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National Healthcare Disparities Report, 2013

Chapter 3. Effectiveness of Care Across the Lifespan

Much valuable health care is delivered to prevent disease, disability, and discomfort rather than to treat specific clinical conditions. These services improve health and quality of life and are often better characterized by stage over a lifespan rather than by organ system. For example, effectively managing pain is an important aspect of health care regardless of the underlying etiology. Like effective care for common conditions, many Americans do not receive the full benefits of these services.

This chapter is organized around four types of health care services that typically cut across clinical conditions: maternal and child health, lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care. The lifestyle modification section relates closely to national priorities identified in the National Strategy for Quality Improvement in Health Care.i Tracking smoking cessation supports the priority "promoting the most effective prevention and treatment practices for the leading causes of mortality," while tracking obesity measures supports the priority "working with communities to promote wide use of best practices to enable healthy living."

In this chapter, process measures are organized the same way as in the chapter on effectiveness of care for common clinical conditions. In this chapter, more process measures relate to preventive care than to acute illness and chronic disease. Again, some measures may be considered to belong in more than one category. Outcome measures are also identified.

Prevention

Caring for healthy people is an important component of health care. Educating people about health and promoting healthy behaviors can help postpone or prevent illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs.

Treatment

Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible.

Management

Some diseases, such as diabetes and end stage renal disease (ESRD), are chronic, which means they cannot simply be treated once; they must be managed over time. Management of chronic disease often involves promotion and maintenance of lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic diseases can mean the difference between normal, healthy living and frequent medical problems.

Outcomes

Many factors other than health care influence health outcomes, including a person's genes, lifestyle, and social and physical environment. However, for many individuals, appropriate preventive services, timely treatment of acute illness and injury, and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life. 

Maternal and Child Health

Importance

Mortality
Number of maternal deaths (2007) 548 (Xu, et al., 2010)
Number of infant deaths (2011 prelim.) 23,910 (Hoyert & Xu, 2012)
Demographics
Number of childrenii (2012 est.) 73,728,088 (U.S. Census Bureau, 2013)
Number of babies born (2011 prelim.) 3,953,593 (Hoyert & Xu, 2012)
Cost
Total cost of health care for children (2010) $115,785 billion (AHRQ, 2010)
Cost-effectiveness of childhood immunization series (2001) approx. $16 per $1 spent (Zhou, et al., 2005)

Measures

The National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) track several prevention, treatment, and outcome measures related to maternal and child access to and use of health care. The measures highlighted in this section are:

  • Prenatal care.
  • Receipt of recommended immunizations by young children.
  • Dental visits.
  • Untreated dental caries.
  • Well-child visits in the last year.
  • Receipt of meningococcal vaccine by adolescents.
  • Adolescent receipt of counseling or information about birth control.

Findings

Prevention: Early and Adequate Prenatal Care

The timing of initiation and the quality and quantity of prenatal care (PNC) may influence pregnancy outcomes, in particular the occurrence of preterm birth and low birth weight (Debiec, et al., 2010; Cox, et al., 2011; AAP, 2007). In the past, the NHQR and NHDR have followed a measure of PNC access in the first trimester as a key maternal and child health preventive measure. Because this measure does not take into account whether women then receive additional PNC throughout the pregnancy, we now report on a measure of early and adequate PNC.

One of the Healthy People 2020 objectives is that 77.6% of pregnant women receive early and adequate PNC, based on the Adequacy of Prenatal Care Utilization Index. This index looks at both initiation of PNC and number of visits; thus, early and adequate PNC is defined as PNC initiated by month 4 of the pregnancy and in which the woman also had at least 80% of the number of expected PNC visits.

The target number of PNC visits is based on when PNC started and on the infant's gestational age at birth. Because of consistency problems between the 1998 and 2003 versions of birth certificates, PNC timing and adequacy were evaluated only for the 34 States using the 2003 standard birth certificate for all of 2010. Because we have data for only 34 States, national estimates were not generated. However, these 34 States accounted for 61% of live births in the United States in 2010.

Given the persistent Black-White disparity in infant mortality and low birth weight, we mapped the absolute percentage point differences between White and Black infants (based on the reported race of the mother) in the proportion whose mothers had obtained early and adequate PNC. The map below shows overall State rankings (by quartiles) for these differences. The first quartile represents States with the largest differences and the fourth quartile represents States with the smallest differences. States ranged from a minimum difference between Whites and Blacks of 0.3% to a maximum difference of 29.5%.iii

Figure 3.1. Absolute differences between percentages of White and Black infants born in 2010 whose mothers had obtained early and adequate prenatal care, by State quartiles

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Key: Q = quartile.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics, National Vital Statistics System, 2010.
Note: Georgia, Maryland, Nevada, and DC were missing information on prenatal care for >15% of records. Go to ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdf (PDF File, 1.4 MB)

  • Interquartile ranges were as follows:
    • Fourth quartile (best): 0.3%-8.9% (CA, DE, ID, KY, NM, NV, OR, SC, TX).
    • Third quartile (second best): 9.4%-11.3%.
    • Second quartile (second worst): 11.5%-16.5%.
    • First quartile (worst): 17.4%-29.5% (DC, IA, IL, IN, MO, ND, SD, UT).
  • There was no clear pattern based on geographic region (Figure 3.1).
  • Only two States (CA and OR) were in the best quartile for the overall State rates shown in the NHQR and also in the best quartile for the difference between White and Black rates as shown here. New Mexico was in the worst quartile for overall receipt of early and adequate PNC and was in the best quartile for differences between Blacks and Whites. This presumably reflects relatively poor performance in both the reference group (Whites) and the comparison group (Blacks).

Also, in the NHQR:

  • State rates for obtaining early and adequate PNC ranged from 61.8% to 88%. There was no clear pattern based on geographic region.

Prevention: Receipt of Recommended Immunizations by Young Children

Immunizations are important in reducing mortality and morbidity. They protect recipients from illness and protect others in the community who are not vaccinated. Beginning in 2007, recommended vaccines for children that should have been completed by ages 19-35 months included diphtheria-tetanus-pertussis vaccine, polio vaccine, measles-mumps-rubella vaccine, Haemophilus influenzae type B vaccine, hepatitis B vaccine, varicella vaccine, and pneumococcal conjugate vaccine. These vaccines constitute the 4:3:1:3:3:1:4iv vaccine series tracked in Healthy People 2020. The Healthy People 2020 target is 80% coverage in the population ages 19-35 months.

Figure 3.2. Children ages 19-35 months who received the 4:3:1:3:3:1:4 vaccine series, by race/ethnicity, 2009-2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2009-2011.
Denominator: U.S. civilian noninstitutionalized population ages 19-35 months.
Note: White, Black, Asian, and more than one race are non-Hispanic; Hispanic includes all races. Full series of Haemophilus influenzae type b (Hib) vaccine is ≥3 or ≥4 doses, depending on brand type.

  • In 2011, 68.5% of children ages 19-35 months had received all recommended vaccinations (Figure 3.2).
  • From 2009 to 2011, Black children were less likely than White children to receive all recommended vaccinations.
  • The 2010 top 5 State achievable benchmark was 72%.v At the current rate of improvement, most racial/ethnic groups could achieve the benchmark in a year.

Also, in the NHQR:

  • In 2011, children from high-income households were more likely to receive all the recommended vaccinations than those from poor, low-income, and middle-income households.

Prevention: Children's Dental Care

According to the National Institute of Dental and Craniofacial Research, presence of dental caries is the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma (NIDCR, 2000), the second most common chronic disease in children. Regular dental visits help to improve overall oral health and prevent dental caries.

Figure 3.3. Children ages 2-17 with a dental visit in the calendar year, by income and race/ethnicity, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: White and Black are non-Hispanic; Hispanic includes all races.

  • Between 2002 and 2010, there were no statistically significant changes in the percentage of children ages 2-17 who had a dental visit in the calendar year (Figure 3.3). Increases were observed among Black, Hispanic, poor, and low-income children.
  • In all years, Black and Hispanic children were less likely than White children to have a dental visit. Poor, low-income, and middle-income children were less likely than high-income children to have a dental visit.

Also, in the NHQR:

  • In all years, children ages 2-5 were less likely than children and teens ages 6-17 to have a dental visit, and children with public insurance only or no insurance were less likely than children with any private insurance to have a dental visit.

Outcome: Untreated Dental Caries

Dental caries is the disease commonly known as tooth decay. Left untreated, dental caries can lead to pain, infection, and potential tooth loss. Among children, the lack of adequate treatment of dental caries may affect speech, nutrition, growth and function, social development, and quality of life. Left untreated, dental caries can progress to infections that can lead to life-threatening complications (NIDCR, 2000). Routine dental checkups help prevent dental caries and improve overall health (IOM, 2011). Early treatment will prevent infection and the tooth can usually be saved.

Figure 3.4. Adolescents ages 13-15 with untreated dental caries, by income level and race/ethnicity, 2009-2010 combined

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Key: FPL = Federal poverty level.
Source: Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by selected Healthy People 2020 oral health objectives for the United States, 2009-2010. NCHS data brief, no 104. Hyattsville, MD: National Center for Health Statistics; 2012. Available at: http://www.cdc.gov/nchs/data/databriefs/db104.htm.
Denominator: U.S. civilian noninstitutionalized population ages 13-15.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races.

  • Overall, 11.4% of adolescents ages 13-15 had untreated dental caries (Figure 3.4).
  • Black (24.6%) adolescents were more likely than White adolescents (9.4%) to have untreated dental caries.
  • About 20% of adolescents in families with incomes below 100% of the Federal poverty level had untreated dental caries compared with 9.4% of adolescents in families with incomes above 100% of the Federal poverty level.

Also, in the NHQR:

  • The percentage of children with untreated dental caries was higher for ages 6-9 than for ages 3-5 and 13-15.

Prevention: Well-Child Visits in the Last Year

The American Academy of Pediatrics recommends annual preventive health care visits for all children (AAP, 2008). Current recommendations are for 7 well-child visits prior to 12 months of age; 5 well-child visits between 12 and 30 months of age, inclusive; and one well-child visit per year from 3 years of age on.

Figure 3.5. Children ages 0-17 years with a well-child visit in the last 12 months, by income and race/ethnicity, 2011-2012 combined

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Source: Data Resource Center for Child and Adolescent Health, National Survey of Children's Health, 2011-2012.
Denominator: Civilian noninstitutionalized population ages 0-17.
Note: White and Black are non-Hispanic; Hispanic includes all races.

  • In 2011-2012, children from poor (78.5%), low-income (81%), and middle-income (85.9%) households were less likely to have well-child visits than those from high-income (90.3%) households (Figure 3.5).
  • Black children had lower rates of well-child visits compared with their White counterparts, while Hispanic children had lower rates than White, Black, and other non-Hispanic children.

Also, in the NHQR:

  • In 2011-2012, uninsured children were less likely to have a well-child visit than children with private or public insurance.
  • Children ages 0-5 were more likely to have a well-child visit than those ages 6-11 and 12-17.

Prevention: Receipt of Meningococcal Vaccine by Adolescents

According to the 2010 Census, individuals ages 10-14 years made up 6.7% of the U.S. population while those ages 15-19 years made up 7.1% of the population (U.S. Census Bureau, 2010). Youth in these age groups are at risk of contracting meningitis, which is an infection of the membranes that cover the brain and spinal cord. If meningitis is caused by bacteria, it is often life threatening.

Meningococcal diseases are infections caused by the bacteria Neisseria meningitidis. Although Neisseria meningitidis can cause various types of infections, it is most important as a potential cause of meningitis. It can also cause meningococcemia, a serious bloodstream infection. The meningococcal vaccine can prevent most cases of meningitis caused by Neisseria meningitidis and is recommended for all children ages 11-12 years. Effective in January 2011, a second dose is recommended at age 16.

Figure 3.6. Adolescents ages 13-15 who ever received at least 1 dose of the meningococcal vaccine, by income and race/ethnicity, 2008-2011

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2008-2011.
Note: White, Black, and Asian are non-Hispanic; Hispanic includes all races.

  • In 2011, 71.5% of adolescents ages 13-15 had ever received at least 1 dose of the meningococcal vaccine (Figure 3.6).
  • In all years, adolescents from high-income households were more likely to receive the meningococcal vaccine than those from poor, low-income, and middle-income households.
  • In 2008, 2010, and 2011, Hispanic adolescents were more likely to receive the meningococcal vaccine than White adolescents.
  • The 2009 top 5 State achievable benchmark was 75%.vi Adolescents in high-income families and Hispanics have achieved the benchmark. At the current rate, most other racial/ethnic and income groups could achieve the benchmark in a year.

Also, in the NHQR:

  • From 2008 to 2011, there were no statistically significant differences by sex among adolescents ages 13-15 who received the meningococcal vaccine.
  • In all years, residents of nonmetropolitan areas were less likely to receive the meningococcal vaccine than those living in metropolitan areas.

New! Prevention: Adolescent Receipt of Counseling or Information About Birth Control

Teen pregnancy rates are declining. In 2012, a total of 305,420 babies were born to teenagers 15 to 19 years old. The number of births to teenagers 15 to 19 years old dropped 7% during 2011-2012, an all-time low since the end of World War II (CDC, 2013). Eighty-seven percent of teen pregnancies are unintended (Finer & Zolna, 2011), and almost all teen births are to unmarried women (Hamilton, et al., 2013).

Racial disparities in teen birth rates are declining but persist. In 2012, the birth rate per 1,000 women for teenagers 15 to 19 years old was 46.3 for Hispanics, 43.9 for non-Hispanic Blacks, and 34.9 for American Indians and Alaska Natives (AI/ANs), compared with 20.5 per 1,000 for non-Hispanic Whites and 9.7 per 1,000 for Asians and Pacific Islanders (APIs). (Hamilton, et al., 2013).

In 2011, 47% of high school students reported ever having had sex, including 44% of non-Hispanic Whites, 60% of non-Hispanic Blacks, and 49% of Hispanics.vii Females (46%) and males (49%) were about equally likely to report having had sex. From 2006 to 2010, among never-married females, 42.1% of Hispanics, 41.9% of non-Hispanic Whites, and 46.4% of non-Hispanic Blacks reported ever having sex. Similarly, among never-married males, 46.0% of Hispanics, 36.7% of non-Hispanic Whites, and 58.4% of non-Hispanic Blacks reported ever having sex (Martinez, et al., 2011).

Much of teen sex is unprotected (MMWR, 2012). Without use of contraception, the rates of teen pregnancies and births are likely to remain elevated. A recent Institute of Medicine report pointed to teen pregnancy, births to teens, and decreased availability of contraceptives as key factors in the relatively poorer health of Americans versus people in similar countries (IOM, 2013).

Reducing teen pregnancy is the focus of the President's Teen Pregnancy Prevention Initiative. A key component of the initiative's relevant program model is increasing access to contraceptives among youth.viii Although evidence is limited (Jaccard & Levitz, 2013), health care provider counseling on the use of contraceptives can be effective in reducing teen pregnancy (Young, 2007; Oringanje, et al., 2009) and is recommended by leading professional societies and others (MQIC, 2012; Breuner, 2013). The Affordable Care Act requires that most health plans provide access at no cost to all contraceptive methods approved by the Food and Drug Administration, sterilization procedures, and patient education and counseling, as prescribed by a health care provider.

Figure 3.7. Teens 15 to 19 years old who received counseling or information from a health care provider during the last 12 months about birth control, by sex and race/ethnicity, 2007-2010 combined

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Family Growth, 2007-2010.
Denominator: People ages 15-19 years.
Note: White and Black are non-Hispanic. Hispanic includes all races.

  • Among males ages 15-17, Blacks (22.7%) were more likely than Whites (10.7%) or Hispanics (10.3%) to receive counseling from a health care professional on a method of birth control (Figure 3.7).
  • Among Hispanic teens ages 18-19, females (31.8%) were more likely than males (13.6%) to receive counseling from a health care professional on a method of birth control.
  • In 2007-2010, Hispanic males ages 15-19 (11.7%) were less likely than Hispanic females ages 15-19 (18.1%) to receive counseling from a health care professional on a method of birth control (data not shown).

Also, in the NHQR:

  • In 2007-2010, 12.6% of females ages 15-17 and 12.9% of males ages 15-17 received counseling from a health care professional on a method of birth control.
  • In 2007-2010, uninsured females ages 15-19 were more likely than uninsured males ages 15-19 to receive counseling from a health care professional on a method of birth control.
  • In 2007-2010, females ages 18-19 were more likely than males in the same age group to receive counseling from a health care professional on a method of birth control.

Lifestyle Modification

Importance

Mortality
Number of deaths per year attributable to smoking (2005-2009 est.) 480,000 (OSH, 2014)
Prevalence
Number of adult current cigarette smokers (2012) 42.1 million (Agaku, et al., 2014)
Number of obese adults (2009-2010) 78 million (Ogden, et al., 2012)
Number of obese children (2009-2010) 12.5 million (Ogden, et al., 2012)
Percentage of adults with no leisure-time physical activity (2005) 40% (Barnes, 2010)
Percentage of adults who are obese (2009-2010) 35.7% (Fryar, et al., 2012b)
Percentage of children who are obese (2009-2010) 16.9% (Fryar, et al., 2012a)
Cost
Annual cost of smoking (2009-2012 est.) $289-332.5 billion (OSH, 2014)
Total health care cost related to obesity (2008 est.) $147 billion (MMWR, 2010)

 

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 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. Since the first Surgeon General's report on smoking and health in 1964, there have been more than 20 million premature deaths attributable to smoking and exposure to secondhand smoke (OSH, 2014). Smoking causes more than 87% of deaths from lung cancer and more than 79% of deaths from chronic obstructive pulmonary disease (OSH, 2014).

Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general (OSH, 2004). 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.ix

Figure 3.8. Adult current smokers with a checkup in the last 12 months who received advice from a doctor to quit smoking, by race/ethnicity and sex, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
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 2010, 65.7% of adult current smokers received advice to quit smoking (Figure 3.8).
  • In 6 of 9 years, White adult current smokers were more likely to receive advice to quit smoking than Hispanic adult current smokers.
  • From 2002 to 2010, the percentage of Hispanic adult current smokers who received advice to quit smoking improved from 52.0% to 67.1%.
  • In 5 of 9 years, female adult current smokers were more likely than male adult current smokers to receive advice to quit smoking.

Also, in the NHQR:

  • In all years, adult current smokers ages 45-64 and 65 and over were more likely to receive advice to quit smoking compared with those ages 18-44, except in 2007 for those age 65 and over.
  • In 6 of 9 years, adults with basic or complex activity limitations were more likely to receive advice to quit smoking than those with neither basic nor complex activity limitations.

Prevention: Counseling About Exercise

Approximately one-third of adults are obese and about 17% of children and adolescents ages 2-19 are obese (CDC, 2011). 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 at least 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, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.x

Although physician guidelines recommend that health care providers screen all adult patients for obesity (USPSTF, 2012), obesity remains underdiagnosed among U.S. adults. Opportunities for obesity screening and diagnosis are often missed in ambulatory care settings. Research shows that lifestyle modification counseling is rarely provided, even among patients with physician-diagnosed obesity (Ma, et al., 2009). Physicians encounter 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.

Prevention: Counseling Obese Adults About Exercise

Figure 3.9. Adults with obesity who ever received advice from a health provider to exercise more, by race/ethnicity and age, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized adults age 18 and over with obesity.
Note: Estimates are age adjusted to the 2000 U.S. standard population using three age groups: 18-44, 45-64, and 65 and over. Obesity is defined as a body mass index of 30 or higher. White and Black are non-Hispanic; Hispanic includes all races.

  • Overall, in 2010, 58.4% of adults with obesity reported ever receiving advice from a health provider to exercise more (Figure 3.9).
  • From 2002 to 2010, 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, who improved from 45.9% to 58.8%.
  • Until 2008, obese White adults were more likely to receive advice to exercise than obese Hispanic adults.
  • In all years, obese adults ages 45-64 and 65 and over were more likely to receive advice to exercise compared with obese adults ages 18-44.
  • From 2002 to 2010, the percentage of obese adults ages 18-44 who received advice to exercise improved from 46.5% to 52.1%.

Also, in the NHQR:

  • In all years, obese adults ages 18-64 without insurance were less likely to receive advice to exercise compared with those with private insurance.
  • In all years, obese adults with basic or complex activity limitations were more likely to receive advice to exercise compared with those with neither basic nor complex activity limitations.
Outcome: Obese Adults Who Do Not Exercise

Figure 3.10. 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 income, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 18 and over with obesity.
Note: For this measure, lower rates are better. Estimates are age adjusted to the 2000 U.S. standard population using three age groups: 18-44, 45-64, and 65 and over. Obesity is defined as a body mass index of 30 or higher. White and Black are non-Hispanic; Hispanic includes all races.

  • Overall, in 2010, 48.8% 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 3.10).
  • In 8 of 9 years, there were no statistically significant differences between Blacks and Whites in the percentage of adults with obesity who did not spend half an hour or more engaged in moderate or vigorous physical activity.
  • From 2002 to 2010, the percentage of obese adults who did not spend half an hour or more engaged in moderate or vigorous physical activity decreased for Blacks and people from poor and high-income households.
  • In all years, adults from poor households were less likely to spend half an hour or more engaged in moderate or vigorous physical activity compared with those from high-income households. In 6 of 9 years, adults from low-income households were less likely to spend half an hour or more engaged in moderate or vigorous physical activity compared with those from high-income households.
  • From 2002 to 2010, the percentage of obese adults who did not spend half an hour or more engaged in moderate or vigorous physical activity decreased for obese adults in high-income households (from 51.2% to 42.7%).

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.
  • In all years, obese adults age 65 and over and those ages 45-64 (except in 2003) 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 ages 18-44.

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, 2011). The 2008 Physical Activity Guidelines for Americans recommend that children and adolescents engage in 1 hour or more of physical activity everyday.xi

Figure 3.11. Children ages 2-17 for whom a health provider gave advice within the past 2 years about exercise, by race/ethnicity and sex, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: Exercise advice includes the amount and kind of exercise, sports, or physically active hobbies children should engage in. White and Black are non-Hispanic. Hispanic includes all races.

  • Overall, in 2010, 39.7% of parents or guardians reported receiving advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies their children should engage in (Figure 3.11).
  • In 8 of 9 years, there were no statistically significant differences between Blacks and Whites in the percentage of children who were given advice about exercise.
  • From 2002 to 2010, the percentage of children who were given advice about exercise improved for Whites (from 30.5% to 40.6%) and Hispanics (from 30.4% to 42.3%).
  • In all years, there were no statistically significant differences by sex for children who received advice to exercise.
  • From 2002 to 2010, the percentage of children who received advice to exercise improved for females (from 30.9% to 40.3%) and males (from 29.2% to 39.1%).

Also, in the NHQR:

  • From 2002 to 2010, the percentage of children who received advice to exercise improved for those with private insurance and public insurance.
  • In all years, children with special health care needs were more likely to receive advice to exercise than 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.xii

Figure 3.12. Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods, by race/ethnicity and sex, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 18 and over with obesity.
Note: Estimates are age adjusted to the 2000 U.S. standard population using three age groups: 18-44, 45-64, and 65 and over. Obesity is defined as a body mass index of 30 or higher. White and Black are non-Hispanic; Hispanic includes all races.

  • Overall, in 2010, 51.4% of adults with obesity received advice from a health provider about healthy eating (Figure 3.12).
  • From 2002 to 2010, the percentage of obese Hispanic adults who received advice about healthy eating increased from 38.6% to 53.7%. The percentage of obese Blacks who received advice increased from 46.7% to 54.5%.
  • In all years, there were no statistically significant differences by sex in the percentage of obese adults who received advice about healthy eating.

Also, in the NHQR:

  • From 2002 to 2010, the percentage of adults who received advice about healthy eating increased for adults with public insurance and for those without insurance.
  • In all years, adults with basic or complex activity limitations were more likely to receive advice about healthy eating compared with those with neither basic nor complex activity limitations.

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 3.13. Children ages 2-17 for whom a health provider ever gave advice about healthy eating, by race/ethnicity and sex, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: U.S. civilian noninstitutionalized population ages 2-17.
Note: White and Black are non-Hispanic; Hispanic includes all races.

  • Overall, in 2010, 55.7% of parents or guardians reported receiving advice within the past 2 years about their children eating a healthy diet (Figure 3.13).
  • From 2002 to 2010, the percentage of children who received advice about healthy eating increased for Whites, Hispanics, and males.
  • In all years, there were no statistically significant racial/ethnic differences in the percentage of children given advice about healthy eating.
  • In all years, there were no statistically significant differences by sex in the percentage of children who received advice about healthy eating.

Also, in the NHQR:

  • In all years, children without insurance were less likely to receive advice about healthy eating compared with those with private insurance.
  • In all years, children with special health care needs were more likely to be given advice about healthy eating than those without such needs.

Focus on Hawaii

This year, the NHDR features findings from a report by the Department of Native Hawaiian Health and its Center for Native and Pacific Health Disparities Research. They are located at the John A. Burns School of Medicine at the University of Hawaii. The report is titled Assessment and Priorities for Health & Well-Being in Native Hawaiians and Other Pacific Peoples (Look, et al., 2013).

Obesity in Hawaii

The prevalence of having two or more chronic conditions increases with obesity (Must, et al., 1999). In the United States, more than half of Native Hawaiians and Other Pacific Islanders (NHOPIs) are either overweight (31.7%) or obese (31.0%) (Cook, et al., 2010). This rate is higher than most other racial groups.

Existing literature identifies several factors contributing to the higher prevalence of overweight and obesity among NHOPIs. These include biologic and cultural factors (Grandinetti, et al., 1999); increasing adoption of Western lifestyles (McGarvey, 1991); and a high consumption of fatty foods (Blaisdell, 1993). A recent Hawaii study about childhood obesity shows the prevalence of overweight and obese children at 32.6%, with children of NHOPI ethnic backgrounds having distinctly higher levels than Whites or Asians (Novotny, et al., 2013).

Figure 3.14. Overweight adults, by ethnicity, Hawaii, 2008

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Source: Hawaii State Department of Health, 2009, Hawaii Health Survey 2008. Retrieved from http://health.hawaii.gov/hhs/hawaii-health-survey-2008/.

  • In Hawaii, in 2008, the percentage of overweight adults varied by ethnic group. Native Hawaiians had the highest percentage of overweight adults (Figure 3.14).
Physical Activity in Hawaii

A 2010 report noted that about two in five NHOPI adults (42%) in the United States were physically inactive, with others getting at least some exercise or regular exercise. This estimate is similar to other ethnic groups. However, given the burden of chronic diseases already present in many NHOPIs, interventions to increase physical activity would prove to be especially beneficial due to the health benefits of physical activity, such as lowering blood pressure and blood glucose and improving insulin sensitivity (Cook, et al., 2010).

Figure 3.15. Adults achieving recommended physical activity levels, by ethnicity, Hawaii, 2001-2005

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Source: Hawaii State Department of Health, 2009. Physical activity levels. Retrieved from http://www.hhdw.org/cms/index.php?page=physical-activity.

  • The percentage of Native Hawaiians meeting recommended physical activity levels increased by almost 8% between 2001 and 2005, the highest increase among all groups examined (Figure 3.15).

i Available at https://www.ahrq.gov/workingforquality/reports.htm.
ii In this report, children are defined as individuals under age 18, unless otherwise specified.
iii In States with small numbers of births to Black women, caution should be used in interpreting the White-Black differences in adequacy of prenatal care.
iv Full series of Haemophilus influenzae type b (Hib) vaccine is ≥3 or ≥4 doses, depending on brand type.
v The top 5 States that contributed to the achievable benchmark are Louisiana, Maryland, Massachusetts, New Hampshire, and Ohio.
vi The top 5 States that contributed to the achievable benchmark are District of Columbia, Massachusetts, New Jersey, North Dakota, and Rhode Island.
vii Data from the Youth Risk Behavior Surveillance System, which includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention; and State and large urban school district school-based YRBSs conducted by State and local education and health agencies.
viii More information is available at http://www.cdc.gov/TeenPregnancy/PreventTeenPreg.htm.
ix 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/clinicians/update/treating_tobacco_use08.pdf (PDF File, 472 KB).
x More information about the 2008 Physical Activity Guidelines for Americans is available at www.health.gov/paguidelines/guidelines/default.aspx.
xi For more information about the 2008 Physical Activity Guidelines for Americans, go to www.health.gov/paguidelines/guidelines/default.aspx.
xii For more information about the Dietary Guidelines for Americans, go to www.dietaryguidelines.gov.
 


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 3. Effectiveness of Care Across the Lifespan. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr13/chap3.html

 

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