including the three leading causes of preventable death (tobacco use, improper diet and physical inactivity, and alcohol use). Seventy percent of health-care costs in the United States are for chronic diseases. In 1999, to allow public health officials to uniformly define, collect, and report chronic disease data, the Council of State and Territorial Epidemiologists released Indicators for Chronic Disease Surveillance.

The report provided standard definitions for 73 indicators developed by epidemiologists and chronic disease program directors at the state and federal level. The indicators were selected because of their importance to public health and the availability of state-level data. This report describes the latest revisions to the chronic disease indicators. The revised set of 92 indicators includes 63 indicators that were unchanged from the first edition, six that have been revised, and 23 that are new. Four indicators from the first edition were deleted.

Of the indicators, 24 are for cancer; 15 for cardiovascular disease; 11 for diabetes; seven for alcohol; five each for nutrition and tobacco; three each for oral health, physical activity, and renal disease; and two each for asthma, osteoporosis, and immunizations. The remaining 10 indicators cover such overarching conditions as poverty, education, life expectancy, and health insurance. Additional information regarding the indicators for chronic disease surveillance is available at http://www.cdc.gov/nccdphp/cdi.

Introduction

During the 20th century, the leading causes of death in the United States shifted from infectious to chronic diseases. Chronic diseases (e.g., cardiovascular disease, cancer, and diabetes) are now among the most prevalent, costly, and preventable of all health problems. Seven of every 10 U.S. residents who die each year (>1.7 million persons) do so as a result of a chronic disease. Chronic diseases affect the quality of life of 90 million U.S. residents (1), and the cost of medical care for persons with these diseases accounts for 70% of total medical care expenditures (2).

Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Adopting healthy behaviors (e.g., eating nutritious foods, being physically active, and avoiding tobacco use) can prevent or control the effects of these diseases. In addition, quality of life is enhanced when chronic diseases are detected and treated early. Regular screening can reduce morbidity and mortality from cancers of the breast, cervix, colon, and rectum. Clinical preventive services can prevent the debilitating complications of diabetes and cardiovascular disease.

Increased chronic disease mortality and greater opportunities for primary and secondary prevention of chronic disease have resulted in an expansion of chronic disease programs in state public health agencies. Community intervention programs have proved to be effective, and certain ones have become model programs for public health (3,4). Within the past decade, each state has developed programs in tobacco control and breast and cervical cancer control.

Comprehensive public health programs necessarily include monitoring of disease or risk factors through public health surveillance, which is defined as the ongoing systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementing, and evaluating public health practice (5). Multiple data systems form the foundation for chronic disease surveillance. Chronic disease surveillance initially focused on mortality data from the National Vital Statistics System, managed by CDC's National Center for Health Statistics.

However, in the 1970s, morbidity from selected chronic diseases came under surveillance through disease registries. For example, the National Cancer Institute established the Surveillance, Epidemiology, and End Results cancer registry system to record and follow every new case of cancer among nine specific U.S. populations, four of which were states. In 1992, Congress authorized the National Program of Cancer Registries (NPCR) at CDC to monitor local trends in cancer incidence and mortality with statewide, population-based cancer registries.

In the 1980s and 1990s, CDC and state health agencies collaboratively developed additional surveillance systems to monitor behavioral risk factors for chronic disease. In 1984, with CDC assistance, 15 state health agencies began to use the Behavioral Risk Factor Surveillance System (BRFSS) to monitor adult behaviors related to the leading causes of death. Recognizing the usefulness and flexibility of BRFSS, all 50 states, the District of Columbia, and three territories participated in the system by 1994. By 2003, a total of 43 states and 22 local areas (also supported with financial and technical assistance from CDC) used the Youth Risk Behavioral Surveillance System (YRBSS) to monitor health risk behaviors among high school students.