2012 National Healthcare Disparities Report

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 five measures highlighted in this section are:

• Influenza vaccination.
• Receipt of recommended care for pneumonia.
• Completion of tuberculosis therapy.
• Daily asthma medication.
• Written asthma management plan.

Findings

Prevention: Influenza 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 having influenza vaccination in the past 12 months, by race/ethnicity and income, 2000-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2010.
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. White and Black are non-Hispanic; Hispanic includes all races.

• Overall, the percentage of adults age 65 and over who reported having influenza vaccination in the past 12 months did not change between 2000 and 2010 (Figure 2.39). Only Blacks showed significant improvement over time.
• In all years, Blacks and Hispanics were less likely than Whites to have influenza vaccination.
• In all years, poor and low-income adults were less likely than high-income adults to have influenza vaccination.
• The 2008 top 5 State achievable benchmark was 74%.^xxv Only Blacks showed progress toward the benchmark but could not achieve it for 35 years.

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 influenza vaccination.
• In all years, adults with less than a high school education were less likely than adults with any college education to have influenza vaccination.

  Figure 2.40. State variation in disparities related to education: Adults age 65 and over who reported having influenza vaccination in the past 12 months, 2010

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Key: Largest Disparity Quartile identifies States with the largest relative differences in rates of influenza vaccination between adults with less than a high school education and adults who graduated from college; Smallest Disparity Quartile identifies States with the smallest relative differences in rates of influenza vaccination between adults with less than a high school education and adults who graduated from college.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2010.

• The States in the lowest quality quartile had influenza vaccination rates under 65.5% while the States in the highest quality quartile had vaccination rates over 70.1% (see NHQR).
• States in the East North Central, South Atlantic, and East South Central census divisions tended to have larger education-related disparities in influenza vaccination while States in the New England, Mountain, and Pacific census divisions tended to have smaller education-related disparities in influenza vaccination (Figure 2.40).

Also, in the NHQR:

• States in the East South Central, West South Central, Mountain, and Pacific census divisions tended to have lower rates of influenza vaccination.

Treatment: Receipt of Recommended Care for Pneumonia

CMS tracks a set of measures for quality of pneumonia care for hospitalized patients. This set of measures was adopted by the Hospital Quality Alliance. Recommended care for patients with pneumonia was measured by 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 2.41. Hospital patients with pneumonia who received recommended hospital care, by race/ethnicity, 2007-2010

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Key: AI/AN = American Indian or Alaska Native.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2007-2010.
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 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 2010, the 2008 top 5 State achievable benchmark of 94% was attained (Figure 2.41). Improvements were observed among all racial/ethnic groups.
• 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 2010, the new top 5 State achievable benchmark was 96%.^xxvi Whites, Blacks, and Asians were within 1 year of the benchmark. Hispanics would need 2 years and AI/ANs 3 years to achieve the benchmark.

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 2.42. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by race/ethnicity and place of birth, 2000-2008

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Key:API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2000-2008.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.
Note: White, Black, and API are non-Hispanic; Hispanic includes all races.

• The percentage of patients who completed tuberculosis therapy within 1 year increased from 80.2% in 2000 to 84.7% in 2008 (Figure 2.42). Improvements were observed among foreign-born patients and among all racial/ethnic groups.
• In 7 of 9 years, Hispanics were less likely than Whites to complete tuberculosis treatment.
• The 2008 top 4 State achievable benchmark was 94%.^xxvii At the current annual rate of increase, this benchmark could not be attained overall for about 15 years. Whites, Blacks, and APIs could achieve the benchmark sooner while Hispanics would need about 29 years. Foreign-born people would need about 19 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.
• Since 2004, males have been less likely than females to complete tuberculosis treatment.

  Figure 2.43. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by Asian and Pacific Islander and Hispanic granular ethnicities, 2008

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Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 2008.
Denominator: U.S. civilian noninstitutionalized population treated for tuberculosis.

• There is considerable variation in completion of treatment for tuberculosis among API granular ethnicities and among Hispanic granular ethnicities (Figure 2.43).
• Most groups are far from the 2008 top 4 State achievable benchmark of 94%.^xxvii

Most groups are far from the 2008 top 4 State achievable benchmark of 94%.

  Figure 2.44. People with current asthma who report taking preventive asthma medicine daily or almost daily, by race/ethnicity and income, 2003-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2009.
Denominator: Civilian noninstitutionalized population with current 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; Hispanic includes all races.

• From 2003 to 2009, the percentage of people with current asthma who reported taking preventive asthma medicine daily or almost daily fell from 29.6% to 25.1% (Figure 2.44). Decreases were observed among all racial/ethnic and income groups.
• In 4 of 7 years, Blacks were less likely to take daily preventive asthma medicine than Whites.
• In 4 of 7 years, poor and low-income people were less likely to take daily preventive asthma medicine than high-income people.

Also, in the NHQR:

• From 2003 to 2009, people ages 18-44 were less likely than other age groups to take daily preventive asthma medicine.
• In all years, uninsured people under age 65 were less likely than people under age 65 with any private health insurance to take daily preventive asthma medicine.

New! Management: Written Asthma Management Plan

A successful partnership for asthma care requires providers to educate patients about daily management and how to recognize and handle worsening asthma. Hence, providers should develop a written asthma management plan as part of educating patients regarding self-management, especially for patients with moderate or severe persistent asthma and those with a history of severe exacerbation.

  Figure 2.45. People with current asthma who received a written asthma management plan from their health provider, by race, ethnicity, income, education, and activity limitation, 2008

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2008.
Denominator: Civilian noninstitutionalized population with current asthma.
Note: Estimates are age adjusted to the 2000 U.S. standard population. Hispanic includes all races.

• In 2008, only one-third of people with current asthma received a written asthma management plan from their provider (Figure 2.45).
• Blacks were more likely than Whites to receive a written asthma management plan.
• People with any college education were more likely than people with less than a high school education to receive a written asthma management plan.

Also, in the NHQR:

• Among people under age 65, those who were uninsured were less likely to receive a written asthma management plan than those who had private health insurance.
• Among people age 65 and over, those who had Medicare and private insurance were less likely to receive a written asthma management plan than those who had Medicare and other public insurance or Medicare only.
• Residents of micropolitan and noncore areas were less likely to receive a written asthma management plan than residents of large fringe metropolitan areas (suburbs).

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 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 eight core report measures:

• Counseling smokers to quit smoking.
• Obese adults told by a doctor that they were overweight.
• Obese children and teens told by a doctor that they were obese.
• Counseling obese adults about exercise.
• Obese adults who do not exercise.
• Counseling for children about physical activity.
• Counseling obese adults about healthy eating.
• Counseling for 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). 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 (OSH, 2010).

Smoking is a modifiable risk factor, and health care providers can help encourage patients to change their behavior and quit smoking. The 2008 update of the Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence concludes that counseling and medication are both effective tools alone, but the combination of the two methods is more effective in increasing smoking cessation.^xxviii

  Figure 2.46. Adult current smokers with a checkup in the last 12 months who received advice from a doctor to quit smoking, by race/ethnicity and education 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized adult current smokers who had a checkup in the last 12 months.
Note: Estimates are age adjusted to the 2000 U.S. standard population using three age groups: 18-44, 45-64, and 65 and over. White and Black are non-Hispanic. Hispanic includes all races.

• Overall, in 2009, 67.6%% of adult current smokers received advice to quit smoking (Figure 2.46).
• In 6 of 8 years, White adult current smokers were more likely to receive advice to quit smoking than Hispanic adult current smokers.
• From 2002 to 2009, the percentage of adults with any college education who were advised to quit smoking increased (from 63.9% to 72.8%).
• In 7 of 8 years, there were no statistically significant differences by education among adult current smokers who were advised to quit smoking, except in 2009, when those with any college education were more likely to receive advice than those with less than a high school education and high school graduates.

Also, in the NHQR:

• From 2002 to 2009, there were no statistically significant differences between male and female adult current smokers who were advised to quit smoking.
• In all years, adult current smokers with private insurance were more likely than those without insurance to receive advice to quit smoking.

Prevention: Counseling About Exercise

Approximately one-third of adults are obese and about 17% of children and adolescents ages 2-19 are obese (CDC, 2011d). A larger proportion of individuals are overweight or obese among lower educated groups, Blacks, and Mexican Americans than among other racial, ethnic, and socioeconomic groups. Although women have lower body mass indexes than men, they gain weight faster, putting them at risk of disease (Truong & Sturm, 2005). Obesity increases the risk for many chronic, often deadly conditions, such as hypertension, cancer, diabetes, and CHD.

Physician-based exercise and diet counseling is an important component of effective weight loss interventions. 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.^xxix

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. The Coordinated Approach to Child Health (CATCH) is a successful evidence-based program that promotes physical activity and healthy food choices, which has been implemented in many schools and afterschool organizations nationwide and in Canada, benefiting many children.^xxx

Prevention: Obese Adults Told by a Doctor That They Were Overweight

Although physician guidelines recommend that health care providers screen all adult patients for obesity (USPSTF, 2012), 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.

  Figure 2.47. Adults with obesity age 20 and over who reported being told by a doctor they were overweight, by race/ethnicity and education, 2007-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2007-2010.
Denominator: People age 20 and over with a body mass index of 30 or greater.
Note: Estimates are age adjusted to the 2000 U.S. standard population. Total and race/ethnicity are adjusted using three age groups: 20-44, 45-64, and 65 and over; education is also adjusted using three age groups 25-44, 45-64, and 65 and over. White and Black are non-Hispanic.

• In 2007-2010, 34.8% of obese adults age 20 and over reported being told by a doctor that they were overweight (Figure 2.47).
• In 2007-2010, White (33.3%) adults with obesity were less likely to report being told by a doctor that they were overweight compared with obese Mexican American (40.5%) and Black (46.9%) adults.
• In 2007-2010, obese adults with less than a high school education (38.4%) were more likely than obese adults with any college education (34.2%) to report being told by a doctor that they were overweight.

Also, in the NHQR:

• In 2007-2010, obese adults with less than a high school education (38.4%) were more likely than obese adults with any college education (34.2%) to report being told by a doctor that they were overweight.
• In 2007-2010, there were no statistically significant gender differences among obese adults who were told by a doctor that they were overweight.

Prevention: Obese Children and Teens Told by a Doctor That They Were Obese

Figure 2.48. Obese children and teens ages 2-19 who were told by a doctor or health professional that they were obese, by race/ethnicity and income, 2007-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2007-2010.
Denominator: U.S. civilian noninstitutionalized population ages 2-19 who were obese.
Note: Obese children are identified using age- and sex-specific reference data from the 2000 Centers for Disease Control and Prevention body mass index (BMI) for age growth charts. Children with BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as obese. White and Black are non-Hispanic.

• In 2007-2010, 44.6% of obese children and teens ages 2-19 reported being told by a doctor that they were obese (Figure 2.48).
• In 2007-2010, White children who were obese were less likely than their Black counterparts to report being told that they were obese (41.3% compared with 51%).
• In 2007-2010, obese children from low-income households were more likely to report being told that they were obese compared with those from high-income households (49.6% compared with 38.2%).

Also, in the NHQR:

• In 2007-2010, obese children ages 2-5 were less likely than those ages 6-11 and 12-19 to report being told by a doctor that they were obese.
• In 2007-2010, obese female children were more likely than obese male children to report being told by a doctor that they were obese.

Prevention: Counseling Obese Adults About Exercise

  Figure 2.49. Adults with obesity who ever received advice from a health provider to exercise more, by race/ethnicity and income, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized adults age 18 and over with obesity.
Note: Obesity is defined as a body mass index of 30 or higher. White and Black are non-Hispanic; Hispanic includes all races.

• Overall, in 2009, 59.1% of adults with obesity reported ever receiving advice from a health provider to exercise more (Figure 2.49).
• From 2002 to 2009, 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 45.9% to 59.4%).
• In 6 of 8 years, obese White adults were more likely to receive advice to exercise than obese Hispanic adults.
• From 2002 to 2009, the percentage of obese adults who received advice from a health provider to exercise increased for poor (from 49.6% to 56.4%) and low-income (from 51.1% to 56.2%) groups.
• In all years, obese adults from low-income households were less likely to receive advice to exercise than adults from high-income households; adults from poor households were less likely to receive advice in 7 of 8 years and middle-income households in 5 of 8 years.

Also, in the NHQR:

• In all years, obese female adults were more likely to receive advice to exercise than obese male adults.
• From 2002 to 2009, obese adults with neither basic nor complex activity limitations were less likely to receive advice to exercise compared with those with basic or complex activity limitations.

Outcome: Obese Adults Who Do Not Exercise

  Figure 2.50. 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 education, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
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; Hispanic includes all races.

• Overall, in 2009, 51.7% 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 2.50).
• From 2002 to 2009, 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, except for obese Black adults (from 58.3% to 52.1%).
• In all years, there were no statistically significant differences by race/ethnicity in the percentage of obese adults who did not spend half an hour or more engaged in moderate or vigorous physical activity.
• From 2002 to 2009, obese adults with less than a high school education were less likely to spend half an hour or more engaged in moderate or vigorous physical activity compared with obese adults with any college education.

Also, in the NHQR:

• In all years, obese female adults were less likely to engage in half an hour or more of moderate or vigorous physical activity at least three times a week compared with obese male adults.
• From 2002 to 2009, obese adults with public insurance were less likely to engage in half an hour or more of moderate or vigorous physical activity at least three times a week compared with those with private insurance.

Prevention: Counseling for Children About Physical Activity

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, the incidence of overweight and obesity has tripled since 1980. Children have become more sedentary in the last two decades, necessitating weight management through increased physical activity. In 2007-2008, 20% of children ages 6-11 years and 18% of people ages 12-19 were obese (MMWR, 2011a). The 2008 Physical Activity Guidelines for Americans recommend that children and adolescents engage in 1 hour or more of physical activity everyday.^xxxi

  Figure 2.51. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by race/ethnicity and income, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
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. Hispanic includes all races.

• Overall, in 2009, 34.7% 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 2.51).
• From 2002 to 2009, the percentage of children who were given advice about exercise improved for White children (from 30.5% to 35.2%) and for Hispanic children (from 30.4% to 36.8%).
• In all years, there were no statistically significant racial/ethnic differences among children who were given advice about exercise.
• From 2002 to 2009, the percentage of children who were given advice about exercise improved for all income groups, although children from high-income households were more likely to receive advice to exercise compared with those from poor, low-income, and middle- income households.

Also, in the NHQR:

• From 2002 to 2009, the percentage of children given advice about exercise improved for those ages 2-5 and those ages 6-17.
• In the same period, increases in the percentage who were given advice about exercise were observed for children with special health care needs and those without such needs.

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.^xxxii

  Figure 2.52. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by race/ethnicity and education, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
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; Hispanic includes all races.

• Overall, in 2009, 51.3% of adults with obesity received advice from a health provider about healthy eating (Figure 2.52).
• From 2002 to 2009, the percentage of obese Hispanic adults who received advice about healthy eating increased from 38.6% to 56.7%, but there were no statistically significant changes for other racial/ethnic groups.
• In 5 of 8 years, White adults with obesity were more likely to receive advice about healthy eating than Hispanic adults with obesity.
• From 2002 to 2009, the percentage of obese adults with less than a high school education who were advised about healthy eating increased (from 42.1% to 52.0%).
• In 7 of 8 years, obese adults with a high school education were less likely than those with any college education to receive advice about healthy eating; obese adults with less than a high school education were less likely to receive advice in 6 of 8 years.

Also, in the NHQR:

• In all years, adults with obesity ages 18-44 were less likely to receive advice about healthy eating compared with other age groups.
• From 2002 to 2009, adults without insurance were less likely to receive advice about healthy eating compared with those with private insurance.

Prevention: Counseling for 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 2.53. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by race/ethnicity and household income, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: White and Black are non-Hispanic;. Hispanic includes all races.

• Overall, in 2009, only about half of parents or guardians reported receiving advice within the past 2 years about their children eating a healthy diet (Figure 2.53).
• From 2002 to 2009, statistically significant improvements in the percentage of children given advice about healthy eating were observed only for Hispanic children (from 45.5% to 51.8%).
• In all years, there were no statistically significant differences by race/ethnicity.
• From 2002 to 2009, the percentage of children given advice about healthy eating increased for children from poor (from 42.4 % to 49.8%) and low-income (from 44.1% to 48.7%) households.
• In 5 of 8 years, children from high-income households were more likely to receive advice about healthy eating than those from poor, low-income, and middle-income households.

Also, in the NHQR:

• In all years, children ages 2-5 were more likely to receive advice about healthy eating than those ages 6-17.
• From 2002 to 2009, there were no statistically significant gender differences among children who received advice about healthy eating.

^xxv. The top 5 States that contributed to the achievable benchmark are Colorado, Hawaii, Iowa, Minnesota, and New Hampshire.
^xxvi. The top 5 States that contributed to the achievable benchmark are Florida, Maine, New Hampshire, New Jersey, and Vermont.
^xxvii. The top 4 States that contributed to the achievable benchmark are Colorado, Kansas, Mississippi, and Oregon.
^xxviii. More information about the 2008 Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence can be found at https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html.
^xxix. More information about the 2008 Physical Activity Guidelines for Americans is available at http://www.health.gov/paguidelines/guidelines/default.aspx.
^xxx. More information about Coordinated Approach to Child Health (CATCH) is available at http://catchusa.org/.  
^xxxi. For more information about the 2008 Physical Activity Guidelines for Americans, go to http://www.health.gov/paguidelines/guidelines/default.aspx.
^xxxii. For more information about the Dietary Guidelines for Americans, go to http://www.dietaryguidelines.gov.

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