Self-Reported Physical Inactivity by Degree of Urbanization -- United States, 1996

Physical inactivity is one of the major underlying causes of premature mortality in the United States (1). One of the national health objectives for 2000 is to decrease to 15% the proportion of persons aged greater than or equal to 6 years who are inactive during their leisure time (2). However, a large proportion of adults remain physically inactive: 28.7% in 1992 and 29.4% in 1994 reported no leisure-time physical activity during the preceding month (1). To determine whether area of residence impacts physical activity, CDC analyzed data from the 1996 Behavioral Risk Factor Surveillance System (BRFSS) to estimate physical activity by degree of urbanization and geographic region of respondents. This report summarizes the results of that analysis, which indicate that the level of leisure-time physical activity is related to the degree of urbanization and varies in different geographic regions.

The BRFSS is a random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 18 years. In 1996, data on physical activity were analyzed for 118,778 respondents in 49 states and the District of Columbia (Alaska was excluded for this analysis because rural-urban measures were not available for this state). Respondents were asked whether they had participated in exercise, recreation, or physical activity other than their regular job duties during the preceding month. Respondents were classified as physically inactive if they reported no such participation.

The degree of urbanization of respondents was classified by using the U.S. Department of Agriculture's (USDA) rural-urban continuum codes, which describe metropolitan and nonmetropolitan counties by degree of urbanization and nearness to metropolitan areas (3). The 10 USDA continuum codes were collapsed into five categories: 1) central or fringe metropolitan areas with a population of greater than or equal to 1 million; 2) metropolitan areas with a population of 50,000-999,999; 3) urban areas with a population of 20,000-49,999; 4) urban areas with a population of 2500-19,999; and 5) rural areas with a population less than 2500. Data were weighted and aggregated, and composite estimates and standard errors were calculated using SUDAAN (4). Prevalence estimates and 95% confidence intervals were calculated for demographic groups, geographic region of the country (5), and degree of urbanization.

The overall prevalence of leisure-time physical inactivity was lowest (27.4%) in central metropolitan areas and highest (36.6%) in rural areas (Table_1). Data were stratified by age, sex, level of education, and household income and analyzed within each stratum across urban-rural categories. Inverse relations between physical inactivity and degree of urbanization remained consistent in most strata, although the pattern was weaker in some strata of education, lower income levels, and older age groups. The difference in the prevalence of leisure-time physical inactivity in residents of metropolitan areas compared with residents of rural areas was greater for men (12.0%) than women (6.7%).

The overall prevalence of physical inactivity was lowest for respondents in the West (21.1%) *. In the South, the prevalence of physical inactivity was higher (34.2%) and the inverse relation with degree of urbanization was stronger than in the other regions. The largest difference in reported physical inactivity between urban and rural areas was in the South: the prevalence was 12.3% higher for residents of rural areas than for residents of central metropolitan areas. In the West, Northeast, and Midwest, the relations were less consistent than in the South.

Reported by the following BRFSS coordinators: J Cook, MPA, Alabama; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriweather, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; Y Gladman, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; L Redman, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. Physical Activity and Health Br, Div of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The national health objective for 2000 of reducing physical inactivity has not been reached in any region or in any of the urban or rural settings examined. Overall, leisure-time physical inactivity is more prevalent in rural than urban settings; in rural areas, more than one third of the population is physically inactive during leisure time, regardless of age group or sex. When analyzed by geographic region, this pattern is most evident in the South. In the other regions, the prevalence of inactivity was lower, and urban-rural patterns were less clear.

In this analysis, residents of rural areas were older, less educated, and poorer than those of urban areas. These factors may explain, in part, the difference in prevalence of physical inactivity (6,7). However, after adjusting for these sociodemographic factors, the relation between physical inactivity and degree of urbanization remained significant.

The findings in this report are subject to at least three limitations. First, all data were self-reported, potentially resulting in misclassification of activity status. Second, the study did not assess level of physical activity at work, which may be different in urban and rural areas. Finally, sample sizes were not equal for all strata and were smaller for some racial and age strata in rural areas, which diminished the precision of the results. Further analysis of individual and environmental determinants of physical activity is needed to determine the reasons for the substantial differences in the prevalence of physical inactivity between regions and the urban-rural differences of regions.

Leisure-time physical inactivity is prevalent in all parts of the country, particularly in rural areas and in the South. Because physical inactivity accounts for as many as 23% of all deaths from the major chronic diseases in the United States (8), interventions to increase physical activity could help decrease premature mortality. Recognizing regional and urban-rural differences is an important first step toward developing and tailoring interventions to increase physical activity in specific settings.

References

1. CDC. Physical activity and health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1996.

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

3. Butler MA, Beale CL. Rural-urban continuum codes for metro and nonmetro counties. Washington, DC: US Department of Agriculture, Agriculture and Rural Economy Division, September 1994; staff report no. 9425.

4. Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual, version 6.4. 2nd ed. Research Triangle Park, North Carolina: Research Triangle Institute, 1996.

5. Bureau of the Census. Statistical abstract of the United States, 117th ed. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1997.

6. CDC. Prevalence of sedentary lifestyle -- Behavioral Risk Factor Surveillance System, United States, 1991. MMWR 1993;42:576-9.

7. Stephens T, Jacobs DR, White CC. A descriptive epidemiology of leisure-time physical activity. Public Health Rep 1985;100:147-58.

8. Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess death from nine chronic diseases in the United States, 1986. JAMA 1990;264:2654-9.

Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; and West=Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

TABLE 1. Percentage of adults reporting no participation in leisure-time physical activity, by degree of urbanization and
demographic characteristics -- United States, Behavioral Risk Factor Surveillance System, 1996
==============================================================================================================================================================
                               Metro*                Metro+               Urban&                Urban@               Rural**
                         -------------------   ------------------   ------------------   -------------------   -------------------
Characteristic             %     (95% CI++)      %      (95% CI)      %      (95% CI)      %       (95% CI)      %      (95% CI)
----------------------------------------------------------------------------------------------------------------------------------
Geographic region&&
  Northeast              27.7    (26.6-28.7)   26.8   (25.4-28.1)   27.7   (24.4-31.1)   27.6    (24.5-30.6)   23.3    (15.9-30.7)
  Midwest                28.5    (27.2-29.8)   29.0   (27.4-30.5)   34.2   (30.7-37.6)   31.2    (29.4-33.0)   32.0    (29.1-35.0)
  South                  31.6    (30.3-32.9)   32.2   (31.2-33.2)   36.8   (34.4-39.1)   42.1    (40.4-43.8)   43.7    (40.3-47.2)
  West                   22.6    (21.3-23.9)   23.3   (21.7-24.9)   23.8   (21.8-25.8)   25.5    (22.8-28.2)   24.6    (19.9-29.3)

Sex
  Men                    25.1    (24.2-26.1)   26.8   (25.8-27.8)   29.8   (27.7-31.9)   34.1    (32.5-35.8)   37.1    (33.9-40.3)
  Women                  29.5    (28.7-30.4)   31.2   (30.4-32.1)   32.7   (30.9-34.5)   36.6    (35.2-38.0)   36.2    (33.4-39.0)

Age group (yrs)
  18-29                  22.2    (20.8-23.5)   22.4   (20.9-23.8)   23.6   (20.4-26.9)   25.0    (22.6-27.3)   29.0    (23.7-34.4)
  30-44                  25.2    (24.1-26.2)   26.5   (25.4-27.6)   29.1   (26.6-31.6)   32.8    (30.8-34.7)   34.4    (30.7-38.0)
  45-64                  29.5    (28.3-30.7)   32.0   (30.7-33.3)   34.6   (32.1-37.1)   40.4    (38.4-42.4)   40.4    (36.5-44.3)
  65-74                  32.0    (30.0-33.9)   34.6   (32.6-36.5)   36.4   (32.5-40.3)   38.7    (35.9-41.5)   37.5    (32.1-42.9)
   >=75                  42.2    (39.7-44.7)   43.3

Education
  <High school           49.1    (46.9-51.4)
  High school            33.0    (31.8-34.2)   34.5   (33.3-35.6)   35.9   (33.5-38.3)   37.7    (36.0-39.3)   39.3    (36.1-42.6)
  Some technical school  23.8    (22.7-25.0)   23.4   (22.3-24.6)   25.5   (23.1-27.9)   28.9    (26.9-31.0)   26.9    (22.9-30.9)
  College graduate       16.7    (15.8-17.6)   16.6   (15.6-17.7)   17.2   (14.8-19.5)   20.2    (18.0-22.4)   25.8    (21.1-30.5)

Annual income
         <$10,000        41.2    (37.9-44.5)   4
  $10,000-$19,999        38.9    (36.8-40.9)   39.7   (37.7-41.7)   37.7   (34.2-41.3)   43.7    (41.0-46.4)   42.6    (37.9-47.4)
  $20,000-$34,999        30.9    (29.6-32.3)   30.8   (29.5-32.1)   33.4   (30.8-36.0)   33.9    (32.0-35.8)   36.4    (32.7-40.2)
  $35,000-$49,999        23.4    (22.0-24.8)   24.5   (23.0-26.0)   24.7   (21.5-27.8)   30.0    (27.4-32.5)   31.5    (26.3-36.6)
        >=$50,000        17.5    (16.5-18.4)

Total                    27.4    (26.8-28.0)   29.1   (28.4-29.8)   31.3   (29.9-32.7)   34.4    (33.3-35.5)   36.6    (34.5-38.7)
----------------------------------------------------------------------------------------------------------------------------------
 * Population >
 + Population 50,000-999, 999.
 & Population 20,000-49,999.
 @ Population 2500-19,999.
** Population <
++ Confidence interval.
&& Northeast= Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest= Illinois,
   Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South= Alabama, Arkansas, Delaware,
   District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia,
   and West Virginia; and West= Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
==============================================================================================================================================================

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