recent year of final data available from the National Center
for Health Statistics.
As with previous editions, multiple conditions present at
death are discussed in a separate section. Five diseases in
particular—septicemia, diabetes, hypertension, atherosclerosis,
and nephritis/nephrosis—are considered associated conditions far
more often than underlying causes. Hence, Figures 18. A through
22. B display 1984-88 county rates for deaths associated with a
Vll
PURPOSE AND ORGANIZATION
Although North Carolina has traditionally experienced low
crude death rates, our status among states has worsened. In
1960, only seven of the 50 states had death rates lower than
North Carolina's; this had increased to 14 by 1970 (1); 19 by
1980 (2); and 21 by 1987 (3). Furthermore, while many of the
state's cause-specific rates are consistently below United States
levels, some of North Carolina's age-adjusted rates are substan-tially
higher. For example, cerebrovascular disease, motor
vehicle injuries, other injuries, and septicemia are causes for
which North Carolina's 1987 adjusted rates were 23 to 35 percent
above the corresponding United States rates. For all causes, the
1987 North Carolina unadjusted rate was less than one percent
lower than the United States rate, while the age-adjusted rate
was six percent greater. Finally, four years of successive
decreases in the infant death rate for North Carolina ended in
1987 with a 4.3% increase over 1986, followed by an increase of
4.1% in 1988.
These facts pose a serious challenge to health officials
throughout the state to (i) isolate those determinants of mor-tality
that permit intervention, and (ii) identify high-risk
areas in order to strategically utilize limited medical and
health resources. The data in this volume should aid in these
areas of investigation by providing information against which
North Carolina's county and regional mortality may be assessed in
the present and evaluated in the future.
Nine sections comprise this edition of Leading Causes of
Mortality . This section presents an overview of mortality
1-3
experience in North Carolina as well as the purpose and organiza-tion
of the document. Section II provides technical information
concerning the calculation, interpretation, and appropriate use
of adjusted and unadjusted rates. As in past editions of this
volume, readers are cautioned about using rates based on a small
number of deaths, and the most problematic of the adjusted rates
are "flagged" in the tables with an asterisk. The procedures
used to determine which rates to flag are described in Section
II. Also, the procedure used to analyze geographic clustering of
counties is described.
Sections III through IX consist of maps, tabular data, and
narrative material which describe North Carolina's recent experi-ence
with respect to general mortality, cause-specific mortality
(underlying cause) , infant mortality, and multiple conditions
present at death. For most causes, risk factors, geographic
clustering, differences by race and sex, and trends over time are
considered.
Table 1 describes the selected cause-of-death categories in
terms of codes from the ninth revision of the International
Classification of Diseases (4) . Altogether, the 14 major causes
selected for examination in this report accounted for 85 percent
of all North Carolina deaths during 1988. Some of the cancer
sites listed in Table 1 are not discussed separately in this
report. However, the considerable interest in cancer justified
presentation of rates for these sites.
DESCRIPTION OF TABLES
Sections III-IX contain tables that summarize the recent
mortality experience of the state, four Department of Human
Resources regions, six Health Service Areas, and the counties.
Except in the case of infant deaths (Section VIII) , a table
corresponding to each cause-of-death category includes the
1-4
following items of information:
1. the number of resident deaths occurring during 1988;
2. the 1988 death rate;
3. the number of resident deaths occurring during 1984-88;
4. the 1984-88 average annual death rate;
5. the 1984-88 average annual age-race-sex-adjusted death
rate computed by the direct method (5).
The formulas for calculating single- and five-year rates are
described in Section II. In this report, general mortality rates
(all causes combined) are expressed as deaths per 1,000 popula-tion,
whereas cause-specific rates are expressed as deaths per
100,000 population. The infant death rates of Table 21, Section
VIII, are computed as the number of infant deaths per 1,000 live
births.
DESCRIPTION OF MAPS
This volume contains 64 computer-produced maps which depict
data for the state's 100 counties. The maps on pages v and vi
identify the four regions of the Department of Human Resources
(DHR) and the state's six Health Service Areas (HSA's).
In Sections III-IX, maps depicting geographical patterns in
mortality should aid in the determination of specific types of
health care needs. Up to four maps are shown for each cause-of
-death category. Two maps depict the 1984-88 unadjusted death
rate and the 1984-88 age-race-sex-adjusted death rate for each of
the 100 counties. These maps show six levels of death rates,
where level one is the highest rate interval, represented by
solid black on the maps, and level six the lowest, depicted by
solid white. The interval values (levels) indicated by the map
legends are not necessarily continuous, but reflect the actual
range of values for each interval. These maps must be viewed
1-5
with extreme caution for causes where the number of deaths per
county is small, since in these cases rates can be very unstable.
A clustering routine from the Statistical Analysis System
(SAS) was used to group counties that are "most like each other"
with respect to their unadjusted and then their adjusted rates
(6) . This procedure may result in very large or very small
groups, depending upon how county rates differ from one another.
The other two maps for a particular cause depict "spatial"
clustering of two or more adjacent counties with high unadjusted
and/or adjusted rates, using a procedure described in Section II.
These maps are presented for a given cause only when a statisti-cally
significant spatial cluster was found to exist. Unlike the
maps described above, these maps are presented in reduced form as
part of the narrative and show up to three interval levels of
death rates, depending on the number of significant spatial
clusters found, along with the significance level (i.e., p-val-ue)
.
MULTIPLE CONDITIONS PRESENT AT DEATH
Since 1975, multiple conditions present at death have been
coded, and statistics are available for all conditions reported
by the certifier. Five diseases--septicemia, diabetes, hyper-tension,
atherosclerosis, and nephritis--are considered associ-ated
conditions far more often than they are reported as under-lying
causes. The importance of multiple conditions and the
geographic patterns of these five diseases are discussed in
Section IX, while the etiology and risk factors associated with
septicemia, diabetes, atherosclerosis, and nephritis are dis-cussed
separately in Sections IV and VI. County rate tables for
these diseases as underlying causes are likewise available in
Sections IV and VI. Neither separate discussion nor a county
rate table for hypertension is warranted, since it was reported
1-6
as the underlying cause for only 283 deaths in 1988.
Tables included in Section IX show deaths cross-tabulated by
underlying cause and associated mentioned conditions, death
frequencies for selected pairs of mentioned conditions, and death
rates based on mentioned conditions rather than underlying
causes. Rates are deaths with the condition mentioned per
100,000 population. In addition, ratios of the 14 major causes
(plus hypertension and four site-specific cancers) as mentioned
conditions versus underlying causes are tabulated.
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OVERVIEW OF MORTALITY IN NORTH CAROLINA
Mortality in North Carolina has exhibited a general downward
trend in this century, but an upward trend since 1982, rising
from a low of 8.1 deaths per 1,000 population in 1982 to a high
of 8.9 in 1988. Probably the major factor contributing to this
increase is aging of the state's population. Other factors that
affect mortality include changes in lifestyle (e.g., reduction in
smoking) , environment, risk factors, and the medical care system.
In sections III through IX of this report, these factors and
others are considered in discussing each cause of death. This
overview summarizes four general determinants of mortality as
well as some of the risk factors which are associated with a
number of different causes. Next, some of the major mortality
findings are highlighted, and finally, premature mortality in
North Carolina is examined via the concept of "years of life
lost," which emphasizes the impact of mortality in the younger
age groups (7)
.
DETERMINANTS OF MORTALITY
A broad view of mortality determinants shows that problems
"arise from causes embedded in the social fabric of the nation as
a whole" (8) , and that medical care is only one aspect of health
maintenance. Accordingly, environment, lifestyle, biology and
genetics, and medical care must all be considered as determinants
of health.
Over the past decade, environmental factors, both natural and
man-made, have been increasingly recognized as having a signifi-
1-9
cant impact on health. For example, naturally occurring varia-tions
such as water mineral content and elevation have been cited
as influencing the incidence of cardiovascular disease (9) . A
more important problem may be the natural occurrence of radon gas
in some homes. However, most serious environmental problems are
consequences of man-made pollution of air, water, and food sour-ces.
Recent examples include atmospheric pollution from lead and
ozone, ground water contamination from toxic wastes, and occupa-tional
exposures to hazardous substances. Children are especial-ly
at risk from pollutants such as ozone (10) and lead (11).
While pollution is a by-product of a high-technology,
growth-oriented society, concomitants of economic growth also
include jobs, income, health insurance, and improved access to
medical care. Unemployment, poverty, and their social accompani-ments
are generally associated with less adequate mental and
physical health. The poor, having fewer economic and social
resources, experience higher levels of stress and are more
vulnerable to infectious agents, economic problems, and hazards
in the home and workplace. These problems are typified by
farming. The prolonged decline of economic conditions for many
farmers has increased stress. Pollution from agricultural
chemicals (fertilizers and pesticides) and injuries are relative-ly
common: among all industrial groups, farmers rank near the top
on rates for poisoning, skin diseases, and injuries (12). Also,
rural populations are less likely to have medical insurance
and/or quick access to medical care. In short, economic condi-tions
and environmental factors may interact in complex ways to
affect health status.
Lifestyle refers to behaviors that affect health and over
which individuals have varying degrees of control. There are
substantial data showing that certain health habits (e.g., never
having smoked, moderate or no alcohol consumption, regular
exercise, sleeping 7-8 hours per night, and maintaining appropri-
1-10
ate weight) are associated with improved health and reduced
mortality (13). Individuals' lifestyle decisions regarding these
variables are associated with their socioeconomic status, race,
and sex: men are more likely than women to smoke and drink
excessively and to exercise; younger women are more likely to
smoke than older women; blacks are more likely to be sedentary
and to smoke than whites; and black women are substantially
overweight almost twice as often as white women. Persons with
fewer than 12 years of education are more likely to smoke, sleep
excessively, not exercise, and be substantially overweight. (13)
In short, individuals' decisions are conditioned to a large
extent by their socioeconomic status. "Blaming the victim" by
keeping the problem at the individual level may obscure the
origins of disease in the socioeconomic environment. However,
policies to educate individuals about their health behaviors are
much less complex and easier to sell politically than those aimed
at modifying the underlying social and economic determinants of
lifestyle and health.
This is not meant to suggest that health education is without
impact. Certain population groups are more likely to have
lifestyles associated with increased mortality, and education
programs are effective (although short-run) complements to
policies oriented toward the environmental factors that condition
lifestyle. For example, nutrition education can have a substan-tial
health payoff among the poor, but only if they are provided
sufficient money to buy proper foods and facilities for prepara-tion.
Sex education for prevention of sexually transmitted
diseases and unwanted pregnancies is another area where education
may be very effective in altering specific high-risk behaviors
that are or may be associated with lifestyle. Variables such as
income, education, and residence (urban versus rural) may be
important indicators and determinants of lifestyle (14) , and
effective education programs must consider variations along such
dimensions. In short, targeting specific groups is likely to be
1-11
more successful than generalized education or media campaigns.
Biological factors are relatively powerful determinants of
mortality. The age, race, and sex of an individual are biologi-cally
determined, and mortality rates vary consistently along
these dimensions: health is strongly tied to aging and the life
cycle. Some diseases that vary by race are thought to be geneti-cally
linked, and biological factors account for some of the
differences in incidence rates between males and females for some
diseases, with females living longer on the average. However,
there are health consequences of age, race, and sex that are not
biological in origin. Social stratification is partly based on
these variables, with the elderly, nonwhites, and females gener-ally
being accorded lower socioeconomic status. Some of the
elevated male mortality may result from the aggressive, achieve-ment-
oriented lifestyle that accompanies higher status positions
(15), while higher nonwhite mortality is due in part to a lower
position in the economic hierarchy (16)
.
Many causes of diseases are directly or indirectly genetic in
origin. In North Carolina, an estimated 320,375 persons are
afflicted with serious genetic disorders, resulting in physical
defects, mental retardation, and other health problems, and
approximately 80 percent of birth defects are genetic in origin
(17). Forty percent of the children admitted to inpatient
pediatric care are there because of genetic disorders (18), and
about 50 percent of all childhood blindness is linked to genetic
factors (19). In North Carolina, congenital malformations are
now the leading cause of mortality among infants under one year,
and second only to injuries among children ages one through four
(20). Overall, the 1988 congenital anomalies death rate was 5.3
deaths per 100,000 population. In addition, some persons have a
genetically linked susceptibility to certain diseases. Some
types of cancer, for example, may result from genetic weaknesses
of the immunological system in combination with specific external
1-12
agents (carcinogens)
.
The medical care system is another important determinant of
mortality levels. This complex system is primarily reactive, in
that it responds to health problems by attempting to restore the
individual to a full and productive life. Disease prevention is
also within the purview of the medical care system, as exempli-fied
by vaccination to prevent infectious diseases and by patient
education concerning specific health consequences of certain
behaviors. Medical care personnel may occasionally be involved
in attacking certain environmental and biological causes of
disease, though this type of activity has traditionally been
carried out by the public sector.
McKeown and Brown (21) present evidence suggesting that
medical practice in the first half of the 19th century had little
to do with the large decline in mortality that took place in
Western societies, but rather that transportation improvements,
changes in the economic system that assured a more continuous and
nutritious food supply, and improved sanitation practices urged
on by reformers in the cities were responsible. After the
practice of antisepsis became widespread late in the 19th centu-ry,
medical care became a much more positive factor in reducing
mortality. During the first half of this century, the health and
average life span of Americans improved considerably, due sub-stantially
to efforts in the medical sector to reduce infections
and acute nutritional diseases. Major gains were also observed
in infant and maternal mortality, probably due to improvements in
nutrition, sanitation, and the development of vaccines (22) .
However, McKeown (23) notes that a significant reduction in
mortality from the introduction of antibiotics cannot be demon-strated.
Medical care may sometimes have negative health consequences.
It has been estimated that nosocomial infections (acquired inside
1-13
the hospital) strike five percent of Americans hospitalized each
year, adding to hospital costs by increasing lengths of stay
(24). Inappropriate or unnecessary treatment may also increase
mortality as well as health care costs. Probably less than 20
percent of the procedures used by health professionals have been
demonstrated to be helpful in clinical trials (25) . In short,
risks are always present, even in proper medical treatment, but
in most cases they are far outweighed by the potential benefits.
In summary , a complete program to improve health status and
reduce mortality must include environmental, lifestyle, biologi-cal,
and medical care strategies. Too much emphasis in one area
may involve substantial opportunity costs due to neglect of other
areas. For example, expenditures for basic research, for envi-ronmental
protection, to improve substandard housing, or for
public education regarding specific risk behaviors could have
higher long-term health payoffs than would the same amount
expended just for medical care. The status of heart disease and
cancer as major killers is closely linked to environmental and
lifestyle factors, and medical treatment or attempts to modify
individual behaviors are unlikely to substantially reduce mor-tality
from these diseases. Increased per capita consumption of
foods high in animal fats along with the increase in sedentary
occupations, and drinking and smoking associated with stresses on
the individual and family unit all underlie both heart disease
and cancer. In addition, the spiral of post-WWII economic
production, technological achievements, and personal affluence
have led to chronic exposure of large segments of the population
to increasing numbers of carcinogens in the air, water, and food
supplies. Cancer control is such a difficult policy area pre-cisely
because cancer prevention will require fundamental changes
in the physical--and therefore economic--environment , as well as
modification of behaviors and lifestyle. Policies aimed at
improving the medical treatment of cancer patients, while often
costly, are probably easier to implement, but they do not con-
1-14
front the basic problems. In brief, strategies to deal with
cancer, heart disease, and other leading causes of mortality must
deal with factors that exist in the fabric of contemporary
society.
RISK FACTORS
Risk factors particular to each cause of death are discussed
in separate sections of this volume. In addition, information
about several factors that are common to a number of different
causes of death is summarized here.
Two of the most pervasive factors contributing to U.S.
mortality from various diseases are high blood pressure and
cigarette smoking . Elevated blood pressure is associated with
death from all cardiovascular diseases, diabetes mellitus,
cirrhosis of the liver (26, 27) and renal failure (28) . While
most causes of hypertension are amenable to treatment, many
people either are unaware of having the condition or do not
modify behaviors (e.g., maintain proper weight, diet, and medica-tion
regimen) necessary to control it.
Use of tobacco products contributes to death from a large
number of causes (26, 27, 29-32). According to data compiled by
the U.S. Surgeon General (32), cigarette smoking is a major cause
of lung cancer as well as cancers of the larynx, oral cavity, and
esophagus; it is a contributory factor in the development of
cancers of the bladder, pancreas, and kidney; and approximately
30 percent of all cancer deaths are attributable to cigarette
smoking. There is evidence that it is a contributor in the
development of chronic bronchitis and emphysema, pulmonary heart
disease, myocardial infarction, aortic aneurysm, and a wide
variety of other vascular diseases. It may be a risk factor for
Alzheimer's Disease (33). In addition, smoking seems to interact
synergistically with other risk factors, such as asbestos, ioniz-
1-15
ing radiation, oral contraceptives, and certain dietary factors,
to produce a variety of cancers and vascular diseases. While the
low tar, low nicotine cigarette may be less likely to cause lung
cancer or chronic bronchitis, its carbon monoxide content—which
is associated with vascular disease—remains unchanged. The in-creased
use of smokeless tobacco (snuff, chewing tobacco, and
similar products) is disturbing, since these products are associ-ated
with tongue cancer mortality and oral cancers in general
(34, 35). Finally, the impact of tobacco use on mortality is
such that nearly 50 percent of the difference by sex in total
mortality over the adult age span is likely attributable to
smoking (36). The data indicate that a considerable reduction in
morbidity and mortality related to tobacco usage is likely to
come about only with a substantial reduction in usage of tobacco
products (29)
.
Diet also has an important impact on certain causes of
mortality. Overeating may lead to obesity, which is associated
with high blood pressure, diabetes, and cardiovascular disease.
In turn, diabetes is a risk factor for stroke and other
cardiovascular diseases. In addition, the content of the modern
diet has important consequences for mortality. The contemporary
diet "... is higher in intake of energy, of protein (especial-ly
animal protein) , and of fat (especially animal fat) , but lower
in intake of fiber-containing cereal foods; this diet is associ-ated
with high rates of morbidity and mortality from degenerative
diseases" (37). Based on findings such as these, decreased
intake of animal fat and protein, cholesterol, salt, sugar, and
alcohol are often--but not unanimously--recommended.
Excessive alcohol consumption is the third largest health
problem in America (38) and is associated with a risk of prema-ture
death greatly exceeding normal expectancy from a variety of
diseases (39-41). "While the lifestyle typical of many heavy
drinkers contributes to this risk, the effects of alcohol per se
1-16
account for a substantial part of the excess mortality" (39) . In
two Chicago studies, heavy drinkers had higher mortality from all
causes, cardiovascular diseases, coronary heart disease, and
sudden death than could be entirely explained by other risk
factors such as blood pressure, smoking, and weight (40) . Heavy
alcohol use by pregnant women leads to birth anomalies, including
fetal alcohol syndrome and subsequent mental retardation (38).
In contrast to findings for excessive alcohol consumption, the
mortality experience of moderate drinkers does not seem to differ
notably from that of life-long abstainers (39)
.
Social class has a very strong impact on mortality (16, 30,
42). "Social class gradients of mortality and life expectancy
have been observed for centuries, and a vast body of evidence has
shown consistently that those in the lower classes have higher
mortality, morbidity, and disability rates" (16) . The higher
morbidity rates typically found in lower socioeconomic status
groups indicate that the excess mortality is not simply attribut-able
to a higher case fatality rate, since it is accompanied by a
higher prevalence of morbidity. Differences between white and
nonwhite mortality rates can be attributed largely to social
class differences: persons in lower socioeconomic groups, who are
substantially nonwhite, live in a more toxic, hazardous, and
non-hygienic environment resulting in a broad array of disease
consequences. Low education contributes to poor health practic-es,
and low income affects many aspects of health, including
nutrition. Higher stress levels and ineffective responses to
stress also contribute to higher mortality among the poor (16).
Lower class persons generally receive less adequate medical care,
though this probably does not account for a major portion of the
social class differences in morbidity and mortality (16) . In
fact, the association between excess mortality and low socioeco-nomic
status persists independent of individual behaviors or at-tributes
such as smoking, alcohol consumption, body mass index,
physical activity, martial status, race, and sex; hence the " ...
1-17
properties of the sociophysical environment may be important
contributors to the . . . excess mortality" (43)
.
Sex is another important variable associated with mortality.
Females have lower mortality rates and greater life expectancies
than males in all developed countries (36) . The differential in
death rates is present at conception and continues for every age
group. At birth, the ratio of males to females is 104:100, but
by age 70 females outnumber males by approximately 3:2. In the
United States, the 1987 age-adjusted death rate for males exceed-ed
that of females by 73 percent (3)
.
A substantial amount of excess male mortality is related to
sex differences in behavior, such as cigarette smoking, drinking
alcohol, aggressive competitiveness, and occupational exposure to
environmental and physical hazards (15). For 15-44-year-olds,
more than 90 percent of the excess male mortality may be attrib-utable
to violence and smoking (36) . Biological factors also
contribute to higher male mortality. "Thus, even among
nonsmokers, men have higher mortality than women for certain
types of cancer, and this implies that there must be other
factors, in addition to smoking, that contribute to higher cancer
among men" (36)
.
To the extent that the sex difference in mortality is not due
to biological factors, substantial reductions in male excess
mortality may be possible through lifestyle and behavioral
changes. With the transition earlier in this century from
infectious to degenerative diseases as the major causes of death,
lifestyle became more important in affecting mortality experi-ence,
and the difference between male and female mortality rates
increased steadily. More recently, female mortality relative to
male mortality has actually worsened for several age groups and
for several leading causes (44) . This may be associated with
increased smoking (29) and the adoption of other "male" behaviors
1-1?
by women as job participation and mobility increase and tradi-tional
roles are modified. Thus, social and lifestyle changes
may also help to reduce female mortality.
A number of risk factors have been reviewed that bear on many
causes of death, and efforts to reduce excess mortality must
involve consideration of these important precursors.
NORTH CAROLINA MORTALITY HIGHLIGHTS
o As shown in Table 1, a total of 57,630 North Carolinians died
in 1988, for a rate of 8.9 deaths per 1,000 population. The
1988 crude rate was three percent above the 1987 rate. The
five-year (1984-88) crude rate was 8.6, which was four
percent over the rate for the 1979-83 period. The median age
at death in 1988 increased to 72.9 years, up from 72.6 in
1987 and consistent with a generally steady increase in the
median over the last three decades.
o The number of deaths per 1,000 population was slightly (under
2%) higher for nonwhites than for whites, and substantially
higher for males than for females (by 21%) . A much younger
age structure for nonwhites accounts for the fact that their
crude mortality rate is not higher in comparison for whites.
Age-adjusted mortality is much higher for nonwhites.
o Age-adjusted mortality rates for the 1984-88 period show wide
gaps in the overall risk of mortality by race and sex. In
the 1984-88 period, the male rate for both races was approxi-mately
90 percent greater than the female rate, and the
nonwhite rate for both sexes remained more than 4 5 percent
above the white rate.
o Comparisons of the 1987 N.C. age-race-sex-specific mortality
rates with corresponding rates for the U.S. (3) reveal the
1-19
following major excesses* in North Carolina:
White males: Under 1 and ages 65-74 (11% above the U.S.
rate) ;
White females: Under 1 (17% above U.S. rate)
;
Nonwhite males: Ages 1-4 (50%), 5-14 (36%), 45-54 (29%),
55-64 (26%), 65-74 (27%), 75-84 (16%);
Nonwhite females: Ages 45-54 (18%)
Even after adjusting for age, race, and sex, the eastern
counties, especially the northeastern counties, seem to have
consistently higher mortality rates. Based on the 1984-88
adjusted rates, statistically significant spatial clusters
exist in the eastern third of North Carolina for total
mortality, chronic obstructive pulmonary disease, total
cancer, colon cancer, and cerebrovascular disease. For the
1984-88 period, the highest overall adjusted death rate was
in DHR Region IV (the Eastern region)
.
The ten leading causes of deaths in 1988 were (in descending
order) heart disease, cancer, cerebrovascular disease,
unintentional injuries, chronic obstructive pulmonary
disease, pneumonia/influenza, diabetes, suicide, chronic
liver disease/cirrhosis, and homicide. However, based on
the number of years of life lost prematurely for each cause,
the order of the ten leading causes shifts to cancer, heart
disease, unintentional injuries, suicide, homicide,
cerebrovascular disease, chronic obstructive pulmonary
*North Carolina excesses for nonwhites reflect to some
extent the fact that the proportion of blacks in the N.C.
nonwhite population is greater than for the U.S., and mortality
rates for black males and females in each age group generally
exceed the corresponding nonwhite rates.
1-20
disease, chronic liver disease/cirrhosis, diabetes, and
pneumonia/ influenza
.
Nonwhite males have a greater risk of death from uninten-tional
injuries at every age interval except 15-24 and 85
and older where white males have the highest rates. The
1988 age-adjusted nonwhite male rates for motor vehicle and
all other unintentional injuries exceeded rates for white
males by 47 and 124 percent respectively.
Comparing the U.S. and N.C. 1987 unadjusted rates, mortality
in N.C. was more than 23 percent greater for unintentional
injuries and septicemia, 14 percent greater for cerebrovas-cular
disease, and five percent greater for homicide.
However, for most remaining leading causes including cancer
and diseases of the heart, the N.C. unadjusted rates were
two to 2 percent lower than the corresponding U.S. rates.
Total mortality for N.C. was one percent lower than for the
U.S. After adjusting for the state's more youthful age
structure, mortality conditions in N.C. appear less
favorable, especially for cerebrovascular disease,
unintentional injuries, and septicemia. The adjusted total
mortality rate for N.C. was nearly six percent greater than
for the U.S.
The 1988 total cancer rate was three percent above the rate
for 1987. Site-specific cancers showing large percentage
increases in rates for 1988 were leukemia (+10%) and cancer
of the pancreas (+8%). Of the four major cancers, rates for
three (trachea/bronchus/lung; breast; and prostate) each
increased by about six percent while cancer of the
colon/rectum/anus increased approximately two percent.
Cancer of the cervix uteri and stomach cancer each decreased
by about three percent. However, some of these increases
1-21
reflect aging of the state's population. After adjusting
for age, the increase in the total cancer rate between 1987
and 1988 dropped to one percent; the rate for cancer of the
colon/rectum/anus decreased by three percent; the rate for
breast cancer was essentially unchanged; and rates for
cancer of the trachea/bronchus/ lung and prostrate cancer
showed four percent increases. By race and sex, the 1988
age-adjusted rates for males were substantially higher than
those for females, and rates for nonwhites were higher than
those for whites.
Total cancer mortality (the unadjusted rate) increased
steadily (by 19 percent in total) between 1980 and 1988 and
rose 10 percent during the 1984-88 five-year period in
comparison to the 1979-83 period. Further comparisons of
the five-year periods show that unadjusted rates for cancer
of the trachea/bronchus/ lung and breast cancer each in-creased
by about 2 percent, and prostrate cancer and cancer
of the ovary and other uterine adnexa both increased by 13
percent. The rate for cancer of the cervix uteri decreased
by 10 percent, while leukemia and stomach cancer rates
decreased by two percent. Comparisons based on age-adjusted
rates show that total cancer increased by two percent, while
cancer of the trachea/bronchus/ lung and breast increased by
12 percent and 11 percent respectively.
Between the 1979-83 and 1984-88 five-year periods, the
pneumonia/ influenza and chronic obstructive pulmonary
disease (COPD) crude death rates in N.C. increased 26 and 28
percent respectively. For both causes, large crude rate in-creases
over the last five years occurred between 1987 and
1988. After adjusting for age, the mortality rate for
pneumonia/ influenza shows c relatively moderate increase
of eight percent between the 1979-83 and 1984-88 periods,
whereas the corresponding increase for COPD was more
1-22
substantial (about 15 percent) . Based on 1987 age-adjusted
rates, North Carolina's rates for COPD and
pneumonia/ influenza are about six percent and one percent
respectively less than corresponding U.S. rates (3).
Race-sex-specific age-adjusted rates show that males of both
races die from each of these causes substantially more often
than females. COPD mortality rates for whites are higher
than for nonwhites, while nonwhites have higher rates from
pneumonia/ influenza.
The suicide crude death rate decreased slightly in four of
the last five years. In 1988, the rate fell by less than
two percent, to slightly below the 1987 U.S. rate. Between
the 1979-83 and 1984-88 periods, the age-adjusted suicide
rate remained essentially stable. Based on 1984-88 age-ad-justed
data, the rate for white males is approximately twice
that of nonwhite males and nearly three times that of white
females, while nonwhite females have an age-adjusted rate
less than half that of white females.
The homicide crude death rate increased from 1984 to 1986,
then decreased in 1987 and 1988. For the five-year period
1984-88, the rate was 16 percent lower than for the preced-ing
five years (1979-83), although it was above the U.S.
rate for 9 of the 10 years between 1979 and 1988. Between
1987 and 1988, the age-adjusted homicide rate declined about
11 percent for whites and increased five percent for
nonwhites of both sexes. In 1988 about 40 percent of all
homicide victims were nonwhite males; yet nonwhite males
represent only 11 percent of the total population. The
age-adjusted homicide rate for nonwhite males exceeded that
for white males by 327 percent.
1-23
PREMATURE MORTALITY IN NORTH CAROLINA
Since 1914, when deaths were first centrally recorded in
North Carolina, the leading causes of mortality have been ranked
according to number of deaths. North Carolina deaths in 1988
have been ranked in Table A for each race-sex group based on this
traditional method. As shown, heart disease and cancer are the
leading causes of death for each group, unintentional injuries
are the third leading cause for white and nonwhite males, and
stroke (cerebrovascular disease) is the third leading cause for
white and nonwhite females. The rankings of most causes, as well
as the sizes of the rates for the same cause, vary among the four
groups.
Rankings based only on number of deaths (or rate per 100,000
population), however, do not necessarily indicate where medical
and public health intervention strategies can be most effectively
employed. Since death is postponable but not preventable, age at
death is a key factor to consider. Prevention of a death that
would otherwise occur early in life could be assigned higher
priority than prevention of a death later in life. A convenient
method of ranking causes of death that incorporates age at death
is by "years of life lost" (7) . If the average life expectancy
at birth for white males, for example, is 70 years, a death at
age 65 would mean five years of life lost (on the average) , while
a death at age 40 would mean 30 life-years lost. A white male
infant death results in 70 years of life lost, whereas deaths at
ages 70 and over do not contribute to "life-years lost" for white
males. Based on the 1990 life tables for North Carolina (43) ,
the life expectancies used here to calculate years of life lost
were 72 for white males, 80 for white females, 67 for nonwhite
males, and 76 for nonwhite females. For each death in a given
cause group, age at death was subtracted from the appropriate
life expectancy and all of these life-years lost were then
summed for that race-sex group. Deaths over the specified life
1-24
expectancies were not counted. A rate of years-of-life-lost per
100,000 population was then computed tor ranking the causes of
death, so that comparisons can be made across race-sex groups.
These rates are given in Table B.
A more accurate determination of years of life lost is based
on an average expected remaining years of life for each age of
death rather than an average life expectancy at birth. This
procedure was considered too complicated for the present applica-tion,
and probably would not produce rankings substantially
different from those in Table B. It v/ould place somewhat less
emphasis on infant mortality, since more years of life lost would
be generated for the causes listed in Table B.
Table B displays the leading causes of death ranked accord-ing
to years of life lost per 100,000 population. Heart disease
and cancer are still very important causes of death from this
perspective, but other causes become much more prominent than
before. Unintentional injuries (motor vehicle injuries and other
injuries combined) account for more than twice as many years of
life lost for nonwhite males than any other cause except heart
disease, and were also the top-ranked cause for white males. The
general seriousness of injuries as a life and health hazard is
clearly shown in this table. Unintentional injuries become a
much more important cause of death relative to heart disease from
this perspective, since injury decedents (who died prior to
normal life expectancy) are on average about 28 years younger
than heart disease decedents. Likewise, cancer decedents who die
prior to normal life expectancy are on average more than two
years younger than heart disease decedents. Cancer accounts for
the most years of life lost among white women and in total, in
part because the life expectancy for white women is substantially
longer than for any other race-sex group.
1-25
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REFERENCES FOR SECTION I
United States Department of Health, Education, and Welfare.
Public Health Service, National Vital Statistics Division.
Vital Statistics of the United States. Volume II-Mortality
(Part A) . Washington, 1960, 1970.
U.S. Department of Health and Human Services. Public Health
Service, National Center for Health Statistics. Vital
Statistics of the United States, Volume II-Mortality (Part
A) . Washington, 1980.
U.S. Department of Health and Human Services. Public Health
Service, Centers for Disease Control, National Center for
Health Statistics. Vital Statistics of the United States.
Volume II-Mortality (Part A) . Washington, 1987,
International Classification of Diseases. 9th Revision.
Volume 1. Diseases; Tabular List . Commission on Professional
and Hospital Activities, Ann Arbor, MI, 1980.
Grove, R.D.; Hetzel, A.M. Vital Statistics Rates in the
United States: 1940-1960 . Public Health Service Publication
Number 1677, U.S. Government Printing Office, Washington,
1968.
SAS Institute Inc. SAS User's Guide; Statistics. 1982
Edition . Cluster Procedure. Cary, N.C.
1-2!
7. Kleinman, J.C. Statistical Notes for Health Planners; Mor-tality
. Public Health Service Publication Number 1677, U.S.
Government Printing Office, Washington, 1968.
8. Lalonde, M.A. A New Perspective on the Health of Canadians .
Government of Canada, Ottawa, 1974.
9. North Carolina Department of Human Resources, Division of
Health Services, Public Health Statistics Branch. "Associa-tions
Between Mortality and Various Social, Economic, and
Environmental Factors in North Carolina," PHSB Studies . No.
3, Raleigh, April 1977.
10. Landrigan, P.J. "Comment: The Effects of Ozone Pollution on
Our Children." The Nation's Health . Vol. XIX, No. 4, April,
1989, pg. 9.
11. Gannon, I.R., "President's Column," The Nation's Health ,
Vol. XIX, No. 7, July, 1989, pg. 2.
12. Gannon, I.R., "President's Column," The Nation's Health .
Vol. XIX, No. 4, July 1989, pg. 2.
13. Schoenborn, C.A. "Health Habits of U.S. Adults, 1985: the
"Alameda 7" Revisited," Public Health Reports . Nov-Dec; Vol
101, No. 6, 1986, pp. 571-580.
14. North Carolina Department of Human Resources, Division of
Health Services, Public Health Statistics Branch. "Health
Characteristics of Adults in North Carolina," PHSB Studies .
No. 11, Raleigh, NC, July 1978.
15. Waldron, I, "Why Do Women Live Longer Than Men?," Social
Science and Medicine . Vol. 10, 1976, pp. 349-362.
1-29
16. Syme, S.L.; Berkman, L.F. "Social Class, Susceptibility, and
Sickness," American Journal of Epidemiology . Vol. 104, No.
1, 1976, pp. 1-8.
17. What Are The Facts about Genetic Disease ? The National
Institute of General Medical Sciences, The National Insti-tutes
of Health, Bethesda, MD, 1980.
18. North Carolina Department of Human Resources, Division of
Health Services, Public Health Statistics, North Carolina
Vital Statistics ; Quarterly Provisional Report . Raleigh,
January-March, 1978.
19. Robinson, C.G. "Causes, Occular Disorders, Associated
Handicaps, and Incidence and Prevention of Blindness in
Childhood," in Visual Impairments in Children and Adoles-cents
, eds. Jan, S.E.; Freeman, R.D.; and Scott, E.P.; Grune
& Stratton, New York, 1977.
20. N.C. Department of Human Resources, Division of Health
Services, State Center for Health Statistics, "North Caroli-na
Surveillance of Birth Defects." SCHS Studies . No. 52,
Raleigh, September 1989.
21. McKeown, T. ; Brown, R.G. "Medical Evidence Related to
English Population Changes in the Eighteenth Century,"
Population Studies . No. 9, 1955, pp. 119-141.
22. Jonas, S. Health Care Delivery in the United States . Third
Edition, Springer Publishing Company, New York, 1986, pp.
24-25.
23. McKeown, T. The Role of Medicine: Dream. Mirage, or Nemesis .
London: The Nuffield Provincial Hospitals Trust, 1976.
1-30
24. Cassel, E. Human EcoIocty and Public Health . Kilbourne and
Smillie, Editors, 1969, pg. 353.
25. White, K. Personal communication. 1982, in Jonas, S. Health
Care Delivery in the United States . Third Edition, Springer
Publishing Company, New York, 1986, pg. 25.
26. Paf fenbarger, R.S.; Brand, R.J.; Sholtz, R.I.; Jung, D.L.
"Energy Expenditure, Cigarette Smoking, and Blood Pressure
Level as Related to Death from Specific Diseases," American
Journal of Epidemiology . Vol. 198, No. 1, 1978, pp. 12-18.
27. Eyer, J. "A Diet/Stress Interaction Hypothesis of Coronary
Heart Disease Epidemiology," International Journal of Health
Services . Vol. 9, No. 1, 1979, pp. 161-168.
28. Manton, K.G.; Patrick, C.H. ; and Johnson, K.W. "Health
Differences between Blacks and Whites: Recent Trends in
Mortality and Morbidity," The Milbank Quarterly . Vol. 65,
Suppl. 1, 1987, pp. 129-199.
29. Doll, R. "The Smoking Induced Epidemic," Canadian Journal of
Public Health . Vol. 72, November-December, 1981, pp. 372.
30. Curtiss, J.; Grahn, R.B.; Grahn, D. "Population Characteris-tics
and Environmental Factors That Influence Level and
Cause of Mortality: A Review," Journal of Environmental
Pathology and Toxicology . Vol. 4, No. 2, 1980, pp. 471-511.
31. Doll, R. ; Peto, R. "The Causes of Cancer: Quantitative
Estimates of Avoidable Risks of Cancer in the U.S. Today,"
Journal of the National Cancer Institute . 1981.
1-31
32. US Department of Health and Human Services, Office on
Smoking and Health. The Health Consequences of Smoking;
Cancer, A Report of the Surgeon General . Rockville, Md.,
1982.
33. Shalat, S.L; B.; Pidcock, C. , et. al. "Risk Factors for
Alzheimer's Disease: A Case-Control Study," Neurology . Vol.
37 No. 10, October, 1987 pp. 1630-1633.
34. Davis, S.; Severson, R.K. "Increasing Incidence of Cancer of
the Tongue in the United States Among Young Adults". (Let-ter),
Lancet 2 (8564), pp. 910-911, October 17, 1987.
35. Connoly, G.N.; Blum, A; Richards, J.W. Smoke Screen Around
Oral Snuff. (Letter), Lancet 2 (8551), pg. 160, July 18,
1987.
36. Waldron, I. "The Contribution of Smoking to Sex Differences
in Mortality", Public Health Reports . 101(2), March-April
1986, pp. 163-173.
37. Walker, A.R. "Dietary Goals, Sensible Eating, and Nutrition
in the Future," South African Medical Journal . Vol 57, No.
4, 1980, pp. 471-511.
38. West, L.J.; Maxwell, D.S.; Noble, E.P.; Solomon, D.H.,
"Alcoholism." Annals of Internal Medicine . Vol. 100, 1984,
pp. 405-416.
39. Schmidt, W. ; Popham, R.E. "Heavy Alcohol Consumption and
Physician Health Problems: A Review of Epidemiological
Evidence," Drug and Alcohol Dependence , Vol. 1, No. 1, 1975,
pp. 27-50.
1-32
40. Dyer, A.R. ; et al. "Alcohol Consumption, Cardiovascular Risk
Factors, and Mortality in Two Chicago Epidemiologic Stud-ies,"
Circulation . Vol. 56, No. 6, December, 1977, pp.
1067-1074.
41. Buescher, P. A.; Patetta , M.J., "Alcohol-Related Morbidity
and Mortality in North Carolina." SCHS Studies . N.C.
Department of Human Resources, Division of Health Services,
State Center for Health Statistics, No. 41, July, 1986.
42. Egbuonu, L. "Child Health and Social Status," Pediatrics .
Vol. 69, No. 5, 1982, pp. 550-557.
43. Haan, M. ; Kaplan, G.A.; Camacho, T. "Poverty and Health:
Prospective Evidence from the Alameda County Study." Ameri-can
Journal of Epidemiology . Vol. 125, No. 5, June, 1987,
pp. 989-998.
44. Verbrugge, L.M. "Recent Trends in Sex Mortality Differen-tials
in the United States," Women and Health , Vol. 5, No.
3, 1980, pp. 17-37.
1-33
11. TECHNICAL NOTES
NORTH CAROLINA POPULATION BASES
Every ten years (years ending in zero) the United States
Bureau of the Census has conducted a count of the United States
population, which includes a profile of the population's charac-teristics
such as age, race, and sex. After a census year,
estimates of population size and composition are based on knowl-edge
of the population in the census year plus subsequent events
such as births, deaths, and migration. In the later years of a
decade, these estimates may depart considerably from the "true"
population values if the assumptions about population changes
differ significantly from what actually occurred. Since almost
all mortality rates in CHES publications are based on population
counts in the denominator, changes in estimates of population
such as might result from a new census could cause substantial
changes in the trend of rates over time.
State and county population bases are obtained from the
North Carolina Office of State Budget and Management, and incor-porate
assumptions about births, deaths, net migration, and
institutional populations (1) . In this volume the reader should
note that pre-1988 rates have been corrected for changes in
population bases in order to interpret trends. These corrected
rates may differ slightly from the rates shown in previous CHES
publications.
2-3
MORTALITY RATES
COMPUTATION OF MORTALITY RATES
In this report, total death rates are expressed as resident
deaths per 1,000 population while all cause-specific mortality
rates are expressed as resident deaths per 100,000 population.
All rates in Tables 1-20 use total population in the denominator,
except rates for the sex-specific cancer sites, which use male or
female population in the denominator. Population bases for these
rates were provided by the Office of State Budget and Management
in the Governor's Office. The infant mortality rates of Table 21
and Figure 17 are computed as the number of resident deaths under
one year of age per 1,000 resident live births.
Vital events in this report are allocated to place of
residence. For deaths of inmates of long-term institutions
(mental, penal, old age, orphan, nursing home, rest home, etc.),
the institution is considered the usual residence provided the
decedent had resided in the institution at least one year.
College students and military personnel are considered residents
of the college or military community.
The following definitions apply to the rates of Tables 2-20.
Unadjusted Annual Death Rate: the annual death rate
computed as resident deaths per 1,000 or 100,000
population. These rates permit the user knowledge of
an area's status with respect to the observed incidence
of mortality during the given year.
2-4
Unadjusted 5-year Death Rate: the average annual death
rate computed as average resident deaths per 1,000 or
100,000 average population. These rates permit the
user knowledge of an area's status with respect to the
observed incidence of mortality during the 5-year
period. These rates are depicted in the Series A maps
(e.g.. Figures 2. A, 3. A, etc.).
Adjusted 5-Year Death Rate: the average annual age-race-
sex-adjusted rates computed by the direct method.
Also expressed as deaths per 1,000 or 100,000 popula-tion,
these rates are those which would be expected if
the average annual age, race, and sex composition of
each county's population were the same as that estimat-ed
for the state. These rates are free of differing
effects of age, race, and sex and thus permit the user
knowledge of an area's status with respect to other
determinants of mortality during the 5-year period.
Adjusted rates for different time periods cannot be
directly compared unless they were adjusted by the same
standard population. The adjusted rates are depicted
in the Series B maps (e.g., Figures 2.B, 3.B, etc).
[Note: For the two sex-specific cancer sites (female
breast and prostate) , rates are adjusted for age and
race and denominators are sex-specific]
Except as noted in the text of this report, the age-adjusted
death rates cited in the narrative (not the age-race-sex adjusted
rate in tables 2-20) use the 1940 U.S. Census as the standard for
direct age-adjustment, following the convention of the National
Center for Health Statistics. The use of this standard is
necessary for comparison of N.C. and U.S. age-adjusted rates.
2-5
For the maps, a clustering routine* from the Statistical
Analysis System (SAS) was used to group counties that are "most
like each other" with respect to their unadjusted rates and then
their adjusted rates (2). These maps show six levels of death
rates, where level one is the lowest rate interval and level six
the highest.
INTERPRETATION OF MORTALITY RATES
To assess an area's relative mortality conditions during a
five-year period, both the unadjusted rate and the adjusted rate
can be compared to the state rate for a particular cause of
death. Then, provided the area's unadjusted rate represents a
relatively stable situation, viz., the rate has not fluctuated
widely in recent years, the following alternative diagnoses will
apply:
Relative Status Of
Unadjusted Adjusted
Rate Rate Diagnosis
Low Low Low mortality is not due to age, race,
and sex factors; other mortality condi-tions
are favorable.
*In 1983 the CHES conducted an evaluation of several
clustering methods. It was found that one method, called
"Average Linkage Method," produced tighter clusters (i.e.,
clusters with smaller within-cluster variances) than the
other methods examined. Consequently, we have used this
method henceforth to cluster county rates in all CHES publica-tions.
2-6
Relative Status Of
Unadjusted Adjusted
Rate Rate Diagnosis
Low High Low mortality is due to favorable age,
race, and sex factors; other mortality
conditions are unfavorable.
High Low High mortality is due to unfavorable
age, race, and sex factors; other mor-tality
conditions are favorable.
High High High mortality is not due to age, race,
and sex factors; other mortality condi-tions
are unfavorable.
In using adjusted rates, it is important that the user
understand the reason for adjustment. The following hypothetical
example illustrates. Here, A and B stand for population sub-groups,
e.g., whites and nonwhites, males and females, etc.
COUNTY STATE
DEATH DEATH
POPULATION DEATHS RATE* POPULATION DEATHS RATE*
Population A
Population B
Total
300, 000
10,000
310, 000
1,000 333.3
10 100.0
1,010 325.8
500, 000
800, 000
1,300,000
2,500 500.0
1,000 125.0
3,500 269.2
Deaths per 100,000 population.
Compared to the state, county subgroups A and B both have
lower rates, but the county as a whole (A and B combined) has a
higher rate. This seemingly paradoxical situation results from
two factors: different proportions of A and B in the county vs.
2-7
the state population and wide differences between the rates for A
vs. B. In this example, it is true that the county has a higher
total rate—BUT ONLY BECAUSE THE POPULATION CONTAINS A HIGH
PROPORTION OF SUBGROUP A.
Certainly, it is important for program planners to know that
the county has a high rate relative to the state rate; this
information is needed in determining manpower and facility needs,
etc. But in assessing "risk," the researcher needs to adjust for
confounding factors such as age or race. To do this, one multi-plies
each population-specific county rate by the corresponding
"standard" population, sums these results, and divides by the
total "standard." In the above example, using the state popula-tion
as the standard, the computation is:
(1,000/300,000 X 500,000) + (10/10,000 X 800,000)
= 0.001897 or
189.7 per
1,300,000 100,000 population
Thus, as rates specific for A and B imply, the county's rate
is lower than the state's rate after adjustment for the factor
represented by A and B.
CAUTION!
In assessing the relative mortality conditions of a county,
one should be particularly aware of rates based on small numbers
of deaths since, in such cases, random fluctuation in the rate
may render rate comparisons risky. The reader should read very
carefully the next section entitled "Flagging Biased Rates."
2-8
FLAGGING BIASED RATES
This section discusses the problem of unstable mortality
rates and then describes a method of flagging rates with a large
bias in a given year. The reason for flagging an unstable or
possibly biased rate is to provide the reader with a criterion
for placing confidence in statements, tables, maps, and other
interpretative displays of the mortality data. Not all calcu-lated
rates are an accurate portrayal of the "true" force of
mortality, and the intent of this section is to caution the
reader against uncritically using the rates in this volume.
Especially in the maps, the reader should be alert to unusually
high rates that may result from very small numerators or from the
type of bias described below.
Any rate with a small number of events (deaths) in the
numerator will be unstable, with possibly large random fluctua-tions
from year to year that do not comprise a significant trend.
Such a rate is said to have a large standard error . A useful
rule is that any rate based on fewer than 20 events in the
numerator may have a 95 percent confidence interval that is wider
than the rate itself (3). For example, in an area with 20 deaths
out of 20,000 population, the measured rate, stated as deaths per
100,000 population, would be 100. But due to variability over
time in rates based on small numerators, one could say with 95
percent certainty that the underlying or "true" rate (of which
the sample rate of 100 is the best estimate) is between approxi-mately
50 and 150 deaths per 100,000. The width of the interval
(100) is relatively large because rates based on small numerators
may differ considerably from the actual or "true" rate. Many of
the rates in this volume have numerators smaller than 20 and thus
a large standard error, and any conclusions about trends based on
these rates should be made very cautiously, if at all.
The age-race-sex-adjusted rates in this volume, described in
2-9
the previous section, are likewise subject to random variability
over time, and those rates involving a small number of deaths
will be the most unstable. For example, one death out of an
estimated population of 5 would produce a death rate of 20,000
per 100,000 population. If this rate were applied to the appro-priate
age-race-sex group of the standard population, a very
large number of expected deaths would result and the adjusted
rate would be biased.
Counties with a small number of persons in one or more of
the 40 age-race-sex groups are most likely to have adjusted rates
with a large standard error, and these rates therefore show
substantial random fluctuation over time. In this volume an
adjusted rate is flagged if: a) applying the age-race-sex-specif-ic
rates of a county for a given cause to the standard population
results in more than 25 percent of the total expected deaths
being generated by one cell, and b) the denominator of the rate
is also less than 50 (an average of 10 per year) . These criteria
will catch only the worst problems. Only 21 out of a total
of 1900 county adjusted rates in this volume are flagged by this
method
.
In addition to putting asterisks by those 1984-88 adjusted
rates with a large bias due to an extremely high age-race-sex-specific
rate, the rates have been recomputed by substituting the
appropriate North Carolina age-race-sex-cause-specific rate in
the problem cell. Table C on the next page compares the flagged
rates with the rates where the state rate has been substituted.
The reader who must use one of these flagged rates is advised to
use the rate in this table with the substitution instead. If the
latter rate is clearly out of line with the North Carolina rate
in the last column, the rate should be treated as missing data.
2-10
u
PROCEDURE FOR GEOGRAPHIC CLUSTERING OF COUNTIES
In all editions of this report, county rates for each
leading cause of mortality have been mapped. As described in the
Introduction of this volume, these maps show counties grouped
together (in six groups) based on similar rates—in other words,
a numerical clustering of rates. From these maps, one might
imply "spatial" clustering if counties with high rates happen to
be contiguous to each other. However, under this procedure there
is no way to know whether this clustering is a statistically
significant geographic cluster or an artifact of the SAS cluster-ing
procedure (2)
.
In 1980 the CHES in conjunction with the UNO Department of
Biostatistics developed a new statistical procedure for detecting
and characterizing spatial clusters. This procedure determines
whether apparent geographic clustering of counties with high
rates is statistically significant. Only a brief summary of the
mechanics of the procedure is presented in this section. For a
detailed description, readers should consult the appropriate
reference (4) or contact the Center for Health and Environmental
Statistics.
Briefly the mechanics of this procedure are as follows:
1. Counties are listed in rank order of their unadjusted or
adjusted rates (highest rates first) for each cause of
death.
2-12
For each county listed, cumulative counts are obtained of
the number of counties and the number of adjacencies in-volved
between the county and other counties with higher
rates. Two counties are considered adjacent if they have a
common nonsalt-water boundary. For some "pairs" of counties
(in particular, counties which seem to touch only at one
point on a map) , it was difficult to decide whether these
counties are adjacent. These "troublesome pairs of coun-ties"
in North Carolina are discussed in the paper refer-enced
above as are the decisions made with regard to these
pairs.
Finally, a reference table is used to obtain for the cumula-tive
number of high-rate counties a significance level based
on the number of adjacencies observed. While a few adjacen-cies
might be expected to occur randomly, a relatively large
number of adjacencies will have a low probability of random
occurrence. In this report, the high-rate counties are said
to cluster geographically if the probability of such random
occurrence is .05 or less; maps for a given disease are
included in the text only if statistically significant
geographic clusters were found to exist.
This procedure can result in one or more groups of contigu-ous
high-rate counties. For some diseases, no clusters of
this type exist. For some others, one, two or more clusters
exist. In the latter case, a disease may cluster with high
rates in one part of the state and with other tiers or
levels of high rates in other parts of the state. In this
report each map shows the multi-tiers or levels via differ-erent
shading schemes to represent the relative levels of
the high death rates.
This method is a simple and inexpensive approach for recog-nizing
mortality patterns of varying intensity in geographi-cal
areas and for testing for clusters.
2-13
REFERENCES FOR SECTION II
1. North Carolina Office of State Budget and Management,
Management and Information Services. North Carolina Popula-tion
Projections; 1988-2010 , Raleigh, 1988.
2. SAS Institute Inc. SAS User's Guide: Statistics, 1982
Edition . Cluster Procedure. Cary, N.C. 1982.
3. Kleinman, J.C. "Infant Mortality," Statistical Notes for
Health Planners . No. 2, National Center for Health Statis-tics,
Rockville, Md, July, 1976.
4. Crimson, R.C.; Wank, K.C.; & Johnson, P.W.C. "Searching for
Hierarchical Clusters of Diseases: Spatial Patterns of
Sudden Infant Death Syndrome," Social Science Medicine , Vol.
15D, pp. 287-293, 1981.
2-14
GENERAL MORTALITY IN
NORTH CAROLINA
GENERAL MORTALITY IN NORTH CAROLINA
During 1988 a total of 57,630 North Carolinians died. This
number represents an annual death rate of 8.9 resident deaths per
1,000 population, three percent above the rate of 8.6 for 1987,
and is the highest rate over the past 10 years. The 1987 rate
for the United States (the most recent year for which data are
available) was higher at 8.7 (1). The N.C. unadjusted rate rose
in six of the last 10 years. The greatest increases occurred
during the 1984-88 period, when the overall rate was five percent
greater than in the preceding (1979-83) five-year period.
One confounding factor in making comparisons of mortality
rates is that age structure of a population, which has an impor-tant
impact on mortality, may vary among geographic areas and
over time. Compared to the nation. North Carolina has a younger
but more rapidly aging population. Thus, adjusting the North
Carolina and United States mortality rates for age, a higher
mortality rate is obtained for N.C. than for the U.S. The 1987
age-adjusted North Carolina rate (5.7) was nearly six percent
higher than the age-adjusted United States rate (5.4), illustrat-ing
that N.C.'s lower unadjusted rate (in comparison to the U.S.)
is due to its favorable age structure (i.e., more people at the
young low-risk ages)
.
While the N.C. trend for unadjusted rates indicates some
increase in mortality, examination of age-adjusted rates shows a
different pattern. From 1979-83 to 1984-88 the risk of death for
North Carolinians actually declined by five percent, from 6.0 to
5.7 per 1,000 population. Over the longer span since 1974-78,
3-3
the state's age-adjusted rate declined by 15 percent.
Age. Race, and Sex Groups
Within the general comparisons of mortality noted above,
significant subgroup differences are concealed, especially
between N.C. and the U.S. For example, while the 1987 unadjusted
U.S. rate was higher than that for North Carolina, mortality
rates for infants and for age groups 1-4, 5-14, and 45-54 were
each more than 10 percent greater than corresponding United
States rates. In fact, only two age groups (15-24 and 85 and
over) had rates lower than the U.S. rates.
As observed with age, general comparisons can mask varia-tions
by race and sex. Looking at North Carolina deaths in the
1984-88 period, the male rate (9.5) exceeded the female rate
(7.7) by 23 percent. For the previous five-year period (1979-
83) , the male rate was 3 4 percent greater than the female rate;
hence differences in mortality by sex have diminished over time.
Differences in unadjusted death rates by race were relatively
minor and have also decreased: the white and nonwhite rates were
each 8.6 during the 1984-88 period, while the nonwhite rate
exceeded the white rate (8.4 to 8.2) during the 1979-83 period.
(2, 3) Nonwhites have a younger age structure than whites and
this accounts for their similar unadjusted death rates.
These comparisons mask the exceedingly high overall
mortality rate for nonwhite males. Adjusting the race-sex-spe-cific
rates for age using the 1940 U.S. population as the stan-dard,
the 1984-88 adjusted rate was lower than the unadjusted
rate for each race-sex group except nonwhite males, who had a
higher rate after adjustment. This finding implies that nonwhite
males are dying at younger ages than any other race-sex group, a
fact also revealed by the age-specific rates. With the exception
of the 85+ age group (based on 1988 data) , nonwhite males had the
highest age-specific mortality rates of the four race-sex groups.
3-4
In each of the ten-year age groups between ages 2 5 and 54, the
rates for nonwhite males were at least twice the rates for white
males (the next highest group). However, after age 54, differ-ences
between white and nonwhite males are much smaller, and the
rate for nonwhite males older than 84 is lower than that for
white males.
In Sections IV through IX, important differences in risks of
mortality by age, race, and sex groups will be described for each
cause.
Underlying Causes of Death
A statistically complex study conducted by the CDC (4,5)
shows that only 11 states ranked worse than North Carolina on a
composite index based on 1986 age-adjusted mortality rates for
nine causes* (i.e., stroke, coronary heart disease, cirrhosis,
obstructive pulmonary disease, lung cancer, breast cancer,
colorectal cancer, cervical cancer, and diabetes mellitus)
.
These causes accounted for 52 percent of deaths nationally and in
North Carolina during 1986.
Four major causes of mortality—heart disease, cerebrovascu-lar
disease, cancer, and cancer other than lung-- have exhibited
interesting patterns of change in North Carolina over the past 38
years. The following figures depict cumulative percent changes
in death rates for these causes as well as total mortality over
seven successive time periods since 1950-59. Results are shown
for four race-sex groups. The first figure represents decedents
*Groupings of ICD codes for these diseases differ from the
groupings used by CHES in this volume. These nine diseases were
selected based on diversity in their mortality rates between 1979
and 1986.
3-5
45-64 years old at death. The cumulative percent increase in
lung cancer rates for each race-sex group is striking: it
exceeds 100 percent earliest (by the 1965-69 period) for nonwhite
men and white women and latest (by the 1975-79 period) for
nonwhite women. However, after the 1960-64 period, the rate of
increase for nonwhite women appears to accelerate.
CUMULATIVE PERCENT CHANGE IN DEATH ElATES — SELECTED CAUSES OF DEATH
BY RACE AND SEX, AGE 45-M, SINCE TIME PERIOD 1950-1959
NORTH CAROLINA
WHIIT MHN WlilTE WOMtN NONWHITE MEN Nt)NWHlTE WOMEN
CUMULATIVE
PERCENT
CHANGE
2 3 4 5 6 7
ToLal Morulity
TIME PERIODS
—K Heart OiseaK
-^ Cerchrovascular Dis<:aM-Cancer
other than Lung ^ Lung Cancer
1950-1959
1960-1964
1965-1969
1970-1974
1975-1979
1980-1984
1985-1988
For nonwhite men, the cumulative percent change for cancer
other than lung increases sharply through the 1975-79 period,
after which a modest decline appears. The pattern for white men
is similar, but the cumulative percent increase is smaller and
the decline occurs later. Cumulative percent changes for white
3-6
women are relatively small with no clear trend, while the cumu-lative
changes for nonwhite women show a decreasing trend over
most of the time intervals.
The patterns and magnitudes of changes for total mortality .
heart disease . and cerebrovascular disease are essentially
similar among the race-sex groups: after the 1970-74 period, all
cumulative percent changes are negative, reflecting decreasing
mortality rates. Total mortality for white women declined the
least, while total mortality for nonwhite women showed the
greatest cumulative percent decrease. The cumulative percent
decrease for white men was greater than for nonwhite men.
The following figure presents the same information for
decedents in the 65-74 age group. While the lung cancer rate for
nonwhite women showed a slight decrease in the 1975-79 period,
the cumulative percent increase still exceeded 100 percent by the
1980-84 period. For the remaining causes, the pattern and
magnitude of changes in cumulative percentages are similar to the
preceding figure with one notable exception: for each race-sex
group except white women, the cumulative percent change for
cancer other than lung is clearly positive by the 1985-88 period.
Taken together, these figures show that the rates for total
mortality, heart disease, and cerebrovascular disease have
decreased for each race-sex group, while lung cancer rates have
increased. Cumulative percent changes for cancer other than lung
show clear increases for nonwhites and white males in the 65-74
age group, but only for nonwhite males in the 45-64 age group.
These trends are especially noteworthy because of the relatively
long time periods involved.
3-7
CUMULAllVE PERCENT CHANGE IN DEATH RATE^ — SELECTED CAUSES OF DEATH
BY RACE AND SEX, AGE 65-74, SINCE TIME PERIOD 1950-1959
NORTH CAROLINA
WHITE WOMEN NONWHITE MEN NONWHITE WOMEN
CUMULATIVE
PERCENT
CHANGE
12 3*567 12 3 4 5 8 7 2 3 4 5 6 7
TIME PERIODS
X X K K
e e 6 e
Total Mortality
¥. Hean Dueaic
^ Cerebrova*cular Di^ea&e
Cancer other than Lung
Lung Cancer
Time Period 1 1950-1959
1960-1964
1965-1969
1970-1974
1975-1979
1980-1984
1985-1988
GEOGRAPHIC PATTERNS
The 1984-88 unadjusted total mortality rates for counties
(Figure 2. A) ranged from 4.3 in Onslow County to 12.9 in Swain
County, with a state rate of 8.9 per 1,000 population. Figure
2. A shows several scattered groups of high-rate counties, with
the northeast seemingly having the largest cluster. In some
cases, these high rates reflect unfavorable mortality conditions
other than age, race, and sex, since among the 33 counties in the
two highest rate levels (Figure 2. A), 16 were in the top three
levels after adjustment for age, race, and sex (Figure 2.B). In
addition, Figure 2.B shows a large band of contiguous, high-rate
3-8
counties extending from Virginia to South Carolina in the eastern
third of North Carolina.
Based on procedures described in Section II of this volume,
the clustering of 13 northeastern counties with high unadjusted
death rates was found to be statistically significant (see map
below) . In fact, eight of the ten highest-rate counties are in
the northeastern cluster. A smaller cluster of seven counties
appears in the southwest. Together, these clusters include 2 of
the 25 counties with the highest mortality rates in the 1984-88
period.
GENERAL MORTALITY
MORTALITY RATES PER 100,000 POPULATION
11.1310 12.87 (P<-05)
10.32 to 10.97 (p<-.05)
D 4.30 to 10.32
NORTH CAROLINA
RESIDENT DATA
1984-1988
The cluster of high adjusted rates forming a north-south
band of 19 eastern counties was also found to be statistically
significant (see next map) . Unlike the unadjusted rates, only a
single two-county adjacency appears in the west. Thus, eastern
North Carolina is experiencing high levels of mortality that
cannot be explained on the basis of age, race, and sex factors.
In this case, high mortality may be due to socioeconomic and
health resource factors, or to some other set of local conditions
that invite intervention. A similar north-south cluster appeared
in the 1981 version of this volume (6) ; hence this grouping of
counties with high rates of total mortality persists.
3-9
The cause-specific data in the sections to follow will aid
counties in identifying their particular kinds of mortality
proneness.
GENERAL MORTALITY
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
9.44 to 10.93 (P<-05)
9.35 to 9.42 (fX-05)
H 9.28 to 9.35 (P<-01)
D 7.07 to 9.20
NORTH CAROLINA
RESIDENT DATA
1984-19B8
3-10
r A b L c - 2
murtality statistics hjr 19b&
-^ortm Carolina klSiocuTs
total deathi,(ptr 10 jo population;
GcOORaPHICAL
ARfcA
NORTH CAROLINA
REGIONS
DHR I wcSTcRN
OUR II N. CENTRAL
0^R III S. CtNTRAL
OHR IV tASTtRN
riSA
HSA III
HSA
HSA
riSA
I MfcSTcRN
II PIcD^UNT
S. PIbDIUNT
IV CAPITAL
V CARDINAL
VI EAST CRN
NOMbER
MOKTALITy STATISTICS FOK I9a8. l^^OKTH CAROLINA RESIDENTS
T3TAL UEATHSCt-ER 1000 POPULATIO-^) CONT'D.
GENERAL MORTALITY
MORTALITY RATES PER 100,000 POPULATION
n
12.75 to 12.87
10.05 to 11.97
8.55 to 9.97
7.69 to 8.44
5.82 to 7.30
4.30 to 4.30
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 2.A
GENERAL MORTALITY
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
10.93 to 10.93
9.75 to 10.30
9.02 to 9.59
8.33 to 8.92
7.80 to 8.26
7.07 to 7.67
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 2.B
3-13
REFERENCES FOR SECTION III
1. U.S. Department of Health and Human Services. Public Health
Service, Centers for Disease Control, National Center for
Health Statistics. Vital Statistics of the United States.
Volume II-Mortalitv (Part A) . Washington, 1987.
2. N.C. Department of Environment, Health, and Natural Resourc-es,
Center for Health and Environmental Statistics. North
Carolina Vital Statistics 1988. Volume 1; Births. Deaths.
Population. Marriages. Divorces . Raleigh, November 1989.
3. North Carolina Department of Human Resources, State Center
for Health Statistics. North Carolina Vital Statistics
1983. Volume 1: Births. Deaths. Population. Marriages.
Divorces. Raleigh, March 1983.
4. Thacker. S.B.; Koplan, J. P.; Letter to State Epidemiologists
and Chronic Disease Program Directors. Centers for Disease
Control, Atlanta, GA, November 1989.
5. "Chronic Disease Reports: Mortality Trends - United States,
1979-1986." Morbidity and Mortality Weekly Report . Massa-chusetts
Medical Society, Waltham, MA, March 31, 1989.
6. North Carolina Department of Human Resources, State Center
for Health Statistics. Leading Causes of Mortality: North
Carolina Vital Statistics. Volume 2. 1981 . Raleigh, Septem-ber
1983.
3-14
IV. MAJOR CARDIOVASCULAR
DISEASE MORTALITY
HEART DISEASE
Nearly 34 percent of deaths among North Carolina residents
in 1988 resulted from heart disease, which has been the leading
cause of death for the state and the nation for more than 50
years (1). Heart disease ranks second behind cancer in potential
years of life lost by all North Carolinians. It ranks first
among nonwhite females.
Diseases of the heart accounted for 19,421 North Carolina
deaths in 1988, a rate of 299.4 per 100,000 population. While
the 1987 rate for the United States was higher at 312.4, North
Carolina's 1987 age-adjusted rate was 6.2 percent higher than the
nation's (2). In 1986, N.C.'s age-adjusted coronary heart
disease death rate was the tenth highest among the 50 states (3).
The risk of death from heart disease has declined in North
Carolina, with the 1984-88 age-adjusted rate representing an 11
percent decrease since 1979-83. The largest decrease was among
white males for whom the 1984-88 age-adjusted rate was down about
15 percent. Age-adjusted rates for the other race-sex groups
also declined, for white females by 9 percent and for each of
nonwhite males and females by 4 percent.
RISK FACTORS
A number of alterable risk factors for heart disease exist.
Among these are smoking, hypertension, elevated cholesterol,
4-3
obesity, and sedentary lifestyle (3) . Cigarette smoking is the
single factor responsible for the most preventable deaths in our
society, the largest numbers of those excess deaths being due to
coronary heart disease, lung cancer, and chronic obstructive lung
disease (4) .
The smoking behavior of the U.S. population has changed
dramatically, from 52 percent of men and 34 percent of women in
1965 to 33 percent of men and 28 percent of women in 1985, In
1985, however, the North Carolina age-adjusted percentage of
current smokers among men ranked in the top quartile among the 50
states. North Carolina women did better, ranking in the second
lowest quartile. (4)
North Carolina's decrease in heart disease death rates is
consistent with a decline nationwide. Possible reasons for the
decline include smoking cessation, increased control of hyper-tension,
dietary changes, reduced serum cholesterol levels, and
improvements in medical care (4). In recent years, the ability
of aspirin to prevent the occurrence or recurrence of vaso-oc-clusion
has been studied extensively. Taken together, the
results of these studies are highly suggestive of a beneficial
effect of aspirin. (5)
GEOGRAPHIC PATTERNS
Unadjusted and age-race-sex-adjusted heart disease death
rates for 1984-88 are depicted in Figures 3. A and 3.B respec-tively.
After adjustment, a number of contiguous high-rate
counties are found to exist, almost exclusively in the east.
Based on the procedures described in Section II of this
report, the following map reveals that, of the 25 counties with
the highest unadjusted death rates, statistically significant
4-4
geographic clusters exist in the east-northeast and
west-southwest
.
the
DISEASES OF THE HEART
MORTALITY RATES PER 100,000 POPULATION
391.55 to 533.67 (p<-.01)
385.69 to 390.73 (fX-01)
M 381.00 to 383.02 (P<--01)
D 116.71 to 380.37
NORTH CAROLINA
RESIDENT DATA
1984 1988
After adjustment for age, race, and sex, clusters of high-rate
counties are no longer statistically significant. The
interpretation here is that no significant clusters of counties
are experiencing higher levels of heart disease mortality than
can be explained on the basis of age, race, and sex. This is in
sharp contrast to a significant spatial grouping of 15 counties
observed in 1979-81 (6) .
4-5
T A B L E - 3
MORTALITY STATISTICS FDR 1988
NORTH CAROLINA RESIDENTS
DISEASES OF THE HEART
ceOiiRAPHICAL
AREA
NORTH CAROLINA
REGIONS
OHR I WESTERN
OHR II N. CENTRAL
OHR III S. CENTRAL
DHR IV EASTERN
NUMOER
OF DEATHS
1968
19t2 1
MORTALITY STATISTICS FOR 1988. NORTH CAROLINA RESIDENTS
DISEASES OF THE HEART CONT'D.
COUNTIES
(CONT'D)
hZ HALIFAX
ifi HARi\ETT
^'t HAYwOOD
^b HENDERSON
hb HERTFORD
VT hOKE
-ta HYDE
«t9 IREUcLL
50 JACKSON
b\ JOHNSTON
52 JONES
53 LEE
S-t LENOIR
55 LINCOLN
56 MCDOWELL
57 MACON
56 MADISON
59 MARTIN
60 MtCKLENbURl.
61 MITCHELL
62 MONTGOMERY
63 MOORE
b^ NASH
65 NEW HANOVER
66 NORTHAMPTON
67 UNSLUn
68 ORANbE
69 PAMLICO
70 PASjUOTANK
71 PENDER
72 PERJUIMANS
73 PERSON
Ih PITT
75 POLK
76 RANDOLPH
77 RICHMOND
78 ROBESON
79 ROCKINGHAM
80 ROWAN
81 RUTHERFORD
&Z SAMPSON
83 SCOTLAND
a't STANLY,
85 STOKES
86 SURRY
87 SWAIN
88 TRANSYL\/ANIA
39 TYRRELL
90 UNION
91 VANCE
92 WAKE
93 WARREN
9^ WASHINGTON
95 WATAUGA
96 WAYNE
97 wILKES
98 WILSON
99 YADKIN
100 YANCEY
NUMBER
DISEASES OF THE HEART
MORTALITY RATES PER 100,000 POPULATION
HD
D
533.67 to 533.67
434.26 to471. 86
317.99 to415.08
261.60 to310. 69
175.11 to 245.89
116.71 to 116.71
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 3.A
DISEASES OF THE HEART
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100.000 POPULATION
446.96 to 446.96
350.06 to 396.55
M 315.38 to 344.64
El 274.73 to 31 0.77
D 244.84 to 269.50
D 210.17 to 232.97 FIGURE 3.B
NORTH CAROLINA
RESIDENT DATA
1984-1988
4-8
CEREBROVASCULAR DISEASE
Cerebrovascular disease, or stroke, claimed the lives of
4,780 North Carolinians during 1988. It was the third leading
cause of death in North Carolina with an overall rate of 73.7
deaths per 100,000 population. The North Carolina unadjusted
rate was 15 percent higher than the 1987 U.S. rate, and the
state's 1987 age-adjusted rate was 24 percent higher than the
nation's (2). In 1986, North Carolina's age-adjusted stroke
death rate was the third highest in the nation, exceeded only by
rates for South Carolina and Georgia (7)
.
The state's age-adjusted cerebrovascular mortality rate
dropped a dramatic 19 percent between 1979-83 and 1984-88. By
race and sex, the reductions ranged from 14 percent for nonwhite
females to 21 percent for white males. The age-adjusted rates
for nonwhite males and females remain considerably higher than
those for whites.
RISK FACTORS
The risk factors associated with cerebrovascular disease are
essentially the same as those for heart disease: hypertension,
diabetes, cardiac impairment, elevated blood lipids, obesity, and
cigarette smoking. The large racial differential is at least
partially explained by the higher prevalence of hypertension and
diabetes among the black population. (4)
4-9
In addition to lifestyle changes, other factors possibly
associated with reduced cerebrovascular and other cardiovascular
mortality are improved patient and physician education and
increased availability of medical services including rescue
squads, coronary care units, and physician supply (8) .
Improvements in hypertension detection and control have probably
contributed to the observed declines (4) . There is convincing
evidence from several studies for the efficacy of aspirin in the
prevention of stroke (5)
.
GEOGRAPHIC PATTERNS
Figure 4. A shows a scattering of counties with relatively
high unadjusted rates and several pockets of high-rate counties,
primarily in the east. After adjusting for age, race, and sex
(Figure 4.B), even more counties appear in the high-rate groups,
and nearly all are contiguous to other high-rate counties.
Based on procedures described in Section II, the eastern
pockets of high unadjusted county rates were found to cluster
significantly (see first map on next page) . Spatial clustering
continues to prevail in the east after adjusting for age, race,
and sex (see second map on next page) . Thus, it is clear that
some eastern North Carolina counties are experiencing inordi-nately
high cerebrovascular mortality that cannot be explained by
age, race, and sex factors. Both the unadjusted and adjusted
cerebrovascular death rates of 1979-81 exhibited similar clus-tering
properties (6)
.
4-10
CEREBROVASCULAR DISEASE
MORTALITY RATES PER 100,000 POPULATION
111.32 to 136.37 (p<-.05)
100.71 to 109.52 (p<-.01)
El 96.34 to 100.50 (p<-.01)
D 28.77 to 96.20
NORTH CAROLINA
RESIDENT DATA
1984-1988
CEREBROVASCULAR DISEASE
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
84.57 to 105.88 (p<-.05)
D 33.47 to 84.37
NORTH CAROLINA
RESIDENT DATA
1984-1988
4-11
T A B L E - ^
MORTALITY STATISTICS FOR 1936
NORTH CAROLINA RESIDENTS
CEREBROVASCULAR
NUMBER
MORTALITY STATISTICS FOR 1983. NORTH CAROLINA RESIDENTS
CEREBkOVASCULAR CJNT'U.
COUNTIES
(CONT'D)
•*2 HALIFAX
^3 HARNETT
hk HAYWOOD
^tS HENDERSON
46 HERTFORD
47 HOKE
4b HYDE
49 IREDELL
50 JACKSON
51 JOHNSTON
52 JONES
53 LEE
54 LENOIR
55 LINCOLN
5b MCDOWELL
57 MACON
58 MADISON
59 MARTIN
oO MECKLENtJURb
61 MITCHELL
t)2 MONTGOMERY
b3 MOOKE
64 NASH
t>5 NEW HANOVER
66 NORTHAMPTON
67 ONSLOW
68 ORANGE
69 PAMLICO
70 PASQUOTANK
71 PENDER
72 PERQUIMANS
73 PERSON
74 PITT
75 POLK
76 RANDOLPH
77 RICHMOND
78 kOoESON
79 ROCKINGHAM
80 ROwAN
81 RUTHERFORD
82 SAMPSON
83 SCOTLAND
84 STANLY
85 STOKES
86 SURRY
87 SwAIN
88 TRANSYLVANIA
69 TYRRELL
90 UNION
91 VANCE
92 WAKE
93 WARREN
94 WASHINGTON
95 WATAUGA
96 WAYNE
97 WILKES
98 WILSON
99 YADKIN
100 YANCEY
* SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE.
DIVISION OF STATISTICS AND INFORMATION SERVICES
DEPARTMENT OF ENVIRONMENT. HEALTH AND NATURAL RESOURCES
4-13
NUMbER
CEREBROVASCULAR DISEASE
MORTALITY RATES PER 100.000 POPULATION
124.94 to 136.37
99.49 10 114.81
M 87.38 to 97.48
M 66.94 to 84.77
D 42.35 to 63.90
D 28.77 to 28.77
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 4.A
CEREBROVASCULAR DISEASE
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
92.42 to 105.88
73.61 to 89.32
62.48 to 72.72
51.21 to 61.01
42.51 to 46.67
33.47 to 36.98
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 4.B
4-14
ATHEROSCLEROSIS
Atherosclerosis is a general term covering a number of
diseases of the blood vessels and is often called "hardening of
the arteries." Like hypertension, atherosclerosis is listed as a
contributing cause on the death certificate far more often than
it is considered the underlying cause of death. In particular,
atherosclerosis contributes to deaths from heart disease, stroke,
and diabetes. It was estimated that in 1970, 87 percent of the
more than 1 million deaths in the United States due to heart and
blood vessel diseases were attributable to atherosclerosis and
its sequelae (1).
As the underlying cause of death, atherosclerosis accounted
for 414 North Carolina deaths in 1988, a rate of 6.4 deaths per
100,000 population. The 1987 U.S. rate was considerably higher
at 9.2. However, after adjustment for age, the 1987 N.C. and
U.S. rates were virtually the same at 3.4 and 3.6 respectively.
(2)
The recent decline in North Carolina's age-adjusted
atherosclerosis mortality far exceeded the declines observed for
heart disease and stroke, and the decline was virtually the same
for all race-sex groups at an average 28 percent between 1979-83
and 1984-88.
Noteworthy are the race and sex differentials. The 1984-88
white male rate was about a third higher than that for white
females, and the nonwhite male rate exceeded that for nonwhite
females by 58 percent. Nonwhite rates were considerably higher
4-15
than the white rates, 54 percent higher for males and 31 percent
higher for females.
Compared to 414 deaths with atherosclerosis as the underly-ing
cause, a total of 12,329 death certificates had a mention of
atherosclerosis. This suggests that 21 percent of all North
Carolina deaths in 1988 involved atherosclerosis, though it is
not known just how completely this condition is recorded on the
death certificate. Of these 12,329 deaths with mention of
atherosclerosis, 66 percent had heart disease as the underlying
cause of death and 12 percent had cerebrovascular disease as the
underlying cause. Around 40 percent of the deaths with heart
disease and 30 percent of those with cerebrovascular disease as
the underlying cause had a mention of atherosclerosis, and about
35 percent of the deaths with a mention of heart or
cerebrovascular disease had a mention of atherosclerosis. These
data are from Tables 23 and 24 of this report.
RISK FACTORS
Three major treatable risk factors contributing to
atherosclerosis have been identified: elevated blood cholesterol
levels, high blood pressure, and cigarette smoking. A number of
additional factors are also recognized: diabetes, physical
inactivity, obesity, age, male sex, and certain personality
types, that is, "type A" or coronary-prone behavior. (1)
Increasing epidemiological evidence supports the hypothesis
that higher concentrations of high-density lipoproteins (HDLs)
may be a protective factor in the development of atherosclerosis.
"Levels of HDL have been correlated positively with exercise and
moderate ingestion of alcohol and inversely related to obesity,
smoking, poor control of diabetes, and the use of
progestin-containing contraceptives" (1). However, the cause and
effect of the inverse relationship between HDL and
atherosclerosis remain unclear.
4-16
GEOGRAPHIC PATTERNS
The clustering procedures described in Section II of this
report revealed no statistically significant clusters of counties
with high unadjusted or adjusted atherosclerosis death rates.
Although a cluster of six southcentral counties was identified by
the adjusted rates of 1979-81, it was noted that the pattern
should be considered cautiously due to very small numerators in
the six counties' rates (6). Due to this problem in most
counties of the state, the two maps on atherosclerosis use
mentioned conditions rather than underlying cause data. These
maps, along with an associated analysis, are presented in the
Multiple Conditions Section (Section IX) and show 1988
atherosclerosis mentions per 100,000 population.
4-17
T A B L E - 5
MORTALITY jTATISTlLS HOH 1988
NORTH CAROLINA RESIOc.NTS
ATHEROSCLEROSIS
NUMbER DEATH f»iJMbbR DEATH AUJUSTED
GtOijRAPHICAL OF DEATHS RATE^> OF OEATHS RATE=:' JbATH RATE<
AREA 198B 1988 igS^t-Sa 1984-88 198'>-88
NORTH CAROLINA 'tl'* 6.38 Z^ifb 8.05 8.05
KEUIONS
UHR
MORTALITY STATISTICS FOR 19a8, NOkTH CAROLINA RESIDENTS
ATHtROSCLEROSIS CJNT'O.
REFERENCES FOR SECTION IV
1. Levy, R.I.; Moskowitz, J. "Cardiovascular Research: Decades
of Progress, A Decade of Promise," Science . Volume 217,
July 9, 1982, pp. 121-129.
2. National Center for Health Statistics. "Advance Report of
Final Mortality Statistics, 1987," Monthly Vital Statistics
Report . Volume 38, Number 5 supp. , Hyattsville, Maryland:
Public Health Service, September 26, 1989.
3. Centers for Disease Control. "Chronic Disease Reports:
Coronary Heart Disease Mortality - United States, 1986,"
Morbidity and Mortality Weekly Report . Vol. 38, Massachu-setts
Medical Society, Waltham, Ma. 1989, pp. 285-286.
4. National Center for Health Statistics. Health. United
States. 1988 . DHHS Pub. No. (PHS) 89-1232. Public Health
Service. Washington, U.S. Government Printing Office,
March 1989.
5. Reilly, I. A.; Fitzgerald, G.A. "Aspirin in Cardiovascular
Disease," Drugs . Vol. 35, No. 2. February 1988, pp. 154-76.
6. North Carolina Department of Human Resources, State Center
for Health Statistics. Leading Causes of Mortality: North
Carolina Vital Statistics. Volume 2. 1981 . Raleigh, Septem-ber
1983.
4-2
7. Centers for Disease Control. "Chronic Disease Reports:
Stroke - United States, 1986," Morbidity and Mortality
Weekly Report . Vol. 38, Massachusetts Medical Society,
Waltham, Ma. 1989, pg . 193.
8. Tyroler, H.A.; Haynes, S. "Community Cardiovascular Surveil-lance
Program: Phase Il-Protocol," Unpublished Paper.
Department of Epidemiology, School of Public Health, UNC-Chapel
Hill, N.C., April 1982.
4-21
V. CANCER MORTALITY
ACKNOWLEDGEMENTS
We are indebted to the following people who contributed to the
cancer sections:
Cancer -Donald Lannin, M.D.
Associate Professor, East Carolina University
Medical School
Chief of Surgical Oncology, Pitt Memorial
Hospital, Greenville
Cancer of the -Robert Sandler, M.D., Ph.D.
Colon, Rectum Associate Professor, Department of Medicine
University of North Carolina at Chapel Hill
Cancer of the -Electra Paskett, Ph.D.
Lung Assistant Professor, Department of Public
Health Services
Bowman Gray School of Medicine,
Winston-Salem
Cancer of the
Female Breast
-Sara Ephross, M.S.P.H.
Research Assistant, Department of
Epidemiology
School of Public Health, University of
North Carolina at Chapel Hill
Cancer of the
Prostate
-Dexter Morris, M.D., Ph.D.
Assistant Professor, Department of
Epidemiology
School of Public Health, University of
North Carolina at Chapel Hill
Cancer in -Paul Godley, M.D., M.P.P.
Special Research Fellow, Department of Medical Oncology
Populations University of North Carolina at Chapel Hill
5-2
CANCER
A recent article in the New England Journal of Medicine (1)
asserted that, despite years of work and millions of dollars for
research, there has been little progress against cancer. The
main evidence in favor of this viewpoint is that cancer is still
the second leading cause of mortality in the United States, and
it is the only major illness which causes more deaths today than
it did in 1950. The article stimulated quite a bit of debate in
the scientific and lay press, and most observers concluded that
it is a complex issue which cannot be reduced to generalizations.
However, at least these considerations should be kept in mind as
one evaluates the viewpoint of the referenced article:
1) For lung cancer, which is the most frequently occurring type
of cancer in men and now the leading cause of cancer death
in American women, the survival picture is dismal. The
large proportion of cancer victims experiencing poor surviv-al
creates the statistical "evidence" that no progress is
being made.
2) Other leading causes of death are declining in the United
States, e.g., heart disease and cerebrovascular disease (1).
As these causes of death claim fewer and fewer lives, per-sons
survive longer, leaving a substantially larger pool of
individuals at higher risk for cancer than previously exist-ed.
This phenomenon of "competing causes of death" is one
reason for the absence of a decline in U.S. cancer mortality
since 1950.
5-3
It is also apparent that progress with one form of cancer or
in one geographic location is easily hidden by worsening results
elsewhere. Furthermore, to really answer the question, the
incidence trends for different cancers and survival figures after
treatment as well as mortality data must be examined. However,
mortality is still the bottom line. In 1986, the National Cancer
Institute set a goal to reduce cancer mortality by 50 percent
before the year 2 000 (1) . The data in this volume can be used to
measure how far we must go to achieve this goal.
In addition to measuring progress, the data presented here
may suggest strategies which could be used to reduce cancer
mortality. There are two possible ways to make progress against
cancer: to make new discoveries or develop new technology and to
apply current knowledge and technology more effectively. Where
the data show a marked difference in mortality between two
geographical areas for a certain cancer, attempts should be made
to identify reasons for the discrepancy. It is likely that
methods may be found to better apply existing knowledge to lower
the mortality in the higher area. Thus, the data in the follow-ing
pages not only measure our progress toward the goal of
reducing cancer mortality, but also provide clues as to how this
goal may be achieved.
In 1988, a total of 12,700 North Carolinians died from
cancer. These deaths represent 2 2 percent of the state's deaths,
the same proportion observed in the U.S. (2). The 1988 cancer
death rate was 195.8 deaths per 100,000 population, an increase
of 3.5 percent over the 1987 rate. However, the state's age-ad-justed
cancer death rate rose less than 1.1 percent in 1988.
The state's 1984-88 age-adjusted cancer death rate was two
percent higher than that for the five-year period 1979 -83.
Comparisons of the age-adjusted rate changes for race-sex groups
reveal increases of about five percent for all but white males
whose rate declined slightly.
5-4
The number of cancer deaths in North Carolina begins to
increase at ages 35-44 and peaks at ages 75-84. The death rate
peaks in the 8 5 and older category except among nonwhite males
whose rate is highest at ages 75-84. A recent study concerning
the health of the elderly in North Carolina found an increase in
cancer rates for all age, race, and sex groups over 65, especial-ly
nonwhite males, between 1968-72 and 1983-87 (3).
In 1987, the state's age-adjusted cancer death rate was 0.3
percent higher than that for the United States. The rate for
N.C. white females was 9.5 percent lower while rates for the
other race-sex groups were all higher. The rate for N.C. non-white
males was more than 16 percent higher than the corre-sponding
U.S. rate. (4)
An interesting criterion for evaluating the impact of
cause-specific mortality is the measure "years-of-life-lost,
"
i.e., the loss in years of expected survival due to "early"
death. Years-of-life-lost (YLL) cancer rates in North Carolina
in 1988 reveal that for white females cancer had the highest
overall YLL due largely to the fact that white females have the
highest life expectancy of all the race-sex groups. Cancer
ranked second or third in YLL for each of the other race-sex
groups
.
GEOGRAPHIC PATTERNS
Unadjusted and age-race-sex-adjusted county death rates for
1984-88 are mapped in Figures 5. A and 5.B respectively. For this
five-year period, as in the past, high unadjusted rates were more
prevalent among western and eastern counties with relatively low
rates occurring in the southcentral portion of the state.
However, these differences are due largely to age-race-sex
differences since adjustment for these factors considerably
changes the mortality picture. The western counties' rates are
5-5
generally lower while the high rates, although diminished, remain
in the eastern counties.
Based on procedures described in Section II, the following
map reveals several statistically significant clusters of coun-ties
with high unadjusted rates. These clusters are located in
northeastern and western North Carolina, and are similar to
clusters of unadjusted county rates observed in 1979-81 (5) .
After adjustment for age, race, and sex, there were no statisti-cally
significant clusters of high-rate counties. Hence, clus-tering
of high-rate counties reflects variations in age, race,
and/or sex among the populations of these counties. In contrast,
in the 1979-81 period there were two small clusters of three and
four counties (based on adjusted rates) in the eastern part of
the state (5) .
CANCER -ALL SITES
MORTALITY RATES PER 100.000 POPULATION
225.88 to 292.23 (P<-.01)
D 96.83 to 224.73
NORTH CAROLINA
RESIDENT DATA
1984 • 1986
SITE-SPECIFIC CANCER
This report is designed to address mortality patterns for
several cancers that are leading causes of death (lung,
colorectal, breast, and prostate). Other cancers previously
reported in this volume are not included this year due to growing
concern about instability of the county death rates (due to the
relatively small numbers of deaths involved) . A separate
report will be forthcoming on these more rare cancers.
5-6
T A B L E - 6
MORTALITY STATISTICS FOR 1V68
NORTH CAROLINA RESIDENTS
CANCER - ALL SITES
btOURAPHICAL
AREA
NORTH LAKOLINA
NUMbEk
MORTALITY STATISTICS FOR 19a8i
CANCeR - ALL SITtS CONT'D.
NORTH CAROLINA keSIOfcNTS
COUNTIES
CANCER -ALL SITES
MORTALITY RATES PER 100,000 POPULATION
277.05 to 292.23
223.00 to 258.78
M 182.59 to 217.41
O 156.93 to 179.78
D 125.58 to 148.49
D 96.83 to 113.39
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 5.A
CANCER - ALL SITES
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
231.98 to 231.98
213.36 to 225.15
194.32 to 207.69
176.01 to 192.27
164.72 to 173.95
141.80 to 160.55
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 5.B
5-9
Meanwhile, because of their substantial public health interest, a
brief narrative follows for three of these "rare" cancers:
pancreas, uterine cervix, and leukemia.
PANCREAS (ICD 157)
This cancer has been increasing in frequency in the United
States for the last two decades (2) . Debate continues over
whether the increase is due to better detection and reporting, or
whether it is a real trend (1)
.
The 1988 North Carolina rate of 10.3 deaths per 100,000
population represented an eight percent increase over the 1987
rate, while the age-adjusted rate increase was 5.5 percent.
Between the five-year periods 1979-83 and 1984-88, there was
virtually no change in the state's age-adjusted death rate
although nonwhite males and females experienced small increases.
During 1984-88, the age-adjusted death rates for nonwhite
males and females were approximately 50 percent higher than the
corresponding rates for whites. This race differential warrants
close public health attention and surveillance; unfortunately,
clear-cut options for prevention are not established.
CERVIX UTERI (ICD 180)
Cervical cancer is still a common diagnosis in the United
States; yet increasingly, it is not life-threatening because of
early detection and the availability of excellent treatment
capabilities.
Between 1987 and 1988, the North Carolina death rate for
cervical cancer declined 2.8 percent to 4.2 deaths per 100,000
population. The age-adjusted rate declined 3.5 percent. Between
5-10
1979-83 and 1984-88, the age-adjusted rate declined approximately
12 percent; the decline was approximately 20 percent for non-whites
compared to 10 percent for whites.
During 1984-88, the age-adjusted nonwhite female death rate
was about three times that for white females. This wide differ-ential
probably involves late access to health care and perhaps
socioeconomic and sexual activity factors often associated with
the disease.
LEUKEMIA (ICD 204-208)
Leukemia is second only to injuries as a leading cause of
death among children. Childhood leukemia presents as a very
aggressive disease, while for adults leukemias are often quite
indolent processes. Risk factors for leukemia are generally
environmental and occupational. Leukemia is managed primarily
with chemotherapy; today the prognosis is quite good for early
diagnoses.
North Carolina's leukemia death rate in 1988 was 7.0, which
was 11 percent above the 1987 rate. However, the age-adjusted
rate increase was half that at 5.5 percent.
Between 1979-83 and 1984-88, the state's age-adjusted
leukemia death rate declined about nine percent with most of the
decrease occurring among whites. During 1984-88, the age-adjust-ed
rates for white and nonwhite males were approximately the
same, each being more than 50 percent higher than the correspond-ing
female rate.
In 1987, the state's age-adjusted leukemia death rate was
eight percent below the nation's. However, the rate for North
Carolina's nonwhite males was 15 percent higher than the corre-sponding
U.S. rate. (4)
5-11
NOTE: Due to ready availability, the 1979-83 and 1984-88
age-adjusted death rates examined for the above
site-specific cancers used the 1970 U.S. Census
population as the standard for direct age-adjustment.
Other age-adjusted rates examined in this report use the
1940 U.S. Census as the standard, following the
convention of the National Center for Health
Statistics. In terms of percent differences over time
and between race-sex groups, the two standards yield
generally similar results.
5-12
CANCER OF THE COLON AND RECTUM
Colorectal cancer is the second leading cause of cancer
death in North Carolina, exceeded only by lung cancer. The
marked geographic differences in incidence for this cancer, and
the fact that incidence rates change with migration, suggest that
there may be important environmental determinants. It might be
possible to prevent a substantial proportion of colorectal cancer
if these factors could be identified and modified. A variety of
risk factors for the disease have been examined.
Many studies have explored the relationship between diet and
colorectal cancer. A high-fiber, low-fat diet is thought by
some to protect against large bowel cancer, although studies have
had somewhat contradictory results (6,7). Other dietary factors
that may be protective include calcium, cruciferous vegetables
(broccoli, cabbage, Brussels sprouts), vitamin A, beta carotene,
garlic and onions (8,9).
There is no consistent association with occupation apart
from above-average risk among professional and administrative
workers. There have been reports of increased rates in woodwork-ers,
pattern makers, synthetic fiber workers, and asbestos
workers. Physical activity, both avocational and occupational,
may decrease risk. (10) Individuals with a first-degree relative
with colon cancer appear to be three times more likely to develop
the disease themselves. Recent molecular studies have identified
specific genetic abnormalities in some colon cancers. (11)
5-13
Colon cancers that are discovered early are more amenable to
surgical cure. Although there are techniques available to screen
for colon cancer, they have not been convincingly demonstrated to
confer a survival advantage to those screened. Because screening
programs are expensive, our best hope to decrease the burden of
suffering from colon cancer is through prevention. The data
available from epidemiologic studies suggest that such prevention
may be feasible.
Based on data collected between 1979 and 1984, the five-year
survival rates for colon cancer were 54 percent for whites, 49
percent for blacks, and 53 percent overall (2).
In 1988, a total of 1,331 North Carolinians died of
colorectal cancer. This accounted for 10.5 percent of the
state's cancer deaths and 2.3 percent of all deaths. The mor-tality
rate in 1988 was 20.5 deaths per 100,000 population. This
was a 2.5 percent increase over the 1987 mortality rate of 20.0.
However, after adjustment for age, there was a three percent
decrease between 1987 and 1988.
The five-year age-adjusted mortality rate (1984-88) was the
same as that of the preceding five-year period (1979-83) . There
was a slight decrease for whites (males and females) and increas-es
of 5.4 and 12.5 percent respectively for nonwhite males and
females. In 1986 North Carolina had the thirty-second highest
age-adjusted mortality rate in the nation (12)
.
In North Carolina colon cancer deaths are not often found
prior to age 45, and the death rate is highest at ages 85 and
older (3). This holds true for both sexes and races. The
age-adjusted colorectal cancer death rate for race-sex groups
reveal higher rates among nonwhites, but the race differentials
are relatively small. This suggests that environmental
determinants are largely non-occupational.
5-14
GEOGRAPHIC PATTERNS
More than any other site-specific cancer mortality rates
examined in this report, North Carolina's higher county-level
colon/rectum cancer rates tend to cluster to a statistically
significant degree, following the procedures described in Section
II. When mapped, the high unadjusted rates reveal northeastern,
central, and southwestern clusters as shown in the first text map
^^^°'^
' CANCER COLON, RECTUM AND ANUS
MORTALITY RATES PER 100.000 POPULATION
27.28 lo 40.30 (P<-.01
24.14 to 26.39 (P<-05)
D 9.86 10 23.89
NORTH CAROLINA
RESIDENT DATA
1984-1988
As shown in the age-race-sex-adjusted text map below,
significant clusters of high-rate counties are found in the
east-northeast and central portions of the state. Health offi-cials
should be particularly aware of these areas with high
colon/rectum cancer mortality over and above that due to age,
race, and sex factors. Counties not identified in the text maps
should consult Figures 6. A and 6.B to ascertain their relative
levels of mortality from colorectal cancer.
CANCER - COLON, RECTUM AND ANUS
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100.000 POPULATION
23.77 to 49.03 (p<..05)
n 8.42 to 23.49
NORTH CAROLINA
RESIDENT DATA
1984-1988
5-15
T A tJ L E - 7
MORTALITY STATISTICS FOR 1988
NORTH CAROLINA RESIDENTS
CANCER - COLON, RECTUM AND ANUS
MORTALITY STATISTICS FOR 1988. NORTH CAROLINA RESIDENTS
CANCER - COLONf RECTUM AND ANUS CONT'D.
COUNTIES
(CONT'D)
^2 HALIFAX
hi HARNETT
kt HAYWOOD
<*5 HENDERSON
hb HERTFORD
't? HJKE
1*6 HYOE
'f9 IREDELL
50 JACK.SON
51 JOHNSTON
52 JONES
53 LEE
5^ LENOIR
55 LINCOLN
56 MCDOWELL
57 MACJN
58 MADISON
59 MARTIN
60 MECKLENBURG
61 MITCHELL
62 MONTGOMERY
63 MOORE
6^ NASH
65 NEW HANOVER
6b NORTHAMPTON
67 ONSLOw
68 ORANGE
69 PAMLICO
70 PASJUOTaNK.
71 PENDER
72 PERWUIMANS
73 PERSON
7^* PITT
75 POLK
76 RANDOLPH
77 RICHMOND
78 ROtJESON
79 ROCKINGHAM
80 ROWAN
81 RUTHERFORD
82 SAMPSON
83 SCOTLAND
S'f STANLY
85 STOKES
66 SURRY
87 SWAIN
88 TRANSYLVANIA
89 TYRRELL
90 UNION
91 VANCE
92 WAKE
93 WARREN
9'f WASHINGTON
95 WATAUGA
96 WAYNE
97 WILKES
98 WILSON
99 YADKIN
100 YANCEY
* SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE.
DIVISION OF STATISTICS AND INFORMATION SERVICES
DEPARTMENT OF ENVIRONMENT. HEALTH AND NATURAL RESOURCES
5-17
NUMBER
CANCER COLON, RECTUM AND ANUS
MORTALITY RATES PER 100.000 POPULATION
38.95 to 40.30
33.46 to 35.76
28.47 to 30.97
22.40 to 27.41
13.92 to 21.85
9.86 to 12.82
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 6.A
CANCER COLON, RECTUM AND ANUS
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100,000 POPULATION
40.03 to 49.03
29.77 to 31.95
26.43 to 27.29
17.79 to 24.74
12.73 to 17.46
8.42 to 11.89
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 6.B
5-18
CANCER OF THE TRACHEA, BRONCHUS, AND LUNG
Lung cancer is the leading cause of cancer death in both men
and women in the United States (13) . The incidence rate for this
cancer continues to increase nationwide in both males and fe-males,
black and white. Lung cancer deaths among American women
have now surpassed the number of breast cancer deaths. (2) Among
North Carolina residents in 1988 there were 1,058 female deaths
due to lung cancer while 1,093 women died of breast cancer.
Thus, lung cancer deaths among women are rapidly approaching the
number due to breast cancer. This increase in deaths is larger
than for any other cancer site. There have been increases in
both incidence and death for every group with women increasing
more rapidly. (14)
In 1988, a total of 3,669 North Carolinians died from lung
cancer. This accounted for 28.9 percent of the state's cancer
deaths and 6.4 percent of all deaths. The mortality rate in 1988
was 56.6 deaths per 100,000 population. This was a six percent
increase over the 1987 mortality rate; however, the age-adjusted
rate increase was a third lower at 3.9 percent.
The five-year age-adjusted mortality rate (1984-88) was 12.2
percent higher than that for the preceding five-year period
(1979-83) . All race-sex groups experienced increases over this
time period, with the greatest increase in white females whose
rate rose by one-third. In 1986, North Carolina had the 27th
highest age-adjusted mortality rate in the nation (15) . This
North Carolina rate was 0.6% less than that for the U. S.
5-19
During 1984-88, North Carolina's age-adjusted death rates
were over three times higher for white males than for white
females and almost six times higher for nonwhite males than for
nonwhite females. Thus, there is a wide sex differential in
mortality risk. The 1984-88 nonwhite male rate was 23 percent
higher than that for white males, while the nonwhite female rate
was 31 percent below that for white females.
In North Carolina, lung cancer deaths are not generally
found prior to age 4 5 with the number of deaths peaking at ages
65-74. The death rate also peaks at ages 65-74 except among
white males whose peak occurs at ages 75-84 (3)
.
Lung cancer is very difficult to detect early since symptoms
often don't appear until the disease has advanced considerably.
Only 24 percent of lung cancer cases are detected at the early
(localized) stage. For this reason, only 13 percent of lung
cancer patients (all stages, whites and blacks) live five or more
years after diagnosis. (13)
The major risk factor for the development of lung cancer is
cigarette smoking. Tobacco is responsible for 83 percent of lung
cancer cases overall, 85 percent among men and 75 percent among
women (16) . To date, 4 3 chemicals in tobacco smoke have been
determined to be carcinogenic (13) .
Certain industrial substances such as asbestos, radon decay
products, and other risk factors for lung cancer have been found
to interact with smoking to produce even higher risk estimates
(17) . Air pollution has been estimated to be the cause of 1 to 2
percent of lung cancer cases (18) . Indoor air pollution, mainly
in the form of tobacco smoke and radon, have been linked causally
to lung cancer (6) . Diet has recently been considered as poten-tially
influencing the risk of lung cancer in smokers, in partic-ular
deficiencies in vitamin A, carotene, vitamin E, and vitamin
5-20
C (19) . Clinical trials on vitamin A and lung cancer risk are
now in progress. Finally, exposure to radiation and familial
factors have been suggested to affect lung cancer risk (18).
GEOGRAPHIC PATTERNS
During 1984-88 residents of eastern North Carolina experi-enced
higher lung cancer mortality prior to and after adjustment
for age, race and sex distribution (Figures 7. A and 7.B, respec-tively)
. However, there were no statistically significant
clustering patterns. This contrasts sharply with significant
clustering of the unadjusted and adjusted rates during 1979-81
(5).
5-21
T A B L fc - 3
MOrtTALITV STATISTICS FOR 19Ba
NORTH CAROLINA RESIDENTS
CANCER - TRAChEAf BRONCHUS AND LUNG
NUMBER
MJkTALITY STATISTICS FOR 1968t NORTH CAROLINA RESIDENTS
CANCER - TRACHEA. BRONCHUS AND LUNi CONT'D.
COUNTIES
(CONT'D)
hZ HALIFAX
hi HARNETT
if^ HAYhUOD
<*5 HENDERSON
kb HERTFORD
^7 HOkE
'td HYOE
t9 IREDELL
50 JACKSON
51 JOHNSTON
52 JONES
53 LEE
bk LENOIR
55 LINCOLN
5b MCDOWELL
57 MACON
58 MADISON
59 MARTIN
bO MEC<LENoURt,
bl MITCHELL
bZ MONTbOMERY
b3 MOORE
bk NASh
b5 NEW HANOVER
bb NORTHAMPTON
b7 ONSLOW
b8 ORANCiE
b9 PAMLICO
70 PASOUOTANK.
71 PENDER
72 PERQUIMANS
73 PERSON
Tt PITT
75 P3LK
76 RANDOLPH
77 RICHMOND
7 8 RObtSON
79 kOCKIN&HAM
tiO ROWAN
81 RUTHERFORD
32 SAMPSON
b3 SCOTLAND
8^ STANLY
65 STOKES
86 SURRY
87 SWAIN
88 TRANSYLVANIA
89 TYRRELL
90 UNION
91 VANCE
92 WAKE
93 WARREN
9't wASHlNliTON
95 WATAU&A
96 WAYNE
97 WIL<ES
98 WILSON
99 YADKIN
100 YANCEY
<= SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE.
DIVISION Of STATISTICS AND INFORMATION SERVICES
DEPARTMENT OF ENVIRONMENT, HEALTH AND NATURAL RESOURCES
5-23
NUMBER
CANCER TRACHEA, BRONCHUS AND LUNG
MORTALITY RATES PER 100,000 POPULATION
87.56 to 89.59
66.25 to 78.51
54.02 to 64.88
45.93 to 53.20
36.65 to 44.38
29.10 to 34.78
NORTH CAROLINA
RESIDENT DATA
1984 -U
FIGURE 7.A
CANCER TRACHEA, BRONCHUS AND LUNG
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100.000 POPULATION
CANCER OF THE FEMALE BREAST
Breast cancer is the second leading cause of cancer death in
American women (2). It is estimated that there will be 142,900
new breast cancer cases and more than 453,300 deaths in the
United States in 1989 (20) . According to the American Cancer
Society, one in 10 American women will develop the disease in her
lifetime (2)
.
Several risk factors for breast cancer have been consistent-ly
identified. They include: older age, upper socioeconomic
class, never having been married, urban residence, residence in
the Northern U.S., white race, late age at first full-term
pregnancy, early menarche, late menopause, family history of a
primary cancer of the ovary or endometrium. Artificial menopause
has been shown to exert a protective effect. Additional research
into breast cancer etiology is needed as only 2 5 percent of the
current breast cancer burden can be explained by known risk
factors. Current areas of research include alcohol consumption,
oral contraceptive use, mammographic parenchymal patterns,
hormone replacement therapy, and high-fat diet. (21)
Between 1975 and 1985, there was a 17 percent increase in
the incidence of breast cancer in the National Cancer Institute's
population-based Surveillance, Epidemiology and End Results
(SEER) program (4) . The 1985 age-adjusted incidence rate for
white women was 19 percent higher than that for black women.
Mortality rates over the same period remained essentially stable
for white women while increasing at an average annual rate of
less than one percent for black women (14).
5-25
Survival rates for breast cancer in the SEER areas improved
slightly between 1975 and 1985. Overall five-year relative
survival rates for all stages of breast cancer for the period
1979-84 were 75 percent and 62 percent for white and black women,
respectively. (14) For localized breast cancer, there was a less
radical difference in survival. For white women, the five-year
survival rate was 90 percent and for black women, 87 percent
(21) . An improved survival rate has stabilized the mortality
rate, despite the increased incidence (2) .
In 1988, a total of 1,093 North Carolina women died of
breast cancer, still the leading cause of cancer deaths in N.C.
females. This accounted for 8.6 percent of the state's cancer
deaths. The 1988 mortality rate was 32.5 deaths per 100,000
female population which represents a 6.1 percent increase over
1987. However, there was virtually no change in the age-adjusted
death rate.
The five-year (1984-88) age-adjusted rate was 11.2 percent
higher than in 1979-83. The rate for whites increased 8.4
percent while that for nonwhites rose 23.3 percent. In 1986,
North Carolina had the 25th highest age-adjusted mortality in the
nation (22). This rate was 2.4 percent less than that for the
U.S.
In North Carolina, breast cancer deaths rarely occur prior
to age 3 5 in both white and nonwhite women, and the number peaks
at ages 55-64 for both race groups. For both races, the death
rate is highest at ages 85 and older (3).
GEOGRAPHIC PATTERNS
During the period 1984-88, no statistically significant
clusters of high rates were observed, although moderate rates did
occur in some contiguous counties (Figures 8. A and 8.B). Users
5-26
should consult these maps to ascertain a county's relative level
of unadjusted and age-race-sex-adjusted mortality from female
breast cancer.
5-27
T A b L E - 9
MORTALITY STATISTICS FOR 1988
"^URTH CAROLINA RESIOtNTS
R - B R E ST - FEMALE
:0>,KAPHILAL
AREA
NUMBER
MORTALITY STATISTICS FOk 1988f NORTH CAROLINA RESIDENTS
CANCER - BREAST - FEMALE CONT'D.
COUNTIES
(CONT'U)
<tZ HALIFAX
'»3 HARNETT
't'f HAYwOOO
^tS HENDERSON
hb HERTFORD
V7 HOKE
ka HYDE
'»9 IREDELL
50 JAC<.SON
51 JOHNSTON
52 JONES
53 LEE
5<t LENOIR
55 LINCOLN
56 MCDOWELL
57 MACON
53 MADISON
59 MARTIN
bO MECKLENBURC
61 MITCHELL
bZ MONTCOMERY
63 MOORE
bit NASm
65 NEW HANOVER
66 NORTHAMPTON
67 ONSLOW
t>8 ORANH,E
69 PAMLICO
70 PASUUOTaNK
71 PENDER
72 PERgUIMANS
73 PERSON
Ik PITT
75 POLK
76 RANDOLPH
77 RICHMOND
78 RObtSON
79 ROCKINGHAM
80 ROWAN
81 RUTHERFORD
82 SAMPSON
83 SCOTLAND
ak STANLY
85 STOKES
86 SURRY
87 SwAlN
38 TRANSYLVANIA
89 TYRRELL
90 UNION
91 VANCE
92 WAKE
93 WARREN
9't WASHIN&TON
95 WATAUGA
96 WAYNE
97 WILKES
93 WILSON
99 YADKIN
100 YANCEY
=:= SEE SECTION II
DIVISION OF STATISTICS AND INFORMATION SERVICES
DEPARTMENT OF ENVlRONMENTt HEALTH AND NATURAL RESOURCES
5-29
NUMBER
CANCER FEMALE BREAST
MORTALITY RATES PER 100,000 FEMALE POP.
48.47 to 54.87
42.13 to 47.24
28.40 to 38.36
20.59 to 27.70
14.00 to 18.42
11.11 to 11.11
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 8.A
CANCER FEMALE BREAST
AGE - RACE - SEX ADJUSTED
MORTALITY RATES PER 100.000 FEMALE POP.
61.84 to 61.84
45.78 to 51.92
37.59 to 43.01
26.08 to 36.42
18.55 to 25.60
8.21 to 14.55
NORTH CAROLINA
RESIDENT DATA
1984-1988
FIGURE 8.B
5-30
CANCER OF THE PROSTATE
Prostate cancer is a major cause of morbidity and mortality
among males in the United States, with almost one out of 11 men
developing the disease during his lifetime. In North Carolina
during 1989 alone, an estimated 2,700 new cases will be diag-nosed.
(2) The death rate for this disease changes dramatically
with age, increasing over one-hundred fold between ages 50 and
80. It is also much higher in blacks than whites. In fact,
blacks in certain regions of North Carolina have some of the
highest prostate cancer mortality rates in the world. The high
rate among blacks may be related to genetic or environmental
factors as well as to health care access or quality issues. (23)
Despite the importance of this disease, little is known
about its cause. Studies examining hormonal, social, and sexual
factors have yielded uniformly unimpressive results. Certain
occupations, such as farming, have been associated with an
increased risk of developing prostate cancer as has exposure to
cadmium. The roles of dietary factors, sunlight, and farming