Chapter 2. Effectiveness of Care (continued, 3)

Respiratory Diseases

Importance

Measures

The NHQR and NHDR track several quality measures for prevention and treatment of this broad category of illnesses that includes pneumonia, tuberculosis, and asthma. The four measures highlighted in this section are:

• Pneumococcal vaccination.
• Receipt of recommended care for pneumonia.
• Completion of tuberculosis therapy.
• Daily asthma medication.

Findings

Prevention: Pneumococcal Vaccination

Vaccination is a cost-effective strategy for reducing illness, death, and disparities associated with pneumonia and influenza.

Figure 2.39. Adults age 65 and over who reported ever receiving pneumococcal vaccination, by race and ethnicity, 2000-2009

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2009.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: Age adjusted to the 2000 U.S. standard population. Benchmark is derived from the Behavioral Risk Factor Surveillance System; go to Chapter 1, Introduction and Methods, for details.

• Overall, the percentage of adults age 65 and over who reported ever having pneumococcal vaccination increased from 53% in 2000 to 61% in 2009 (data not shown). Increases were observed among all racial and ethnic groups between 2000 and 2009 (Figure 2.39).
• In all years, Blacks and Asians were less likely than Whites, and Hispanics were less likely than non-Hispanic Whites to have pneumococcal vaccination.
• The 2008 top 5 State achievable benchmark was 67%.^xxi At the current annual rate of increase, this benchmark could be attained overall in about 8 years. Whites could attain the achievable benchmark in about 6 years, while Blacks, Asians, and Hispanics would not attain the benchmark for 16, 19, and 30 years, respectively.

Also, in the NHQR:

• In all years, adults with Medicare only were less likely than adults with Medicare and private supplemental health insurance to have pneumococcal vaccination. Poor adults were less likely than high-income adults to have pneumococcal vaccination.

Treatment: Receipt of Recommended Care for Pneumonia

CMS tracks a set of measures for quality of pneumonia care for hospitalized patients from the CMS Quality Improvement Organization Program. This set of measures has been adopted by the Hospital Quality Alliance. Recommended care for patients with pneumonia includes receipt of (1) initial antibiotics within 6 hours of hospital arrival, (2) antibiotics consistent with current recommendations, (3) blood culture before antibiotics are administered, (4) influenza vaccination status assessment or provision, and (5) pneumococcal vaccination status assessment or provision. An opportunities model composite of these five measures is presented here.

Figure 2.40. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by race/ethnicity, 2007-2009

[D] Select for Text Description.

Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2007-2009.
Denominator: Patients hospitalized with a principal discharge diagnosis of pneumonia or a principal discharge diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.
Note: White, Black, AI/AN, and Asian groups are non-Hispanic; Hispanic includes all races. Recommended care includes initial antibiotics within 6 hours of hospital arrival, antibiotics consistent with current recommendations, blood culture before antibiotics are administered, influenza vaccination status assessment or provision, and pneumococcal vaccination status assessment or provision.

• In 2009, 93% of hospital patients with pneumonia received recommended hospital care (Figure 2.40).
• In all years, the percentage of patients with pneumonia who received recommended hospital care was significantly lower for Blacks, Asians, AI/ANs, and Hispanics compared with Whites.
• In 2008, the top 5 State achievable benchmark was 94%.^xxii By 2009, all racial/ethnic groups were close to the benchmark except AI/ANs.

Also, in the NHQR:

• In 2009, patients ages 75-84 and 85 and over were more likely to receive recommended hospital care for pneumonia compared with patients under age 65.

Outcome: Completion of Tuberculosis Therapy

Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the infection to others. Even worse, it may result in the development of drug-resistant strains of tuberculosis.

Figure 2.41. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by race/ethnicity and place of birth, 2000-2007

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Key: API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2000-2007.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.
Note: White, Black, and API are non-Hispanic groups. Hispanic includes all races.

• The percentage of patients who completed tuberculosis therapy within 1 year increased from 80% in 2000 to 84% in 2007 (Figure 2.41). Improvements were observed among foreign-born patients and among all racial/ethnic groups.
• In 6 of 8 years, Hispanics were less likely to complete tuberculosis treatment than non-Hispanic Whites.
• The 2006 top 5 State achievable benchmark was 92%.^xxiii At the current 0.6% annual rate of increase for the general population and for the foreign-born population, this benchmark would not be attained overall for about 12 years and 14 years, respectively. Blacks could achieve the benchmark in about 7 years while Hispanics would need about 17 years.

Also, in the NHQR:

• In all years, children ages 0-17 with tuberculosis were more likely than adults ages 18-44 to complete a curative course of treatment within 1 year of initiation of treatment.
• In 6 of 8 years, males were less likely to complete tuberculosis treatment than females.

Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program, coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for asthma diagnosis and management (NHLBI, 2007). These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.

While not all patients with asthma need medications, patients with persistent asthma need daily long-term controller medication to prevent exacerbations and chronic symptoms. Appropriate preventive medications for people with persistent asthma include inhaled corticosteroids, inhaled long-acting beta-2-agonists, cromolyn, theophylline, and leukotriene modifiers.

Figure 2.42. People with current asthma who report taking preventive asthma medicine daily or almost daily, by race/ethnicity and education, 2003-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2008.
Denominator: Noninstitutionalized population with asthma.
Note: Age adjusted to the 2000 U.S. standard population. People with current asthma reported that they still had asthma or had an asthma attack in the last 12 months. White and Black are non-Hispanic groups. Hispanic includes all races.

• From 2003 to 2008, the percentage of people with current asthma who reported taking preventive asthma medicine daily or almost daily did not change significantly (data not shown). A significant decline was observed among Blacks and people with any college education. No change was observed among other racial/ethnic or education groups (Figure 2.42).
• In 3 of 6 years, non-Hispanic Blacks were less likely to take daily preventive asthma medicine than non-Hispanic Whites.

Also, in the NHQR:

• From 2003 to 2008, people ages 18-44 were less likely than other age groups to take daily preventive asthma medicine.
• Uninsured people under age 65 were less likely than people under age 65 with any private health insurance to take daily preventive asthma medicine.

Focus on Asian and Hispanic Subgroups

National data on Asian and Hispanic subgroups are limited. In this section, we show rates of daily asthma medicine use among Asian and Hispanic subgroups in California. Data come from the 2009 California Health Interview Survey, which asks about daily medication to control asthma, similar to the Medical Expenditure Panel Survey question presented above.

Figure 2.43. People with current asthma who report taking prescription medication to control asthma, by Asian and Hispanic subgroups and English proficiency, California, 2009

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Source: UCLA, Center for Health Policy Research, California Health Interview Survey, 2009.
Denominator: Civilian noninstitutionalized population in California.
Note: Estimates for Asians who speak English at home were not statistically reliable.

• In 2009, among Asian Californians, there was large variation among subgroups in the percentage of people with current asthma who took prescription medication to control asthma (Figure 2.43). Asians who did not speak English at home but reported speaking English very well or well were less likely to take medication to control asthma compared with Asians who reported speaking English not well or not at all. Other differences were not statistically significant due in part to large standard errors for many subpopulations.
• In 2009, among Hispanic Californians, there also was large variation among subgroups in the percentage of people with current asthma who took prescription medication to control asthma. Central Americans were less likely to take medication to control asthma compared with Californians as a whole. Hispanics who did not speak English at home but reported speaking English very well or well were more likely to take asthma medication compared with Hispanics who did speak English at home. Again, other differences were not statistically significant due in part to large standard errors for many subpopulations. 

Lifestyle Modification

Importance

Measures

Unhealthy behaviors place many Americans at risk for a variety of diseases. Lifestyle practices account for more than 40% of the differences in health among individuals (Satcher & Higginbotham, 2008). A recent study examined the effects on incidence of coronary heart disease (CHD), stroke, diabetes, and cancer of four healthy lifestyles: never smoking, not being obese, engaging in at least 3.5 hours of physical activity per week, and eating a healthy diet (higher consumption of fruits, vegetables, and whole grain bread and lower consumption of red meat).

Engaging in one healthy lifestyle compared with none cut the risk of developing these diseases in half while engaging in all four cut risk by 78%. Unfortunately, healthy lifestyle practices have declined over the past two decades (Ford, et al., 2009).

Helping patients choose and maintain healthy lifestyles is a critical role of health care professionals. This year, the Lifestyle Modification section includes measures for both adults and children. Whenever children are mentioned in the section, the report is actually referencing the parents or guardians who were interviewed on behalf of the children. The NHDR tracks several quality measures for modifying unhealthy lifestyles, including the following six core report measures:

• Counseling smokers to quit smoking.
• Counseling obese adults about exercise.
• Obese adults who do not exercise.
• Counseling children about exercise.
• Counseling obese adults about healthy eating.
• Counseling children about healthy eating.

Findings

Prevention: Counseling Smokers To Quit Smoking

Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Smoking causes more than 80% of deaths from lung cancer and more than 90% of deaths from chronic obstructive pulmonary disease (MMWR, 2008). Heart disease is the leading cause of death in the United States for both men and women (Hoyert, et al., 2005), with approximately 135,000 deaths due to smoking. Cigarette smoking increases the risk of dying from CHD two- to threefold (MMWR, 2008).

Quitting smoking has immediate and long-term health benefits. The risk of a heart attack and death from CHD is reduced by 50% in the first year after smoking cessation. The risk of mortality declines most rapidly in the first 3 years after smoking cessation, taking about 3 to 5 years of abstaining from smoking for cardiovascular risk to disappear (HHS, 2010). Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking.

Figure 2.44. Adult current smokers with a checkup in the last 12 months who received advice from a doctor to quit smoking, by race/ethnicity and income, 2002-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized adult current smokers who had a checkup in the last 12 months.
Note: Estimates are age adjusted to the 2000 standard population using three age groups: 18-44, 45-64, and 65 and over. White and Black are non-Hispanic groups. Hispanic includes all races.

• From 2002 to 2008, there were no statistically significant changes in the percentage of current adult smokers who were advised to quit smoking overall or by race/ethnicity or income (Figure 2.44).
• In 5 out of the 7 years, current non-Hispanic White adult smokers were more likely to receive advice to quit smoking than current Hispanic adult smokers.

Also, in the NHQR:

• From 2002 to 2008, adult current smokers ages 18-44 were less likely to receive advice to quit smoking compared with other age groups.

Prevention: Counseling Obese Adults About Exercise

Approximately one-third of adults are obese and about 17% of children and adolescents ages 2-19 are obese (CDC, 2011e). A large proportion of individuals who are overweight or obese are from lower socioeconomic groups, Black, or Mexican American, and women tend to have higher obesity rates than men (Truong & Sturm, 2005). Obesity increases the risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.

Although physician guidelines recommend that health care providers screen all adult patients for obesity (USPSTF, 2003), obesity remains underdiagnosed among U.S. adults (Diaz, et al., 2004). Physicians have direct access to many high-risk individuals, increasing the opportunity to educate patients about their personal risks, as well as suggesting realistic and sustainable lifestyle changes that can lead to a healthier weight and more active life (Manson, et al., 2004).

Physician-based exercise and diet counseling is an important component of effective weight loss interventions (USPSTF, 2003). Such interventions have been shown to increase levels of physical activity among sedentary patients, resulting in a sustained favorable body weight and body composition (Lin, et al., 2010). Although every obese person may not need counseling about exercise and diet, many would likely benefit from improvements in these activities.

Regular exercise and a healthy diet aid in maintaining normal blood cholesterol levels, weight, and blood pressure, reducing the risk of heart disease, stroke, diabetes, and other comorbidities of obesity. Populations at risk for overweight and obesity may not receive adequate advice about lifestyle changes for many reasons. For instance, access to information, including physician knowledge of the latest recommendations, may be limited. The 2008 Physical Activity Guidelines for Americans recommend that adults engage in 2 hours and 30 minutes a week of moderate-intensity physical activity or 1 hour and 15 minutes a week of vigorous-intensity aerobic physical activity.^xxiv

In addition to physician-based exercise and diet counseling, many national endeavors encourage lifestyle modification. For example, the President's Challenge is a program of the President's Council on Fitness, Sports and Nutrition that promotes an active and fit lifestyle through a suite of recognition programs available to anyone age 6 and over. Several initiatives have used the President's Challenge Presidential Active Lifestyle Award to promote healthy lifestyles, including Box Tops for Education's Family Fitness Night and Let's Move!^xxv

Figure 2.45. Adults with obesity who ever received advice from a health provider to exercise more, by race/ethnicity and education, 2002-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher. White and Black are non-Hispanic groups. Hispanic includes all races.

• Overall, in 2008, 57% of adults with obesity had ever received advice from a health provider to exercise (Figure 2.45).
• From 2002 to 2008, there were no statistically significant changes by race/ethnicity in the percentage of obese adults who received advice to exercise, except for obese Hispanic adults (from 46% to 57%).
• In 6 out of the 7 years, obese non-Hispanic White adults were more likely than obese Hispanic adults to ever receive advice to exercise.
• From 2002 to 2008, there were no statistically significant changes by education in the percentage of obese adults advised to exercise.
• In 6 out of the 7 years, the percentage of obese adults who had ever received advice to exercise was lower for people with less than a high school education and people with a high school education compared with those with any college.

Also, in the NHQR:

• From 2002 to 2008, there were no statistically significant changes in any age group in the percentage of adults with obesity who were advised to exercise.
• In all years, female adults with obesity were more likely than males to receive advice to exercise.

New! Outcome: Obese Adults Who Do Not Exercise

Figure 2.46. Adults with obesity who did not spend half an hour or more in moderate or vigorous physical activity at least three times a week, by race/ethnicity and activity limitation, 2002-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. Obesity is defined as a body mass index of 30 or higher. Basic activity limitations refer to problems with mobility, self-care, domestic life, and activities that depend on sensory functioning, and complex activity limitations refer to limitations experienced in work and in community, social, and civic life. Neither indicates people with neither basic nor complex activity limitations. White and Black are non-Hispanic groups. Hispanic includes all races.

• Overall, in 2008, 53% of adults with obesity did not spend half an hour or more engaged in moderate or vigorous physical activity at least three times a week (Figure 2.46).
• From 2002 to 2008, there were no statistically significant changes by race/ethnicity in the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity.
• In 3 out of the 7 years, the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity was higher for Hispanics than for non-Hispanic Whites.
• From 2002 to 2008, there were no statistically significant changes by activity limitation in the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity.
• In all years, the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity was higher for people with basic and complex activity limitations than for people with no activity limitations.

Also, in the NHQR:

• In 6 out of 7 years between 2002 and 2008, adults with obesity age 65 and over were more likely than other age groups not to engage in half an hour or more of moderate or vigorous physical activity at least three times a week.
• In all years, female adults with obesity were more likely than males not to engage in half an hour or more of moderate or vigorous physical activity at least three times a week.

Prevention: Counseling Children About Exercise

Childhood is often a time when people establish healthy lifelong habits. Physicians can play an important role in encouraging healthy behaviors from a young age. For example, they can educate children and parents about the importance of regular exercise and healthy eating.

Overweight and obese children often become overweight and obese adults, with numerous and costly consequences. Unfortunately, as children have become more sedentary, the incidence of overweight and obesity has risen dramatically in the past two decades (Krebs & Jacobson, 2003), necessitating weight management through increased physical activity. The 2008 Physical Activity Guidelines for Americans recommend that children and adolescents engage in 1 hour or more of physical activity everyday.^xxvi

Figure 2.47. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by race/ethnicity and income, 2002-2008

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: Exercise advice includes the amount and kind of sports or physically active hobbies children should engage in. White and Black are non-Hispanic groups. Hispanic includes all races.

• Overall, in 2008, 34% of parents or guardians reported receiving advice within the past 2 years about the amount and kind of sports or physically active hobbies their children should engage in (Figure 2.47).
• From 2002 to 2008, the percentage of children who were given advice about exercise improved for all racial/ethnic groups.
• In all years, there were no statistically significant differences between non-Hispanic Black and Hispanic children compared with non-Hispanic White children who were given advice about exercise.
• From 2002 to 2008, the percentage of children who were given advice about exercise increased for all income groups.
• In all years, children from poor, low-income, and middle-income households were less likely to receive advice about exercise compared with children from high-income households.

Also, in the NHQR:

• From 2002 to 2008, the percentage of children given advice about exercise improved for children ages 2-5 (from 25% to 30%) and those ages 6-17 (from 31% to 35%).
• From 2002 to 2008, the percentage of children given advice about exercise improved for children with special health care needs (from 40% to 43%) and those without such needs (from 28% to 31%).

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race and socioeconomic status on quality of health care. Past reports have listed some of these findings as odds ratios. This year, the NHDR presents the results of a multivariate model as adjusted percentages for this measure: Children ages 2-17 for whom a health provider ever gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have. Adjusted percentages show the expected percentage for a given subpopulation after controlling for a number of factors, which include race/ethnicity, age, gender, family income, health insurance, and geographic location.

Figure 2.48. Children ages 2-17 for whom a health provider ever gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have, by race/ethnicity, age, gender, family income, insurance, and geographic location, 2002-2008

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, age, gender, family income, health insurance, and residence location.

• In the multivariate model used, Hispanic children (36%) were more likely to receive advice to exercise compared with non-Hispanic White children (32%) (Figure 2.48).
• After adjustment, children under age 6 years (29%) were less likely to receive advice to exercise compared with children ages 6-17 (34%).
• After adjustment, children from poor (31%), low-income (30%), and middle-income (31%) families were less likely to receive advice to exercise compared with children from high-income families (37%).
• After adjustment, children from families with no insurance (24%) were less likely to receive advice to exercise compared with children from families that have any private insurance (33%).
• After adjustment, children living in nonmetropolitan areas (25%) were less likely to receive advice to exercise compared with those living in metropolitan areas (34%).

Prevention: Counseling Obese Adults About Healthy Eating

In addition to increased physical activity, an important factor in maintaining a healthy body weight is modifying eating habits to include a diet that incorporates nutritional food and beverages. It is essential for physicians to emphasize to patients the importance of consuming foods from all food groups, including whole grains and fibers, lean proteins, complex carbohydrates, fruits, and vegetables, as well as providing education about balancing energy intake and energy expenditure. The U.S. Department of Agriculture created the Dietary Guidelines for Americans 2010 to aid people in understanding the complexity of healthy eating for both children and adults.^xxvii

Figure 2.49. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by race/ethnicity and income, 2002-2008

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Obesity is defined as a body mass index of 30 or higher.

• Overall, in 2008, 49% of adults with obesity received advice from a health provider about healthy eating (Figure 2.49).
• From 2002 to 2008, obese Hispanic adults who received advice about healthy eating increased from 39% to 53%, but there were no statistically significant changes for other racial/ethnic groups.
• In 4 out of the 7 years, non-Hispanic White adults with obesity were more likely to receive advice about healthy eating than Hispanic adults with obesity.
• From 2002 to 2008, there were no statistically significant changes by income in the percentage of obese adults advised about healthy eating.
• In all years, obese adults from high-income households were more likely to receive advice about healthy eating than poor, low-income, and middle-income adults.

Also, in the NHQR:

• From 2002 to 2008, adults with obesity ages 18-44 were less likely to receive advice about healthy eating compared with other age groups.

Prevention: Counseling Children About Healthy Eating

An increasing number of children consume diets with too many calories and little nutritional value. Growing evidence has shown the integral role nutrition plays throughout one's lifetime. Eating patterns that are established early in childhood are often adopted later in life, making early interventions important. The Dietary Guidelines for Americans encourage children and adolescents to maintain a calorie-balanced diet to support normal growth and development without gaining excess weight. The American Academy of Pediatrics recommends that pediatricians discuss and promote healthy diets with all children and their parents or guardians, for those who are overweight and those who are not (Krebs & Jacobson, 2003).

Figure 2.50. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by race and household income, 2002-2008

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.

• Overall, in 2008, 50% of parents or guardians reported receiving advice within the past 2 years about their children eating a healthy diet (Figure 2.50).
• From 2002 to 2008, percentages increased for White children (from 47% to 49%) and Black children (from 50% to 53%) who were given advice about healthy eating.
• From 2002 to 2008, improvements were observed for children from poor (from 42% to 52%) households who were given advice about healthy eating.
• In 5 out of 7 years, children from high-income families were more likely to receive advice about healthy eating compared with children from poor, low-income, and middle-income families.

Also, in the NHQR:

• From 2002 to 2008, the percentage of children ages 6-17 who received advice about healthy eating improved (from 44% to 47%).
• From 2002 to 2008, the percentage of children with any private or public health insurance who received advice about healthy eating improved.

^xxi. The top 5 States contributing to the achievable benchmark are Colorado, Delaware, Maine, New Hampshire, and Oklahoma.
^xxii. The top 5 States contributing to the achievable benchmark are Iowa, Maine, New Hampshire, New Jersey, and Vermont.
^xxiii. The top 5 States contributing to the achievable benchmark are Alaska, Indiana, Kansas, Maryland, and Oregon.
^xxiv. More information about the 2008 Physical Activity Guidelines for Americans is available at http://www.health.gov/paguidelines/guidelines/default.aspx.
^xxv. For more information about the President's Challenge, go to http://www.presidentschallenge.org.
^xxvi. For more information about the 2008 Physical Activity Guidelines for Americans, go to http://www.health.gov/paguidelines/guidelines/default.aspx.
^xxvii. For more information about the Dietary Guidelines for Americans, go to http://www.dietaryguidelines.gov.

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